parameters set about it. that's important at looking at the plan and figuring out how to do it. the answer is going to be different depending on where you are. senator sullivan will say his state has a per capita veteran in the nation. i have a veteran population that exceeds the population of several states. the capital planning requirements will be necessarily different than non v.a. care, but we have to come up with plans based on what appears to be the interest of the senate to continue down the multiprong path so you are taking pressure off requirements in some areas and maybe redoubling them in other areas. that's a very important thing that this committee needs to see, but we need to be very specific about what we wont in

the form of non v.a. care and choice care to get this right. >> if i can make two quick observations. you're absolutely spot on. first of all we have to force ourselves to make certain decisions about what care can be most efficiently delivered in the community. so we've talked before my example the chairman remembers optometry. why would we send a veteran 100 miles to get his eyes checked and get some glasses? we can do that anywhere. we wouldn't we routinely be referring that out to the community unless a veteran really wants to come to va. we are learning right now, again working to manage towards requirements rather than just a budget number, every time we improve access to care with a new facility, with additional staff, demand changes. part of what we're trying to understand are what are the dynamics. for example, you look in phoenix

where we know we're under penetrated in the veteran market. we improve access to care and we get a disproportionate response back. we've got to understand that market penetration phenomenon because it will affect our capital planning. i have already talked with the folks in phoenix about getting beyond -- looking over the horizon as it relates to demand for care among veterans in phoenix. we can't keep incrementally doing this because we're just going to stay behind. we have to get ahead of that demand. points are excellent. >> thank you. thank, mr. chair. >> thank you, mr. tellis. >> thank you. there's a shortage of medical personnel in the va, and i note in your testimony, secretary sloan, that you're going to be creating some 1500 new residency positions, and this is a matter i have discussed with our va person in hawaii because if you can create residency positions in the state, more likely that those folks will be able to practice in the state. so how will these residency spots be allocated, by region,

by capacity? are there any planning to increase for hawaii medical students? >> i don't have the list with me today specifically of where the slots are going. >> have you already determined where the residency -- >> not all 1,500. so that is a multiyear plan to deploy the 1,500, and the first round of those started this fiscal year. we actually went out -- i quite frankly did not think our office of academic affiliations would be able to do it, but they went out and sought applications. there are very specific criteria in the law about them going to under resourced communities and specialties. they went out and specifically caught those. we have awarded several hundred for this first round this year. not as many as we had thought

maybe, but a lot more than i anticipated that they would be able to award, and i can get you specifically where those -- >> because hawaii has a lot of rural areas on the islands that are underserved by the va. thank you. you can send me the information or the committee. as we look at the requests of secretary gibson to pay for the denver facility and we're looking -- i think that is really difficult for us to accept that you want to take money from the choice program to do that. so i'd like to ask you this, when a veteran goes to the va to get care for a nonservice connected matter, and this veteran has private insurance, do you have the authority to get reimbursed from the private insurance company for the care that the va provides? >> so if the patient goes out into the community in our normal purchase care program and has insurance, we will bill that insurance company and collect to

offset the cost of the care we provided. under choice we're actually the secondary payer. so under the choice program, the way the law was written, if the patient has commercial insurance, the commercial insurance is the primary payer and then we will make the provider whole up to the medicare rate. >> all right. so under the choice program, that's good because va becomes a secondary payer. my understanding is that in the first instance where the veteran goes to the va and gets the treatment, then often there is no reimbursement from his or her private insurance company. you're telling me otherwise. >> we will bill the private insurance company if the patient has insurance. >> yes. and do they reimburse you? >> we get paid from them. a lot of the patients actually have -- that have insurance have medigap insurance. and without a medicare eob often

times those insurance companies will not pay for the care because it's not medicare -- the insurance is specifically medicare gap coverage, and so we will not often times get paid by those insurers. >> so you're reassuring me that the vagos after every dime from the private insurance carriers that you can get your hands on. >> i can assure you we go after every dime we can collect. about $3 billion a year. >> that's reassuring. there are some questions about the outreach and the choice card program. there's still confusion out there and whether you have found all of the veterans who would qualify for the choice card, so my question goes to -- what are the outreach efforts that you've engaged in? do you think that you are succeeding in explaining the choice program and also to va employees and community health care providers who need to get training on how to explain the program. >> so we originally mailed -- we know who the people are who are eligible to get a choice card,

and we mail a letter to every one of those people back when the program started in november. >> i have talked to veterans, and they found that letter to be rather confusing. >> yeah. we're about to mail a second letter to all of them. hopefully it's a lot simpler to understand. we have actually tested that with veterans before we put it in the envelope. >> good idea. >> and we've made a lot of phone calls and outreach to people. there is no question that i think we can do more to reach veterans through our website, through mobile technology, through mailings and other forms of communication, and we need to do a better job of educating them. >> good. >> we do need to do a much better job. one of the things we've got to remind ourselves of is there's no parallel to this out there. it's not like an insurance card

where you just walk into your doctor's office and present your insurance card. there's no frame of reference for people to understand how it works. you know, do i have a benefit or do i not have a benefit? and that's one of the reasons it's hard for us to explain and why we have to keep trying. >> if we get feedback from my veterans, for example, that could help you all do a better job, i'd be happy to pass that on. >> we'd love it. >> thank you. >> thank you, senator. senator bozeman followed by senator tester. >> thank you, mr. chairman. really very briefly i'd like to ask a question of efficiency. i understand that the third-party administrators have raised the issue of how much clinical documentation is being sent to them by the va. apparently va is sending the clinical documentation of every veteran who was approved do you

to having a wait time in excess of 30 days, which presumably is overwhelming the tpas. you now have a pilot program in 8 and 17 to only send the clinical information of veterans who choose to participate in the choice program. we're leaving this now to take you to the house hearing. members of the veterans affairs sub committee on health will be hearing from a variety of health organizations. live coverage here on c-span 3. >> as a physician who worked fee for service at the air mountain va department of veteran affairs medical center for about 20 years, i know firsthand how rewarding it can be to take care of veterans at the v.a. and having the privilege of caring for veterans on a daily basis was wonderful for me.

the department's ability to effectively and efficiently recruit and retain qualified medical professionals to treat veterans is seriously fractured. for example, in my district at sioux saint marie outbase clinic, in sioux saint marie, michigan, has not had a physician on staff for at least two years. v.a. has adistributed that to the difficulty of recruiting physicians in rural areas m and while i understand that difficulty, i think v.a.'s overtly bureaucratic hiring process is also a significant factor in the facility's inability to recruit a physician for multiple years running. the minor mountain vamc was unable to post the opening for a physician directly. all job postings are filtered through a human resource office in milwaukee, wisconsin.

several hours away in another state. and my understanding all visit to all job postings are one through this one office in milwaukee. what's more, despite repeated assurances by v.a. officials that the department was actively recruiting for a position in sioux saint marie we call it the sioux in michigan. i have yet to single advertisement for that position, besides a s as a blurb on the hospital's website. leaving me to wonder if the v.a. knows what effective recruitment looks like. effective retention of employees is also critical. but according to the 2014 best places to work survey, the number of v.a. employees resigning or reiretiring has risen every year since 2009. it's not hard to see why.

they ranked v.a. 18 of 19 large agencies overall. 18 of 19 in effective leadership. 19 of 19 in pay with the department's overall score last year being the lowest v.a. has received since the report was first published in 2003. when a v.a. medical center is improperly staffed and when a qualified candidate is looking elsewhere for work or when an existing provider makes the decision to leave the v.a. it's our veterans that lose out. the growing physician shortage is causing the health care marketplace to become more and more competitive with the association of american medical colleges projecting a 91000 physician shortfall by 2025. if the v.a. is going to keep pace with the private sector in recruiting and retaining the high quality providers that our veterans deserve, immediate action must be taken to improve

retention of existing staff and ensure that qualified candidates for new or vacant positions are quickly identified, recruited hired and brought aboard. critical to that and to all v.a.'s plans regarding the delivery and quality of care is making sure those on the front lines providing direct patient care are not only involved beut leading the efforts to make the v.a. health care system stronger. to that end, i'm proud to have representatives from the national association of va physicians and dentists. the va physician dentist association and the nurses association physicians of v.a. on our witness panel today. they input you as well as the rest of our witnesses will provide about the daily reality you and your members face at va facilities across the country every day is invaluable. i thank you and all of our witnesses for being here this morning.

