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and then the white house news briefing and then recent data security breaches at banks and retailers. a hearing today looked at staffing shortages at veterans affairs hospitals. witnesses representing va doctors and nurses talked about the need for more medical professionals. this house veterans affairs subcommittee hearing is two hours. this subcommittee will come

to order. before we begin, i would like to ask for unanimous consent for my friend and colleague from pennsylvania to sit in on today's hearings. without objection, so ordered. thank you for joining us today for today's subcommittee hearing, overcoming barriers to more efficient and effective va staffing. as a physician who worked at fee for service at the iran mountain va department of veterans affairs medical center for about 20 years i know how privileged it can be to care for veterans on a daily basis. regardless of how fulfilling va employment often is, the department's ability to effectively and efficiently recruit and retain qualified

medical professionals it to treat veterans is seriously fractured. for example, in my district at the outpatient clinic, it has not had a physician on staff for at least two years. va has attributed that to the difficulty of recruiting physicians in rural areas. and while i understand that difficulty i think va's overtly over hiring bureaucratic process contributes to the inability to recruit a position for years running. the sioux st. marie was unable to post a position directly. instead, they are filtered through a human resource office in milwaukee wisconsin, several hours away in another state. and my understanding, all job

postings are run through this one office in milwaukee. despite repeated assurances that the department was actively recruiting for the position in sioux st. marie, i have not seen an advertisement except for a blurb on that hospital website leaving me to wonder whether they know what it is supposed to look like. as important as effective recruitment is, retention of employees is critical. according to the 2014 best places to work survey the number of va employees resigning has risen every year since 2009. it's not hard to see why. the survey results ranked 18 of 19 large agencies overall. 18 of 19 in effective

leadership. 19 of the 19 in pay with the department's overall score last year being the lowest va has received since the report was first published in 2003, when a va center is inadequately staffed or make as decision to leave the va, our veterans lose out. the growing physician shortage is causing the marketplace to be more and more competitive with the association of american medical colleges projecting a 91,000 physician shortfall by 2025 if the va 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

va'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, but leading the efforts to make the va 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 va 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 va staffing.

section 301 of the veterans access care and accountability act signed by the president last year mandated the va 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 va 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 va 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 va 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 va issues. ventura county is home to more than 47,000 veterans and our local cboc 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 cboc has doubled and the va 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 ventura can county are ones that can be found across the va 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 va 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, va 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 va boston health care system and i'm here as the immediate past president of nova. nova is a professional organization for registered nurses employed by the va. 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 va 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 application system. namely usa jobs that va uses for hiring staff. we are facing a shortage of corporate experience. insufficient 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 non va 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. potentially impacting the recruitment of future hires who

flock to these programs. the nurse practitioner residency program is a pilot and 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. ongoing support for tuition reimbursement alone tuition programs will help nurses with the cost of education if they work for va 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, license sur 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 va facilities by improving wait times and access of care to all veterans. va employs over 90,000 nursing personnel, which is 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 heroes. 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 human resources across the nation will go a long way towards correcting the challenges we face with

staffing. nova once again thank you for the opportunity to testify and i would be pleased to answer any questions from the committee. >> thank you very much, miss clifford. doctor spagnola, please go ahead. >> mr. chairman, we have submitted a written testimony. i will ask that that be entered into the record. 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 va, and i'm here also as the president of the national association of va physicians in dennis, usually referred to as nava. the national association of va physicians in dennis is a 501-c

4 nonprofit 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 nava's celebration of it is 40th year. nava believes the key means of enhancing care of veterans is by employing the best physicians in dennis. we believe 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've had the opportunity to meet nearly all of the secretaries of the va over the last 40 years get to know some of them fairly 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. men and women who want to help improve veterans care. in the late 1960s and '70s nearly all va medical centers were led by directors who were physicians. today, very few centers have physician directors. 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 health. 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 on years of education and patient care. physicians are being loaded with with additional duties more appropriate. such as typing, follow-up calls,

patient perception 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 va health care system. veterans are seen by non-m.d. 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 process of sedation and providing operating room anesthesia 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, straightforward commonsense questions, such as will i be admitted quickly? is the room clean? is there a bathroom in the room? does the call button work? and 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 there be somebody there to help me? do my doctors and nurses spend time and explain things so i can understand what is happening? unfortunately, patient surveys indicate that none of the above questions are being answered very well in the va. although the crisis last year in

va 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 lung cancer removed or a colonoscopy screening because there may not be sufficient physicians or add quit access to the operating room. timely access must be assured throughout the course of care, not just on the initial visit. va is referred to as a health care system. at 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 and simplification of process across the organization to achieve an order of efficiency and common outcomes. when you've seen one va you've only seen one va. in this regard we have seen no

recent operational structural changes in the va. implemented in local facilities perhaps because the facility leaders have not understood that the changes are mandatory. >> doctor you'll have to make -- clean up your time here. >> i'm one sentence left. >> okay. good. >> hearings like this are important and helpful and the va appreciates 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. >> ranking mean north bradley and distinguished members of the subcommittee, we thank you for examining the issue of overcoming barriers to more