and i now yield to the ranking member for any opening statement she may have. >> thank you, mr. chairman, and thank you for calling this hearing today on v.a. staffing. section 301 of the veterans access care and accountability act signed by the president last year mandated the v.a. shall submit a report assessing the staffing of each medical facility of the department. this hearing will assess how they are doing in staffing around the country in respect to the care of our veterans. in its report the v.a. cites the need for an additional approximately 10,000 full-time employees to supplement the approximate 180,000 employees that currently work in veterans health care. i'm looking to find out from the v.a. how both numbers were arrived at. one issue is that last year

secretary mcdonald quoted a number of 28,000 positions needed to fully staff v.a. health care. now we are down to just over 10,000. the staffing report concurs with the inspector general's report listing the top five occupations that are most critical. medical officer, nurse physician assistant, physical therapist and psychologist. one occupation not listed because it's not technically health care related is human resources. these are the people that hire and fire and generally keep a facility fully staffed. i'm interested in hearing how the vha will be streamlining the hiring process and getting more people to work in a reasonable time frame to treat our veterans. veterans in my congressional district face barriers to access and care due to v.a. issues.

ventura county is home to 4800 veterans and -- struggles with staff retention. there are high turnover rates for physicians and medical support staff. the primary care team is down to just one physician, two nurse practitioners and one physician assistant. we are concerned that veterans are not using important wrap-around services because there's no primary care social worker on staff. over the past five years the number of veterans seeking mental health care at the cbok has doubled and the v.a. has been working hard to meet the growing demand, but we still seem to be in a place where we're not fully staffed. i know staffing issues facing ven ventura can county are ones that can be found across the v.a. system. i look forward to hearing how

the va is using the funding to increase the department's workforce and high demand occupations so that the nation's veterans have timely access to the high quality professional care that the v.a. is known for. thank you, mr. chairman and i yield back the balance of my time. >> thank you. joining on our first panel is joan clifford, immediate past present of the nurses organization of veteran affairs. dr. samuel spagnola. the president of veteran affairs physician assistant association. jeff morris, the director of communications and external affairs for the american board of physician specialties. and dr. nicol salvo from the american podiatric medical

association. miss clifford. we allow everybody five minutes. so should be a little light there when it goes red. that means you're up. thanks. >> hi. thank you. chairman ranking member and members of the sub committee on behalf of the nearly 3,000 members of the nurses organization of veteran affairs i would like to thank you for the opportunity to testify on today's important and timely subject, v.a. staffing. as the department of veterans affairs undergoes system wide reorganization to include many challenges of implementing the veterans access choice and accountability act staffing must be at the forefront of the evaluation. i'm deputy nurse executive at the v.a. boston health care association and here as the immediate past present of nova. nov a is professional organization for registered no, sirs employed by v.a. the focus is veteran issues. we're uniquely qualified to share views to efficiently and

effectively recruit and retain qualified health care professionals to treat our veteran patients. as v.a. nurses we are in the medical centers and at the bedside every day. we have identified retention and recruitment of health care professionals as a critically important issue in providing the best care anywhere for our veterans, and we would like to offer the following observations. nova believes that the underlying issues reside in the lack of a strong instruct for human resources. insufficient nursing education opportunities and the complex amly kags system. namely usa jobs that v.a. uses for hiring staff. we are facing a shortage of corporate experience. in sufficient hr staffing to support the multiple priorities required for health care professionals. the complex hiring process with systems that do not interface lead to extended weights for job offers. as times this results in candidates accepting nonv.a.

jobs and puts va back in hunt for qualified candidates. resulting in unnecessary recruitment delays contribute to delays in hiring personnel. reclassification and downgrades of some occupations such as surgical technicians who are brought in and recently downgraded to gs-5 are making it impossible to competitively retain and recruit. a lack of knowledge on how to maximize the law has resulted in inconsistent application of the law, an obstacle to hiring and retention. nova asks it be increased in order to remain competitive. ensuring an infrastructure to sustain programs that produce nursing graduates who honor and respect the programs is vital.

the office of veteran affairs has limited funds. impacting the recruitment of future hires that flock to the program. this will require continued funding for educational infrastructure. nova believes it's a good investment as hiring nurse practitioners will increase access and give access to veterans nationwide. to help nurses with the cost of education, if they work for vha and support for va nursing partnerships is needed. an area of concern is the use of advanced practice nurses, which at this time is subject to state laws in which the facility is located, vha is advocating full practice authority, which would result in all advanced practice registered nurses employed by the va to be able to function to the full extent of their education, licenseture and

training, regardless of the state in which they live and work. legislation has been introduced hr-1247. the improving veterans access to care act of 2015 which is the model already practiced by the department of defense indian health service and public health service systems. nova, together with other national nursing organizations are calling on congress to support the legislation, which would begin to address critical needs within v.a. facilities by improving wait times and access of care to all veterans. va employed 90,000 personnel, about a third of the health care workforce. nova believes there's no greater time to have representatives from the office of nursing services at the table at va organized the way it provides care and services to america's heros. improvements and careful review, increased training and use of the locality pay law, revising the cap on the rn pay schedule to eliminate compression as well as establishing a more user friendly application process and

supporting resources across the nation will go a long way towards correcting the challenges we face with staffing. no va once against thanks you for the opportunity to testify. and i would be pleased to answer any questions for the committee. >> thank you very much, miss clifford. doctor spagnola, please go ahead. >> mr. chairman, we have submitted a written testimony. i will try to keep my few comments here fairly brief. thank you for having us here and thank the the distinguished members of the committee for having us here. we certainly appreciate it. i am here as practicing physician with more than four decades where the v.a., and i'm here also as the president of the national association of v.a. physicians in dennis usually referred the to as navd.

the national association of va physicians in dennis is a 501-c 6 nonprofess organization dedicated to improving the quality of patient care in the va health care system and ensuring the doctor-patient relationship is maintained and strengthened. i appear today in pursuit of that purpose. this year it is the celebration of the 40th year. we believe the key means of enhancing care of veterans is by employing the best physicians in dennis. we belief it's essential for physicians to be involved in decisions requiring delivery and quality of health care. during my many years with the va i have witnessed many changes in the va. some good. some not so good. i had the opportunity to meet all the secretaries of the va over the last 40 years. get to know several of them very well. and a few i have seen as

patients. i believe all of these individuals have been good people and all with the best intentions. i'm sure secretary mcdonald who i have also met with also has good intentions. not withstanding the good intentions of these people however, the role of the physician within the system as a leader of medical care has greatly diminished over the same period. today most physicians in dennis feel like their opinions are neither helpful nor requested. at many centers physicians in dennis no longer are even considered professionals. but referred to simply as workers. these observations come from our members. va docs in dennis. in the late 1960s and '70s nearly all va medical centers were led by directors who were physicians. the position now called the va

undersecretary of health was known as the chief medical director. at that time there was a direct line from the chief of staff at the medical center to the chief medical director. issues of the quality of medical care were raised and addressed by medical professionals. today chiefs of staff report to a clinical specialist at the centers. in more recent times there's also been a strong movement to eliminate the need even to have a physician in the role of undersecretary of held. i ask would it be wise or even possible to run the defense department without generals and admirals in leadership positions? we are not saying that there is no role for nonphysicians in the administration of hospitals or medical care. we are saying, however, that medical judgment should be base d on years of education and patient care. physicians are being loaded withed a the igswith

ed a with additional duties more appropriate. such as typing, follow-up calls and preparation. similarly, it's not cost saving nor efficient to have physicians routinely escort them from waiting rooms to exam rooms and having them help the patients get undressed. there's a growing trend to add nonphysicians and a growing concern that a veteran may never be seen or treated by a physician while in the v.a. health care system. veterans are seen by nonmd doctors without realizing they have not seen a medical doctor. we believe this is dangerous for patients, and their families and it may also raise ethical issues. the va is currently considering a change in the nursing handbook. there will no longer be physician oversight for the profession of sedation by certified registered nurse. the proposed change provides no

guarantee this will provide safer patient care. additionally lpns with little or no psychiatric experience are taking the place of psychiatrists during intake and assessments. taking care of patients and providing excellent care has a lot to do with providing basics and using a lot of common sense. for example when patients are asked what is important to them you will hear simple straight forward common sense questions. such as -- will i be admitted quickly? is the room clean? is there a bathroom in the room? does the call button work? does someone answer and arrive quickly when i need them? does everyone speak so i can understand them? if i need help to eat, will somebody be there to help me? do my doctors and nurses spend time explaining things so i can understand what is happening? unfortunately patients surveys

indicate none of the above questions are being answered very well in the v.a. although the crisis last year did focus on access to care, this is but one small piece of the total package. getting timely initial access is of little value if it takes months to get your hip replaced or have a lung cancer removed or a colonoscopy screening because there may not be physicians or adequate access to the operating room. timely access must be throughout the course of care, not just on the initial visit. va is referred to as a health care system. as best, it's a collective of hospitals and other medical facilities operating under a common umbrella. the operation of standards at every facility appear to be different. there must be unification, simply simplyification to chae an order of efficiency and common outcomes. when you see one va you only

seen one va. in this regard we have seen no recent operational changes that would increase the the efficiency in the va. changes announced by the current secretary are not being consistently implementeded in local facilities. braps because the facility leaders have not understood the changes are mandatory. >> doctor, you'll have to clean up your time here. >> i'm one sentence left. >> hearings like this are important and helpful and we appreciate the opportunity to be here today. we want to help fix the medical care problem. the unfortunate truth, however it's far easier to throw money at the situation than it is to fix it. thank you, mr. chairman. >> thank you doctor. mr. morris. you have five minutes to come across with your testimony. >> chairman, ranking minority

member and distinguished members of the health sub committee. we thank you for examining the issue of overcoming barriers to more efficient and effective va staffing. veterans should never be shortchanged in their medical care. recruiting qualified and highly skilled physicians to work within the va health system is needed now more than ever. what many do not know is physician politics along with existing discriminatory and monopolization practices are keeping excellent physicians out. what is indefensible is they are not denied because of their training exorducation or experience. they're being denied solely based on their choice of board certification. he was a green beret and former member of special forces. he was hand picked to lead the medical treatment of 400 of our special forces. he wanted to work at the va. he applied for seven positions

and was never called back for an interview. this was not due to his training. and as a fellow of american academy of radiology. in addition to his medical profession. he's an attorney in hospital administration with a focus on waste fraud and abuse. the only barrier that prevented him from working at the va was his choice in certification. each physician. and because of that choice, he is consistently denied the opportunity to take care of his fellow veterans. we are here to ask the va to cease their discrimination of physicians. behind this discrimination is the fact that most people do not understand what board certification is. board certification is a choice and indicator that a practitioner has demonstrated their mastery to the core body of skills in their chosen specialty. currently there are three

recognized bodies. the american board of medical specialties, the american board of physician specialties. abms, the largest of the three, is made up of 24 individual specialty bodies making many believe they are all different entities. this structure has hidden the monopoly that abms has been establishing making many believe they are the only one. abms is not the only higher standard board. . there are others that meet or exceed their standards. in fact, avps is the only one of the three to receive an independent affirmation of the high standards through an exhaustive review process. since 1994, avbs has approached regarding the staffing issues creating barriers to hiring skilled physicians. each time the administration would protect the ongoing monopoly and respond they had no plans to recognize anyone else. in 2011 they return thod the administration to stop the the discrimination and further explain we were a part of the current standard of

certification. they refused to see the issues. all these discussions were led by former undersecretaries of health along with dr. karen sanders, all board certified by the very same organization keeping avps and other highly skilled physicians out. cha is most confusing around the gi bill avps has been reviewed and approved by the u.s. department of veteran affairs. yet they stated to us that it does not mean they have to accept it. the va reimburses for avps board certification but will not recognize it for hiring or promotion. the administration also stated to us that board certification is not a requirement, that it is left to the discretion of the local va. however, this has not been the case. according to usa jobs, there's over 1,000 open physician positions. most blatantly discriminate by requiring abms only. limiting the ability to fill much needed positions. only few hospitals recognize them and have hired them to fill

their staffing needs. the kansas city va is a good example of this providing a higher level of care. some also have hired avps physicians but abms openly discriminates against them. many of those physicians are not here because they fear retribution or loss of their jobs. avp wishes to contribute to solutions to ensure veterans receive the highest quality of care. have director from the office of secretary of va needs to be in place to create antidiscrimination policy. that clearly defines board certification and goes beyond the acceptance. job listings should no longer allow for one specific board over another. we also ask that a quarterly reporting structure be developed whereas va health care -- and all aply capital boards being identified. having identified individuals accountable for this oversight. all done in the similar manner as corporations are required to identify and ensure minority

hiring. this will allow for transparent process in local va medical centers will be held accountable. thank you again for this opportunity. the avps looks forward to working with you for hiring practices in the discrimination. most importantly the veterans health safety and care must be placed before politicianlitics and the egos of a few. it's what they deserve. >> thank you mr. morris. miss desilva, you're up next. >> on behalf of the entire membership of the veteran affairs physician association, we really appreciate the invitation to provide this testimony before you today. the pa profession has a very special and unique relationship with veterans. pa profession came into existence in the 1960s. the first graduate of the duke university program in 1967 were

four navy corps. to this day, still the single largest of va employers in the country. these pas provide cost effective high quality health care working in hundreds of medical centers and outpatient clinics. about a quarter of all primary care patients are treated and seen by pa. approximately 32% of those pas are veterans including myself. i'm a former navy hospital coreman. the oig report of january of 2015 conducted a determination with the larging staffing shortages as required by the veterans choice act. oig determined the p,as were the third critical on the list. according to the workforce succession planning of 2015 next year 37% of pas are eligible to retire. this will result in

approximately a loss of 1.15 million eligible. thex year the highest total loss rate of 10%, more than any of the other top ten occupations deemed difficult to recruit and retain. utilizing the va provisions of the veteran choices act of 2015, the va reports no current plans for recruiting for new pa positions and for retaining an optimal pa workforce. they're setting goals to hire only physicians and nurses as they interpret the law as to not including the pa workforce. some facilities are not posting p.a.s at all under the act. nationally for pas there are only 83 postings. this eliminating 50% of eligible applicants. when they do not post for pas they send a message that p.a.s and p.a. veterans should not and cannot apply, even though military pas have higher

experience of care. the education reduction programs continues to be a recruiting and retention barrier. there are three types of providers within the v.a. that provide direct patient care. physicians, physician assistants and nurse prakctitionerspractitioners. by virtue of being a nurse mandated under the yearly rn locality locality. pas fall under specialty races. however, this is not mandated yearly. some have not performed a special salary survey for 11 years. 88 v.a. facilityies report they cannot hire vas because they cannot compete with the private pay secretary. they can convert to covered physicians and pay them to public law. however, the va has refused to review these steps to solve the problems for pas. the the recommendation is congress should legislate a

mandate to include p.a.s and the nurse locality pay system. for the education debt reduction program, va pas is at the discretion of the hiring facility and is not standardized across the p.a. system. during 2013, only 44 physician assistants have received $319,000 in scholarships. compared to 705 registered nurses seek to become nurse practitioners, receiving scholarships awards over $12 million in support of np and np programs. the recommendation is they must advertise in all va vacancy announcements, so they are aware of the education debt reduction. loan forgiveness. move the program application process for accountability nationally since this is not a facility funded but a va funded program. next is the independent care technician. the itc program, also known as the grow your own program. to assist returning oif returning veterans to include

targeteded scholarships, the grow your own mandate that va shall appoint pa director to coordinate the educational assistance necessary for these coremen and medics can follow the the footsteps and become pas. for recruitment move all to the national recruiter workforce. in conclusion, chairman, ranking member and other members, to ensure that veterans receive timely access to quality health care and demand more accountability, we strongly urge you to review the important critical role of the pa profession and ensure they take immediate steps of the problems on a national level and not leave it to the local facilities to address the problems. the pa profession moving up the list. the pa profession was born from the military, and we need to continue that special relationship. on behalf of the entire membership of the veteran

affairs association, i really appreciate this opportunity to testify here before you today and ask for your help in supporting the nation's veterans. >> thank you. >> yes, sir. >> dr. salvo. >> chairman ranking member brownlee and members of the sub committee, i welcome and appreciate the opportunity to testify on behalf of the american podiatric association. i commend the the sub committee for the focus to assist the veterans administration to effectively and efficiently recruit and maintain qualified medical professionals and improve access to quality health care in the v.a. i am a member and director of young physicians at apma. i'm also a practiceing podiatrist. i am before you today representing apma and the podiatric medical profession. while i do not represent v.a. i

do bring firsthand knowledge of hiring practices within v.a. and widespread disparaging between other physicians. mr. chairman, when the v.a.'s qualification standards for podiatry pr adopted in 1976 i was not yet born. podiatry starkly contrasted with that of physicians at the time and a far cry from podiatric medicine as it is today. it has vastly expanded. back then, residencies were few and were not required. today there are mandated standardized comprehensive three-year medical residencies to satisfy all our graduates. with 77 positions housed within the v.a. each requiring completion of a broad curriculum, equitable to medical and osteopathic training. todays are appointed as medical