efficient and effective va staffing. veterans should never be short-changed in their medical care. what many do not know is that physician politics along with existing discriminatory and monday nop poe lie zags is keeping excellent physicians out. what is indefensible, they are not denied because of their training, education or experience. these highly skilled physicians are being denied employment solely because of their choice in board certification. this discrimination is going on within the administration. a veteran himself, was a green beret and member of special forces and was picked to lead the treatment of 400 of our special forces. he wanted to work at the va. he applied for seven positions and was never even called back for an interview. this was not due to his training. the doctor graduated from the

university of alabama medical school and is a fellow of the american academy of radiology. the doctor is also an attorney in hospital administration with a focus on waste, fraud and abuse. the only barrier that prevented him from working at a va was his choice insert if in certification. he chose avps. because of that choice, he's denied the opportunity to take of his fellow veterans. we're asking to cease the discrimination. behind the discrimination is that most people do not understand what board certification is. it's a choice. and an indicator that a practitioner has demonstrated their skills in their chosen facility. there's three agencies. there's the american board of physician specialties and the

largest of the three is made up of 24 individual specialty bodies making everybody believe that they are all different entities. this structure has hidden the monday nop monopoly that has been established. it's the only one of the three to have received an independent of a firm mags of the high standards of the exams through an exhaustive review process. since 1994, avps has approached the department regarding these discriminatory staffing issues. each time they respond that they have no mans to recognize anyone else. in 2011, they returned to the administration to stop the discrimination and further explain that we were part of the current standard of certification. they refuse to see the issues. all of these discussions led by former secretaries of health

along with dr. karen sanders, all board certified by the very same organization keeping avps and other highly skilled physicians out. what is most confusing is under the gi bill, avps has been reviewed and approved but yet they stated to us that it does not mean they have to accept it. the va reimburses for board certification but will not recognize it for hiring or promotion. the board certificateion is not a rermt requirement. according to usa jobs there are over 1,000 physician positions which discriminate limiting the ability to fill much needed positions. only few hospitals recognize avps and have hired them to fill their needs. the kansas city va is an example of providing a higher level of care. some, also, have hired these

avps positions but there's a hostile work environment and openly discriminates against them. many are not here today because they fear retribution or loss of their jobs. avp wishes to contribute to solutions to ensure that veterans receive the highest quality of career. a director from the office of the secretary of va needs to have policies in place that clearly defines board certification. job listings we also ask that a quarter reporting structure be developed and the denial and hiring of physicians in all applicant boards being identified and having identified individuals accountable for this oversight all done in a similar manner as corporations are to ensure minority hiring and this will provide local hospitals accountable. thank you again for this

opportunity. the avps looks forward to working with you to improve hiring practices and end the discrimination. most importantly, our veterans health safety and care must be placed before physician politics and the eeggos of a few. it's what they deserve. >> thank you mr. morris. mr. silva, you're up next. >> on behalf of the association, we appreciate the invitation to provide this testimony before you today. the p.a. relationship has a unique relationship with the veterans. it came into existence in the 1960s due to the shortage of primary care physicians in the united states. the va was the first employer of the p.a. and is the largest single employer of p.a.s in this

country. these p.a.s 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 corpsman. the oig report of january of 2015, conducted a determination with the large staffing shortages as required by the veterans choice act. oig determined the pas 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 workforce will result in approximately loss of 1.15 million veteran eligible patient care appointments.

next 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 p.a. positions and for retaining an optimal p.a. workforce. they are setting goals to hire only physicians and nurses as they interpret the law as to not including the p.a. workforce. some facilities are not posting for vas at all under the veterans choice act. of the total postings nationallily 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 discrepancy in salary benefits and education debt programs continues to be a recruiting and retention

barrier. there are three types of providers within the va that provide direct patient care. physicians, physician assistants and nurse practitioners. by virtue of being a nurse, mandated under the yearly rn low kalt low kalt pay scale. pas fall under specialty races. however, this is not mandated yearly. some have not performed a special salary survey for 11 years. 88 va facilities report they cannot hire vas because they cannot compete with the private pay secretary. sector. the secretary can convert to covered physicians and pay them pursuant to public law. however, the va has refused to review these steps to solve the problems for p.a.s. the recommendation is congress should legislate a mandate to include p.a.s and the nurse

locality basis testimony. 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 seeking to become nurse practitioners, receiving scholarship awards totalling over $12 million. the recommendation is that the va must announce and applicants are away of the education debt reduction loan forgiveness. moving through the process for accountability nationally since this is not a facility fund but a va-funded program. next is the independent care technician the itc program also known as the grow your own program. oif returning veterans to include scholarships, the mandate that the va should appoint p.a. ict director to