staff at the vast majority of hospitals and many serve in leadership roles within the institutions. many of my colleagues have full admitting privileges and are responsible for trauma call. the competency, skill and scope of today's physicians have certainly groan from the podiatrists that practiced before i was born. and tri-care recognizes us as licensed independent practitioners. that's today's podiatrisit. they have more co-morbid disease and disproportionately prohealth status. these increase the burden of diabetic foot ulcers and amputations and as documented in my written testimony, almost 2 million veterans are at risk of amputation with underlying

diabetes sensory neuropothy and foot ulcer ls. one of our major missions is amputation prevention and limb salvage, which provides a cost savings to va and integral role of the veteran quality of life. as part of the interdisciplinary team, podiatrists manage patients within our respective state scope of practice and assume the same clinical, surgical and administrative responsibility as any other unsuper unsupervised medical specialty. there exists a marked disparity in pay and recognition of podiatrists as physicians in the v.a. the mjts of new hires have minimal experience and lack board certification. the majority of these new hires will separate from the v.a. within five years. i am speaking to you from

personal experiences. i am one of the majority. i entered the va without board certification with less than five years of experience. i gained my experience, earned my board certification and then separated from the v.a. to take a leadership position with my parent organization. while i will forever remain loyal to the veterans which is why i still voluntarily treat patients at my local facility without compensation, i testify to the profound disparity. legislative proposals to amend title 389 to include podiatric physicians have been submitted by the director of services annually for the last ten years and these proposals have been denied every single year. as were several requests for an internal fix, despite written letters of support from the former undersecretary of health, robert petzel, md. five years ago we made this issue a top priority.

since then we have alerted the va to our knowledge of this issue and in response, he created a working group with whom we have participated in several meetings, and from whom we recently received acknowledgment of the need of a legislative solution to address the issue. in closing i would like to state that often times we find the simplist solution is the best. i come before the committee today to respectfully request that congress help the va and parents by passing legislation to recognize poed yat rik physicians and surgeons and the physician and dentist pay ban. we believe that simply changing the law to recognize podiatry, both for the advancements we have made to our professions and the contributions we have made for the lower population will resolve revutment and retention problems for the the v.a. and our veterans. mr. chairman and members of the sub committee, thank you again for this opportunity. this concludes my testimony. and i'm available for questions.

>> thank you doctor. appreciate it. i yield myself five minutes for questions. boy, there's a lot of questions i would like to get answered here today from many of you. i think i'll start with miss clifford, though because i think you brought up something that is pertinent here. how long is the average hiring process take? how long is that time and talk the difficulty and getting people to take a job somewhere elsewhere the job is ongoing. >> it's pretty variable. it can go anywhere from two to six months or maybe more in some places. it's a complex process. it will have to go through a resource committee for approval, which is the quickest part of the process. it then has to get posted on usa jobs. so it has to be put in the proper forgnat to be posted on that. and then we wait and get the

certification of who has applied for that position and then they have to go through all of these other processes we have, such as equip, which is the background check. >> two to six months in order to get hired. the least amount of time is two months. >> i think it could be considered a good hire. a quick hire. >> in the private sector, if you apply for a job, it zubt take two -- it doesn't take two months to get hired in the private sector at the local hospital, in my experience. do you have numbers on the private sector? >> that's correct. i don't have any numbers, but i do know that's what we hear from the candidates. it will come to the point where they say we have another job offer. you know, how quickly can can you tell me whether or not i can have it? they probably haven't given notice to another job. so it's another month after we make the job offer to get them in the door? >> can you comment on the same question as far as the physician side of things.

i know there's a lot of trouble with the is qualifications or making sure that the's background is right. and getting that right. but how does that process work in the va from your experience? >> i would echo what you just heard. it takes sometimes up to a year to recruit a physician. i've heard them taking even longer. and i also run the care department and it's usually a year before we can hire a therapist to get through all of the processes and finally get them in, working with hr and near impossible. >> this is all done through the hr department. i mean the physician hired as well. >> more than just the hr, you have to get approved by different committees and chairman and hospital directors and it goes back and forth. it just takes forever.

>> you mentioned podiatrist problem and at the va that i worked at the podiatrist was one of the busiest providers and had a hard time keeping the podiatrist there long enough to do the work they had to do. what's the difference in the payment? not paid as physicians then? tell me -- can you explain that to me a little more? >> poe die tri is on a different pay scale. unofficially, i am aware that the pay scale ranges anywhere from 60 to $100,000 less from other va medical and surgical specialties depending on what the specialty is. >> that would explain why it's difficult to recruit. mr. silva, do you have anything

to add on that recruitment and difficulty in hiring question? >> i would agree that it does take a long time it takes about six weeks on the private sector max where the va can take up to six months. >> can you expand a little bit about your -- my concern about -- when i worked at the va was the fact the doctors weren't involved in making decisions in departments that actually involved how patient care was delivered. you were told what to do and by the administration and left to do that. can you expand on that thought. do you agree with my thinking there and what should be done about it? >> well, we need to empower the physicians in the facilities. i think if you took people in every va facility and took a dozen people in the facility who knew who was going on you would find out quickly what was

working and what wasn't. you need to empower the nurses and empower the physicians to get real input on how to become more efficient and how to provide better care. i think that could be done very quickly. >> thank you, i'm out of time. >> mr. chairman i know that the secretary of the va is really trying to make transformation at the va and i've heard him and others from the va testify that we need to shift the va from a rule based organization to a principle based organization and it sounds to me based on the long he havety of hiring people within the va, it is the rules that are because there are so many is what slows the whole

process down. we would be better off following the practices of private industry in terms of hiring. is that a fair assessment? >> i would say so. there's a lot -- it's very complex, lots of steps in the process from the human resource side. >> for the nurses it is unlike the physicians, it's the problems are predomesticinantly within the human resources department and rules hiring doctors to go through human resources that have to go outside of human resources as well? >> yes, yes. >> i'm not sure i understand the question about going outside. >> doctor spagnolio testified when for long he havety in terms of hiring positions it's within the human resources department but also outside human resources and i presume be interviewed by other physicians or other

departments and i'm wondering for nurses is the whole hiring process within the human resources department? >> the nurse manages other supervisors who they want to hire and the technical parts are done by human resources. en en. >> and the same for physicians? >> every new director that came to our facility in the last 40 years has said night number one priority is to fix hr. it's never been mixed. >> mr. spagnolio your testimony was shocking when you said sometimes that veterans have medical payments for care and leave knowing they did not see a physician or medical expert of any kind.

that's pretcyty shocking testimony to me and when i heard obstacles around physician assistants and the shortage there, it's -- i'm not sure what to say except we have a lot of improvements to make and i mean do you think that's a common occurrence where a veteran comes for a appointment for medical services and never seize a physician? >> what's the question do i think it's common? >> yes. >> i think it's quite common. and how do you think you also said in your testimony that physicians are doing nonphysician care like typing and filing and follow-up calls and helping patients change their clothe ss. how did that happen? how did that become the responsibility of the physician?

is it because of the shortage of people in the operation or are these specific responsibilities of a physician? >> i don't know for specifically how that has occurred over the years but i can tell you when i was chief of staff a number of years ago, i used to say to the hospital director when he would come in and yell at me and say our docs aren't seeing enough patients. i keep telling them the reason they can't see patients, there's knob to assist to see the patient. they have one examining room and they have to get the patient and get the patient undressed and see the patient and then they have to write a note usually on the computer nowadays and help the patient get dressed and then they have to escort the patient out of the room. how many times in a day can you do that when you have no other help? you have nobody to help input data into the computer. you have no one to help you request drugs for patients into the computer.

you're basically doing the physician, the secretary and receptionist and it's very difficult to be efficient, not that the physicians don't want to be efficient, they would love to be efficient but the system doesn't permit it. when you talk to administrators they just glaze over. it's -- it gets physicians extraordinarily frustrated. they would love to see more patients, everybody would love to see more patients. >> thank you, doctor my time is up and i yield back. >> you're recognized for five minutes. >> thank you mr. chairman. and you really threw me off and i realize i've been a doctor longer than alive but i expect you have the same angst as i did. a couple of things to go over quickly i have to catch an airplane but number one, you very clearly pointed out the

loss of professionalism. in my practice, i had an assistant, had a nurse with me and three examining rooms. i can really see a lot of patients very efficiently and very well. you cannot see patients in that -- it's impossible. you can't make it more productive when you have six jobs. and i think that very loss of professionalism has occurred and another thing that has occurred in the va we have fewer providers as hospital administrators. if you've been in the trenches working, you understand exactly how that clinic works. i understand exactly how your clinic works or doesn't. so i think that's one of the issues we've got to deal with. and i think another question i have quickly is how -- what is the retention problem? when you hire people there's a huge turnover in nursing and medical side. what do you all see? why is this? is it working conditions or pay? why is that?

>> i'll take a stab at that. they come to work with great enthusiasm, good people, they get put into these situations after six months or a year they are frustrated and depressed and tired and nobody listens and they leave. so your turnover rates i don't know what they are nationalally but am primary care some places have turnover rates of 100% every year. it's frustration primarily frustration i would say. and go ahead -- >> again, it's dependent on different facilities to your point that people all come in with the best of intentions, but if you happen to be in an area that has a difficult time recruiting and trying to do overtime and lots of shift changes and people get frustrated and burned out and leave. in facilities they are able to maintain that people stay because they stay for the

mission. >> two other quick questions, one is for mr. morris's standpoint is there a barrier if you have a different -- i'm certified by the american board but are there barriers out there for other board certifications that you see that help reduce staffing? is that a real issue that you brought up or not? i guess dr. spagnolio can answer -- and the second -- let me fill the second one out so you can answer it. the veterans choice act which we spent a lot of time on getting passed provided $5 billion to increase staffing for the va. is that money being used that way? that's my two questions. >> if your question is on the veterans choice act, whether they are utilizing it -- >> yes, sir. >> i don't know how much they are utilizing it to be honest with you. i don't know if -- i know we've tried to have a few people go somewhere else one had an artificial heart and it was a

nightmare to get that done. because the facility that they were to go to had no experience with that. i can't tell you how it is across the va. from what i hear it's not very efficient. so if it's going to work, it's going to be efficient. i would like to see within the va more efficiencies and getting these procedures done more quickly. some physicians have no -- their access to the operating room is one or two days a week. >> that second was less physicians, as mr. morris pointed out, being boarding by somebody, is that a barrier to hiring people? >> yes. >> is it a legitimate barrier? >> i think it's a legitimate barrier in some situations. >> okay. any other comments on that? did any of you, dr. salvo, have you seen that? >> in my capacity as a woc

appointment within the va, i have had to deal almost nothing with veterans choice act personally. it's purely administrative by other departments. >> i did want to say with the veterans choice act it has been interpreted to not include physician assistance by some facilities. if you want to talk about increasing recruitment, the jobs aren't even posted physician assistants aren't able to apply for those jobs. that's not going to increase access for care for veterans. >> it isn't really hard to figure out your needs when you just call the people scheduling the appointments and find out you have a six-month wait. it ain't rocket science. i've been doing it for four decades and you find out and all fl you there know, if you have a long waiting list for patients to come in you need to hire people to take care of waiting lists or make the shop more efficient. it's not complicated. i did it for years. and i mean, the way i learned if i needed advice, i would go to

church and somebody say i can't get an appointment for six months. and that's what i see there. my time is expired, mr. chairman thank you for indulging me. >> thank you. >> you're recognized for five minutes. >> thank you mr. chairman. i want to thank everyone on the panel for being here in your commitment to improving the va and serving our veterans gives me an opportunity to remember and think those who serve veterans -- that's the district i have the honor of serving and dr. salvo your story of continuing to treat veterans without compensation reminds me of people i met at the va who are providers there and could be working in the private sector at much greater pay and probably much less frustration and yet choose to work at the va because they want to serve veterans and do a wonderful job. i hear that from the veterans

that they treat and serve directly, that it's really hard to get in and there's a lot of frustration with the bureaucracy, but once you are seen by a provider, typically the experience is excellent. and i think that's something that i've heard my colleagues on the committee share as well. two things stick out to me in terms of the larger picture. one is we heard the deputy secretary say this day before yesterday sloan gibson, that there are 28,000 unfilled positions at the va today. just the hiring challenge there is just monumental staggering i don't know how you get over it and it hasn't improved in a year. and the other is wait times also have not improved in a year. 15 or $16 billion authorized and appropriated this summer,

program went live in new york and dr. spagnolio you're not sure if you've seen significant change in access or treatment. we know from a hearing earlier this week that we thought that $10 billion of that were going to be obligated sometime in the early part of fy 16 which could take you to maybe december or january. the next six months and only $500 million has been obligated. so you all have each offered important suggestions to improve the delivery of care and hiring and speed at which we bring people on board and i'm glad dr. lynch is here to listen to all of this. i know he's taking note of this and will incorporate these, i hope into the operations at the va, but i'm also looking for some kind of big break through in what we're doing. i don't know that with these 28,000 outstanding hires with wait times that haven't improved

despite the notoriety around the crisis in phoenix and all of the attention we've spent and new legislation that we thought would fix it, i don't know this model works nor should we expect it to work. one of you said it's not going to be a matter of resources, we can't throw more money at this and expect -- we can hire people a lot more quickly. i've heard the same stories we had a psychologist hirled from georgia recruited by the va in el paso and he said sure, i'd like to do this job, sign me up and it took three months to bring them on. they recruited him and it took three months. in the that time they said there were several other offers and thought of taking them. i realize i've chewed up most of the time i had but i want to offer the last minute and a half to anyone who might have a big breakthrough idea on how we change what is obviously a system that doesn't work.

>> ms. clifford -- >> i don't know if it's a breakthrough idea, but if we don't address the human resource piece of it -- it's not the staff doing the work there killing themselves trying to help us get these people in. but the task ahead of them is so overwhelming, i don't know what the retention rates are but i would think they are not very good because they turn over quickly because it takes a lot of time to get them trained. they don't stay long enough to get trained and go to other jobs, either in other parts of the government or out of human resources all together. we don't address that area because they are the bread and butter of getting people in. >> that's an open question for me to each of you, i'm sure my colleagues on the committee would be interested in hearing your answer. we won't have a time to get to each of you today. but i speak for myself, very interested in a different way forward. i just think more of the same we've seen from the last year despite what i think is

tremendous leadership on the part of the va and new secretary, it's just not working and the people who are delivering that care in the front lines are suffering and what's even more important, the people that they serve are suffering and we've got to have a big bold path forward to fix this. with that i yield back to the chair. >> thank you. mr. kauffman you're recognized. >> we get scope of practice questions here in the congress relative to the veterans administration. i think a lot of these issues have been resolved down at the state level before state legislatures and i've been on both sides of it as a state legislature where i think they are better qualified at the state level to make those decisions. they can have hearings and they

know that the docs -- providers within their communities. i guess my question to you is clearly people that -- well, my question to you is, what do you think about devofling the scope of practice issues down to reflect whatever the standards are within the given states that these va facilities are in? number one and obviously want to make sure the providers are credentialed and trained to perform those duties within the scope of practice. and so devofling down to the state level reflects state reregulations, as opposed to us relitigating the issues at the federal level. would anybody like to comment on that? >> well, i can speak from the advance practice realm and the issue becomes we care for patients across states and different states have different

nurse practice acts, which allow the nurse prags tigsers to do different things at different levels. we see patients from main and new hampshire and yet the nurse practitioners in this states are able to do things and not able to in other states, it's hard for us to give equitiable care across our veterans when we have different practices. >> anybody else? >> i'm not sure i could respond to that because i never thought of that as an answer. but i'd probably have to look at that a little bit more and see where that would take us because it may be a possibility. i would like to get back to you on that. >> as an example, the issue between an tease yolgist and nurse anecessary thist has been settled in different states and now both sides want us to relitigate it here at the federal level.

i would just as soon defer to state legislators who have made those decisions so that would be an example. >> i would have to look at that across states lines i don't have a good answer but i'll get back to you on that. >> okay. thank you, i yield back. thank you. >> trying to get it right. >> thank you. ms. clifford thank you for your testimony today about the role nurses play in the va and how to better attract and retain nurses. you mentioned about stream lining the hiring process and improving education resources but i'm wondering about your thoughts about giving nurses improved rights to raise grievances about staffing levels and how that can improve the workplace and empower nurses and encourage them to continue serving our veterans?

the statement submitted it mentions through a loophole nurses and other va health care providers are denied full collective bargaining rights that other federal employees have. supports a bill that i've introduced hr 2193 the va employee fairness act to expand ability to negotiate to improve staffing levels and in turn the care our veterans receive. do you think we need to pay attention to the work environment to attract and retain skilled nurses? >> yes sir and in va nursing we actually use an expert panel for staffing methodology model we use front line staff to determine what the staffing levels and numbers should be for those individual units. that's the model we use. we do involve front line staff in that and they look at the demographics of the turbulence of the unit and things going on in the unit and acute levels to

determine what should be the appropriate level. and those recommendations are put to the resource committee. >> similar question regarding the ability to collectively bargain and set staffing levels. do you think expanding collective bargaining rights and physician's ability to negotiate would play a role in ensuring physician's voices are heard you're paid attention to by folks making decisions? >> frankly i'm not sure i have an answer to that question. we currently have union representation in the hospital. it gets involved in a lot -- i think some of these issues seems to me many times makes it more complicated. i think if we could empower more people within the hospital we could probably eliminate a lot of these problems that have to do with working conditions. >> how do you empower them if -- without having collective

organization, how are you going to be heard and listen to? how will you get people to listen to you unless there's some leverage? >> i'm not quite sure i understand that question, if you're talking about pay or talking about working conditions? >> working conditions are also part of what are collectively bargained. >> i'm not sure the issues i've been discussing here i don't know if you need the cliktive bargaining agreement. i think if we sit down we could solve these problems. >> i want to turn to the physician assistant issue -- i want to briefly ask, isn't there a tremendous physician shortage in the country? does that not play into why physicians might be difficult for the va to recruit physicians? >> there's a physician shortage in some areas. >> primary dare? >> primary care but again i keep coming back to the same issue, it's a resolving door.

if you don't make things better, i think the salaries in the last ten years have come ugt significantly. >> on the physician assistant side, i'm wondering about whether or not there might be some education i was interested to hear that the military was the beginning of the whole idea of pas and there are community college programs that take up until now pa people who had up to five years of experience say in the military and community college program a few years they can become pas but i understand it has moved that to a master's degree minimal. is that something you would agree with? >> i went to a community college and applied to a acredited physician assistant program. it is at a master's level now. it's a great pathway to let medics coming back to have a

pathway to go and become physician assistants. it is a masters program and has to be acredited. >> is the loss of that pathway, is that a problem? is that an added burden? >> when i applied to pa school and to my knowledge there's not a path you can go to a community college and become a physician assistant. it was a minimum a bachelor's program when i applied in 19 et. i did not know of any community college that was offering the physician assistant program at that time. there were few offering a bachelors and had all turned to master's program and now even offering doctorates. >> thank you. >> thank you. >> thank you, mr. chairman, i want to thank you and ranking member for putting this panel together and all being here today, it's very insightful and provides us with a lot of turnt r opportunity to make things better in the va to hear what you had to say today.

i know when i got here before phoenix broke and everything else coming from private practice i was concerned and remember asking dr. pet zell if anybody on the administrative staff have ever been in private practice where they had to be in the black to keep the doors open. and none had. i find that significance. when you talk about physician directors today being involved it would be more helpful if they had private practice experience. i also asked, do you think the va, if you took all of the expenditures like a private practice has to do, physical plant and nurses and assistants and supplies and bills they had to pay if the va looked at themselves that way and took fee for service would you be in the black? he said yes. and i about fell out of my chair. because i know how tough it is to be in the black seeing three times as many patients as the va was doing. i greatly appreciate what you're

talking about today where you have physicians doing things that in a private practice you have someone else do so you can care for more people and that really is the bottom line. so i really appreciate what you're saying today. on this committee alone we have five physicians. if we can't make things better sitting here, then we're in trouble. this is an opportunity that should not be wasted. i hope we proceed in that direction. thank you all for educating for the things we believe in. i have one question and it has to do with retention and recruitment and length of time it takes to fill a spot. i think we've touched on the reasons why it's tough but i'm curious how long it takes to fill a spot because i've had young doctors podiatrists and mds come to me and say i looked into it but didn't see a bright future here. and especially when you talk about the poe die trif issue. if you can weigh in on the length of time it takes to fill a slot and challenges i'd

appreciate it. >> i don't know what else to tell you other than the process is to complicated. it has to get approved and reapproved and on a resource committee meeting then off a committee and sometimes a committee doesn't meet for two months then goes to hr and comes back to the resource committee. just takes forever. >> that's what i want to hear and i'm hoping that working with you we can come up with a plan that streamlines that and makes it a whole lot more efficiency. >> i would be delighted to help you work on that plan. mr. chairman i have a clinic at 1:00, we have 40 people waiting on me. may i be excused? >> dr. salvo, i'd like you to weigh in -- >> i'm in complete agreement and he indicated earlier in his testimony and approximate wait time in terms of getting credentialed and privileged and

starting in the va approximately one year. that is certainly if i were to consider the average, that is probably true. when i left my post in the cleveland system it was 14 months before that was filled. i've had two woc positions since i started my current position, one took me 11 months and other one surprisingly took me five. it is an excessive burdensome process when you factor in vet proand the application process alone with all of the forms and the various hr levels and committees that everything has to be completed. so it is extremely xegsively burdensome. >> thank you very much for your testimony. i yield back. >> thank you to our chair and

voice chair for holding this hearing. i apologize that we have flights we have have to catch but i appreciate you being here and look forward to perhaps another time we could bring dr. lynch back so that more of us could hear. i want to focus in -- i had the opportunity just recently to visit the white river junction vermont hospital which is the va hospital that serves the folks many of the folks in my district. >> i think they are very focused in a veteran sen trick care. they've had good results from the choice act in hiring just recently in fact, they were focused on getting nurse practitioners into our krx box so in the rural communities they would have the prescribing ability to stay on top of medications and prescribe without people having to go down to the va hospital. but i want to focus in on the

question of the pas and just generally i'm pretty familiar with the private sector and the fact that we are -- this is a national trend. we are pushing down our medical care to the right person at the right time for the right task. and so it doesn't surprise me that somebody would come in and not see a physician. i don't typically see a physician when i get care in the private sector if i can see a pa or see a nurse practitioner. i get terrific care. so i just want -- i don't want to mislead anyone about what is expected. my concern about the pas is this chronic loss rate, 12 to 14% loss rate. and particularly comparing it to a very favorable practice with the nurse pla tigsers in their residency program, 100% retention of employed nurses

after one year of employment as compared to over a loss rate of 10% in other practices. i'm would be dering and this is for ms. desilva have you seen anywhere in the va or outside, it could be a best practice we could bring in, a residency type program where we could be more focused on our pas, give them the support they need to be able to stay on the job because my understanding is it takes at least six months to replace a pa, that's expensive and expensive to the system. and you know as i say, i'm focus the on veteran sen trick care. can we get them the care they need? >> thank you for that great question. the issue you were talking about the residency program, we don't have a particular like grow your own residency program when i had given my verbal testimony i talk

about the scholarships that are just not available. if you have a medical technician or somebody in the va system who says they want to go on and become a physician assistant there aren't really funds that are naturally set aside for it. there isn't a definite program that you can apply to and have a pathway to become a physician assistant. so if you wanted to do that you would have to take out loans or leave the va system or come into the va system and spend a short amount of time and leave. that's why we're talking about the grow your own. if you do have medics in the va system or returning and coming to work at the va get their pa school paid for and continue to work within the system. that would be the ideal pathway to do. to set aside there is education debt reduction programs to have pas come and work in the system. however, the funding is at a local level. it's not nationally mandated.

if you ask at the local level they may see funds are not available. >> and so i'd be very interested in looking into bipartisan legislation to bring the pas in line with both the debt reduction and the scholarship programming to -- and i love the idea of our returning vets, i know we've talked about a lining their abilities and making sure that they have a path to successful employment in the private sector. and then just briefly, my time is almost up but i did want to just mention, i'm also interested in the mandated surveys to include pas in the mandated salary surveys in the community so that we -- better align the compensation for pas. but i think you know, we should do what we can to make sure that doctors are working at their highest and best use and they have the support to see more patients. i'm a big fan of bringing in

nurse practitioners and nurses obviously for what they can do for it and i want to be supportive of getting p a's up to speed and well compensated so they will be able to participate as well. thank you very much and i yield back. thank you. >> dr. abraham, you're recognized. >> i want to give dr. spagnolio for having the patience of joe if he's able to work four years in the system that requires him to enter data. i know as a practicing physician when my triage nurse would call in when we used the electronic health records would call in sick i would see two thirds, if not 75% less patients that day when i had to do the work. the hard work is done by those nurses and triage people that make us better than we probably really are. saying that i've worked also

with pas and mps in my career and service and the level of care that you provide is outstanding outstanding. i referred patients all my career to podiatrists for -- to diabetic cultures and again, could not ask for a better level of care from your profession. so kudos to you guys. i find it odd that in programs such as choice or anything that's nonrelated that the va doesn't mind our good veterans being seen outside the va clin being by board certification other than abms, they allow the

ao aoa, the ost pathic boards and don't seem to have a problem with that. but they have a problem hiring those same types of board certifications and the va hospitals themselves. again, going back to my little world, i'm a practicing physician before this job, i use physicians for every specialty for hospitals and referral and across the board they all, whether it be the profession you represent, the aoa, all provided outstanding level of care either outpatient or in the hospital. i guess my question is how many physicians do you think have been denied positions at the va because of their different board certification? >> there's a lot of our membership which is why we've been pushing this issue.

>> unfortunately some are afraid to come forward and say things because there are black lists or names that get out to where if they do get an opportunity to get a job they've been denied these instances. the politics has been amazing and something i i was shocked to see when i first came in. you're having great physicians denied opportunities or even great physicians working within the va system denied levels of promotion and movement along in their career solely because they chose the smaller board. and we're here today and we've been here continuously having you meet our physicians to really show them that it should be looked at the physician as a whole on their education and training and experience not what choice they made in their

board certification. >> thank you. >> i yield back. >> thank you. >> well i think everyone has had an opportunity so is there any further questions? otherwise we'll excuse the panel. you all are excused then. thank you very much for your testimony. we really appreciate you coming in here. joining us in the second panel, thomas lynch the va assistant deputy undersecretary for health for clinical operations and dr. lynch is accompanied by hernandez, a deputy chief officer for workforce management and consulting and the chief officer of nursing thank you all for being here. once you get settled you're

welcome to begin your testimony. >> thank you, i think i got the short chair here but i'll make the best of it. i would like to go off script for just a moment in thanking you for the opportunity to discuss the va's ability to recruit on board and retain qualified medical professionals. i want to acknowledge the panel that preceded us and want to acknowledge the opportunities that they afforded us to hear. i want to echo secretary mcdonald's statement of the other day that we really need to engage and empower our employees and need to listen and learn because they will help us provide better care to veterans. with that said, i would also like to acknowledge today that

i'm accompanied about mr. eli as hernandez, recently appointed chief officer for vha office of workforce management and consulting and is responsible for providing human resource support services and training. dr. gauge, who recently joined va from the private sector, serves as vha chief nursing officer and advises on all matters related to nursing and delivery of patient care services. establishing and rerealizing staffing requirements for va's health care system is a complex task. va operates over 1,000 points of care across the country. provides a full range of primary and specialty care services for patients ranging in age from the youngest recently discharged service members to our most senior veterans. rural populations and unique health conditions resulting from combat experiences and increasing number of women veterans require a commence rate array of professionals to address the unique and individual requirements.

adding to the challenge is the fact there are many approaches to medical professional and support staff modeling across large health care systems. there is no one size fits all model and no single set of staffing management tools in the private sector or elsewhere we can borrow. these are indeed challenges but no means insurmountable barrier to achieving the goal of timely access to care for veterans. the va is leveraging our national recruitment program, dedicated recruiters identifying hard to fill positions and marketing and hiring qualified medical professionals. we are promoting scholarships and loan repayment programs such as the education debt reduction program and employee incentive scholarship programs as expanded. we have increased the physician and dentist pay tables to attract and maintain health care providers. we're improving the

credentialing process which involves sharing krecredentials to speed up the process. in the last 12 months hired 37,000 new employees with a net increase over 11,000 medical professionals and staff. this includes about 1,000 physicians and 3,000 nurses. in addition, we are leveraging new technology to expand to the reach of health care providers from 2010 to 2014 there was 114% increase in the use of all health care technology among unique veterans. at the end of 2014 12.7% of all veterans enrolled in care receive telehealth based care. this includes visits touching 700,000 veterans. to address the increase in the rural veteran population, the partnership with office of rural health sponsoring the training initiative, the project is

designed to fulfill v a's mission to serve veterans living in rural areas. funding allows va facilities to expand health professions training to rural va locations. additional training physicians awarded as part of this initiative become part of the permanent base location. as you can see we have made significant progress but we realize we still face many challenges like wait times and provision of rural health care and commitment to health issues. by increasing staff and community care and hours of care available, we believe our recent progress has resulted in some increases in the number of unique patient visits and large increases in the number of appointments for veterans already enrolled. we have completed 2.5 million more appointments inside va this past year. we also believe that in many specific locations with the longest wait times, the more access we offer the more veterans we'll see vha care

services, it's also a challenge to recruit health care professional as at these locations. these are all significant on why we must focus or efforts. in conclusion, we have the best clients in the field of health care. we're grateful for congress's support and look forward to your continued assistance in getting best doctors and nurses to serve professions. our commitment to timely accessible care and positive patient experience is unwaivering. mr. chairman, this concludes my opening remarks. my colleagues and i are prepared to answerny questions you and members of the committee may have. >> thank you, dr. lynch. i yield myself five minutes for questions. >> it's great you come and tell us how well you're doing and stuff, but it's really

frustrating to me to me and you heard the testimony from the previous panel there seems to be way too much orders from above about how things get done. within the va and there's not enough with dr. spagnolio talked about, the people on the ground taking care of patients get to make some decisions that affect how the process works. now, the va provides hospitals and this bureaucratic mess has not occurred to the same level in private hospitals. so not every single private hospital is a 2000 clinic but they seem to do a better job of hiring and firing and having processes work efficiently than the va and i think a lot of it is because people on the ground have more power to actually

change these. i'll give you a great example i went to my district and one of the complaints that i had was that everybody went and had the patient sign in and sign out of the computer. the nurse has to sign into the computer and sign out when shooez done. the doctor comes in he's got to sign in and sign out. to write anything about they can't take their laptop in and keep signed in. they have to waste five minutes signing in every time they see a different patient. it's the cumulative time of signing and signing off was a huge waste. they are telling me this is a big time killer yet nobody could get that changed. because that was some -- the way they were doing it was from above. those are the kind of processes dr. lynch, that need to be solved at the local level. every single little clinic or

hospital will have an issue like that that has to be done. and you know i've been here for years now, listening to what you guys have been doing as far as physician staffing for example, like eight times in the last 30 years the inspector general has told the va that they need a central plan for hiring physicians. eight times the va has agreed to the inspector general that you know, they are going -- they need that. they haven't gotten a central plan over the last 30 years. so what has changed dr. lynch. how can we get this? how can we jump start this? >> i mean, this is the same answers i hear now working. >> let me start by agreeing with you on one point. i think the aggravation of dealing with our computer system is exceedingly frustrating. i think the other side of it, it

provides a very accurate medical record. i would disagree in that i think the solution is probably central. and we need to look for ways to make computer access more efficient across our system. i don't think it's a local problem. i think it's larger. i will also agree -- >> i can tell you at the hospital that i worked at i had a laptop of my own that i used and signed in once and kept it with me and saw a bunch of different patients, didn't have to sign in and sign out. that was not a centrally planned decision, that was a locally planned decision and it was a lot better. the nurse had her computer at the nursing station just went back and forth and didn't have to sign in and sign out, you know, lose your spot, all of that. and somehow you can't solve that simple problem but your answer is it has to be solved centrally. that's the wrong answer. that's what i'm trying to tell you. >> i understand your position but i'm going to disagree and we

end up facing obstacles from homeland security and the risk of access to national computers -- >> everybody has the problem with the security of health computers, don't tell me it's special to you. everybody is concerned about the patient's privacy on health care. so these are answers that don't make any sense to me, dr. lynch. i'm really disappointed to hear this kind of stuff. i want your solution to these problems and i think it -- it goes down to not having enough control locally. mr. hernandez, let me ask you a quick question before i'm out of time. ms. cliffords hr question, what can you do about that? >> thank you, mr. chairman. i would tell you, mr. chairman to acknowledge to the subcommittee that we do have a complex hr system which is comprised of two different --

>> what have you done in the last year to change that? >> we have trained the hr professionals, the credentialers and leaders of the administration to understand the hiring process and the roles and responsibilities -- >> they changed that process in the last year to make it simpler? >> sir, we are looking -- >> you have not then? that's a no? you have not changed the process in the last year to make it simpler. >> we have, mr. chairman. >> what have you done? >> we have visited the -- >> what have you changed in the process of hiring people in the last year that made it simpler? one thing. >> we have educated the hr community -- >> no what about the process have you changed in the last year to make the hiring easier? >> that's what i'm trying to convey, mr. chairman, that the right hiring authority that we have given to us by choice as well as flexibility that we have

of hiring 38 hybrid occupation is being fully utilized systemwide. i know earlier -- >> i'm out of time i'm sorry. >> thank you mr. chairman. just to follow-up on that line of questioning, i think mr. roork asked the first panel what is a big major thing that's what he was looking for, something big and big change. ms. clifford answered by saying it's human resource. i think this is what the chairman was getting after as well, that there's so many rules that you have to follow that that really slows the process down. to me it's the rules and probably need more human beings in human resources to carry out the task and mission of the amount of people that we need to

hire within the va, which many would say is insurmountable. it's a huge number that we need to hire. so you know, can -- you know can you address -- is there anything underway to evaluate rules that we might have been made 20 -- two decades ago that can be changed rules that can be changed and what we can do to hire more in human resources to get this engine running at a higher speed to hire new professionals within the organization. >> yes, ranking member bradley, there have been numerous engagements at the local level by experts from the national level to provide support in terms of the processes we currently have and i would like to state this because it's very important and perhaps made look like a simple issue but we have

integrated the requirements identification at the local level with the responsibilities of the human resources professionals and hiring managers and people that are responsible for space and equipment and the individuals responsible for the credentialing process where at one time those processes used to be independent and used to operate in silence. we have interestgrated that particular process so we don't have delays that other panel made to the subcommittee earlier. we have proven that in phoenix and in the process as worked in st. louis -- >> okay so you've gotten rid of silos and there's an integrated process where we're speeding up the process. have you had any directive from above to say we need to review the rules within human resources and adding additional personnel and is anything like that under way? >> yes, ma'am i would tell you

the last year of the leading access in scheduling initiative looked at the processes and barriers that we had in the local level as well as hr and national level and we were able to change a lot of vha policies that were identified as barriers in terms of the human resources -- human resources situation that we currently have, we are looking at that particular process in terms of bringing up that to the national level to address that particular situation. we have issues in hr -- >> have you had a specific directive to hire additional people and continue to make changes within the rule process to streamline the whole hiring process? you've had directives? >> we've had guidance issued to the field yes ma'am. >> so dr. lynch in terms of the

testimony from the american poe podiatry association, is there something we need to do legislatively to fix what was -- what they testified in if -- if there's not a need for legislative fix, is there something that the department can do to recognize their growing mission and i think they also testified vis a vis their sal re -- salaries et cetera do we need to fix that legislatively or can that be fixed internally? >> let me first acknowledge that the work that podiatrists do as a vascular surgeon, i have worked closely with podiatrists throughout my career and appreciate the value of their product. there have been several

suggestions that had been provided. one was suggested this morning that va be given the authority to recognize podiatrists as physicians, as cms does, other changes are to our handbooks. but it appears that one of the more significant opportunities may be legislation and we're more than happy to work with the committee to provide the clinical input to the development of any legislation that may bring that forward. >> thank you, i'll yield back. >> thank you mr. chairman. dr. lynch you said something that really struck and it's not on you but what you said there's homeland security issues. and i think what a shame it is that the veteran going to the doctor becomes a homeland security issue. that tells me that you -- that

we have become way too connected in everything that we do with the core of the federal government, when you go to the doctor, you have to have these issues. i can connect with all these people and people's medical records are going everywhere instead of staying within your office. any veteran wasn't worried about russia china, north korea or iran. we need to have a solution to that problem. i'd love to hear a solution. that should not be a concern of the veteran that it's a homeland security issue for them to go to the doctor. >> congressman, i don't disagree with you. i'm as frustrated as you are. >> i'm sure you are. >> i've lived it. i don't know what the solutions are. i agree we need to figure out a

way to streamline the medical facility and not let it get tied up in security issues that actually create more work rather than less work. >> i agree it's the same on dod side with personal experience. you're putting your cat card in a million times a day rather than seeing patients. somebody comes and tell a medical assistant how they injured themselves, they turn their ankle. get an x-ray. haven't seen the doctor yet. i haven't had to plug in three times to make that happen and do that from patient to patient. let us help you help fix this problem by coming up with solutions that we can insist that the v.a. make changes. i know as a practicing physician if you've had to experience that or know the difference, help us come up with the solutions and

demand that we get it done. >> yes, sir. >> thank you. >> thank you. you mentioned the v.a. has already hired 2500 medical professionals and support staff. did i get that right? >> 2600. >> were all of those new positions or were some of those staff hired to fill existing vacancies? >> to my knowledge those were new positions. new positions. >> okay. with the resources the choice act provided will the v.a. be able to shorten the wait time it takes to fill the vacancies at the v.a.? >> i am confident they are. i think mr. hernandez implied earlier that human resources had begun looking at their process. it has in the past within a

serial process. it needs to be parallel. it can be complex but it need to be simplified. in certain cases it requires staffing to organizational charts. it involves communication. it involves preparation. this is where the clinical staff does need to get involved to further the efficiency of the prosays that we currently have. it's not efficient. it takes too long. i think we know how to change it. i think we begun to implement changes. we need to go further. >> another provision was the increase of 1500 gme slots. i understand that the first round of residency have already been awarded. >> yes, sir.

>> the v.a. is moving forward with the second round. >> yes, sir. >> will expanding the number of residencies improve the pool of candidates for the vacancies at the v.a.? >> absolutely. two stand points. number one i think v.a. has a unique vant over the private sector. currently we have over 4,000 residents and medical students that rotate through our v.a. we have nurses as well. these are all potential employees. we have first chance at evaluating those individuals. we just need to be able to efficiently move to hire them. what the choice act did was to give us more positions and primary care and mental health in rural areas and in areas where there is not access to care. the goal will be to train people in communities where they may go back to practice.

v.a. once again has the opportunity to say let's try to look for the best and hire them for the v.a. let's do it efficiently. >> i did get a call from a young doctor and express extreme frustration at not being communicated with. this person's applied for a vacancy at the l.a. v.a. hospital. i'm beginning to understand what may underlie this frustration. what do we need to do to breakthrough this inefficiency? you have a plan -- have you pinpointed where the bottlenecks are? >> the bottlenecks are the fact that we don't move fast enough and we don't give people

commitment soon enough. i was talking to mr. hernandez before the subcommittee hearing and we have mechanisms in place where we can offer a job a year advance of the completion of their program. that means we can identify the people we want. we can offer them the job. the only condition is that they have to complete their training. otherwise, we have an opportunity to take advantage of this educational training programs that we have. we haven't been doing it but we need to. do you want to comment briefly on how we can begin to recruit and get these people sooner? >> thank you. going back to my original point is taking advantage of the flexibilities we have on title 38 hybrids. we can engage in early conversations with the residents so we can get their commitments with the condition that once they complete their traping

program we'll be able to convert it to permanent employees for the organization. >> what about people who have trained and certified and planning for vacancies? >> i would tell you we have a very aggressive national recruitment program. i would like to know a little bit about that particular individual. we have dedicated staff that deal with those individuals and working through the entire -- >> i'll be happy to furnish it. >> i would love to have it. >> it's funny that they're solving the problem but your guy can't get a job. dr. abraham.

we are under the gun, so to speak, as much as the v.a. is and we understand. if we have a computer system in the v.a. facility that the record can't move computer to computer then we do have a problem. i'm sure they can and the reason that they don't is a question i do have is why can't that computer travel with the patient or just travel from room to room as the patient travels. just boot that record to another facility.

in the ratio that the ams was able to with their certification, is there a disparity and if so why? >> i take it seriously. it's the opportunity to find more health care for the v.a. and the veterans. i will take it for the record to go back and find out a little more information about that and what has happened in the past. >> i would appreciate if you would send that to me or just a follow up. >> absolutely. >> the first question. >> i share your frustration. i've been there. >> we're past alexander graham

bell and have some pretty good computers these days. >> i grew up in an era where the phones were still dial and you had party lines which was interesting. >> i was also there. >> i can carry a phone in my pocket now. we need to figure out how to harness computers to work for us and not create obstacles for us. >> i appreciate that. my request is that you please look into that. it shouldn't be that hard with the computer systems we have now. i yield back. >> thank you. anyone have any other questions? >> i wanted to make one final comment before we close here. i just want to say i know the employees within the v.a. in human services and you mr. hernandez are working very hard every day. mrs. clifford testified