coordinate the assistance necessary to be a liaison so these corpsmen and medics can become p.a.s. in conclusion, as you strive to assure that veterans received timely access to quality health care and demand more accountability into the va health care system we urge the committee to review the role of the p.a. profession and take immediate steps to address the current problems on a national level and not leave it to the oig report that shows the p.a. position moving up the list. the p.a. profession was born from the military and we need to continue that special relationship. on behalf of the entire membership of the veterans affairs physician assistant 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, mrs. silva. >> yes. >> dr. salvo. >> ranking member brownly and members of the subcommittee, i welcome and appreciate the opportunity to testify on behalf of the american poed at trick medical association. i commend the subcommittee to effectively and efficient low recruit and retain qualified medical professionals and improve access to quality health care in the v.a. i can neb andam a practicing podiatrist and before you representing apma and the podiatric medical profession. i bring with me firsthand experience and knowledge of hiring practices within va and knowledge of the widespread

disparity between podiatric physicians and other physicians. when the qualifications for podiatry were adopted in the 1960s, i was not yet born. back then, residencies were few and not required. today, there are mandated standardized comprehensive three-year medicine and surgery residencies to satisfy all of our graduates. each requiring completion of a broad curriculum, equitable to medical residency training. today's podiatrists serve in leadership roles in those

institutions. many of my colleagues have full admitting privileges. the competency skill and scope of today's podiatric physicians has certainly grown from the podiatrists that practiced before i was born. because of this, cms recognizes the physicians and tri-care recognizes as licensed independent practitioners. that's twu today's podiatrist. veterans plagued by psycho social issues are ailing have co-morbid disease compared to their nonveteran counterparts. these patients increase the burden of diabetic foot ulcers and amputations and it's documented in my testimony, almost 2 million veterans are at risk of amputation. this is my patient population. the veteran population is far

more complex to treat than patients in the private sector as a whole. one of our major missions is am tu precipitation prevention and limb salvation. as part of the team we manage patients within our scope of practice and we assume the same clinical, surge jal and administrative responsibilities as any other unsupervised and medical specialty. despite this equality and work responsibility, there exists a marked disparity and pay and recognition as podiatrists in the va. the majority of the new hires will separate from the va within five years. i am speaking to you from personal experience as 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 va 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 38 in the physician and dentist pay ban 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, m.d. five years ago this was made a top priority. since then we have alerted to the va our knowledge of this issue and secretary petzel

recently received acknowledgement of the need of a legislative solution to address this issue. in closing, i would like to state that oftentimes we find that the simplest solution is the best. i come before this committee today to respectfully request that congress help the va and it is patients by passing legislation to recognize podiatric physicians in the pay band. we believe that simply changing the law to recognize podiatry, both for the advancements that we have made to our profession and for the contribution that we make for our veteran population will improve the problems. mr. chairman and members of the subcommittee, thank you for this opportunity. this concludes my testimony and i'm available for questions. >> thank you dr. salvo. i appreciate it. i'll yield myself five minutes

for questions. boy, there's a lot of questions that i could 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 permanent here. how long does the average hiring process take? how long is that time and talk more about the difficulty in getting people because they take a job somewhere else while the process is ongoing. >> it's pretty variable. it can go anywhere from two to six months in some places. it's a complex process. it has to get posted on usa jobs and put in the proper format 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 that we have such as

equip, which is the background check. >> the least amount of time is two months? >> i think two months would be considered a good hire, a quick hire. >> i know in the private sector if you apply for a job it doesn't take two months. they get hired in the private sector at the local hospital, i mean in my experience, do you have any experience with numbers on the private sector? >> i don't have any numbers but i do know that that's what we have from some of our candidates and it will come to the point where they say we have another job offer, how quickly can you tell me whether or not i can have it? because they probably haven't even given notice to their other job so it's another month before we get them in the door. >> dr. spagnola can you comment on that on the physician side of things? i know there's a lot of trouble with the qualifications or making sure that the person'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 a year to recruit a physician. i've heard them taking even longer. i also run the respiratory care department and it's usually a year before we can hire a therapist to get through all the processes and finally get them in working with hr is near impossible. >> so this is all done through the hr department and physician hires as well? >> it's more than just the hr. you have to get approved by different committees and chairman and hospital directors and then goes back and forth. it just takes forever. >> dr. salvo, at the va i worked

at, the podiatrist was the busiest in the surgery clinic. he had a hard time keeping up there long enough to do all of the work that he had to do. what's the difference? the payment? are they not paid as physicians then? can you explain that to me a little more? >> podiatry 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 sort of explain why it doesn't recruit, right? mr. silva, do you have anything to add on that recruitment and difficulty in hiring question? >> i would agree it does take a

long time, it takes about six weeks on the private sector max where the va system it could take up to six months. >> could you expand a little bit about your -- you know my concern when i worked at the va was the fact that doctors weren't involved with making the decisions in the departments that actually involved how the patient care is delivered. they were sort of told what to do by the administration and then 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 yeah. we need to empower the physicians in the facilities i think if you took people in every va facility, you took a dozen people who really knew what was going on, you could find out very quickly what was working and what wasn't working. you need to empower some of the nurses and the physicians that

get some real input on how to become more efficient and how to provide better care. that could be done very quickly. >> thank you. i'm out of time and i'll yield to miss brownley. >> thank you, mr. chairman. i know that the secretary of the v.a. 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 rural-based organization to a principle-based organization and it sounds to me, based on the longevity of hiring people within the va it is the rules that are -- because there are so many -- is what slows the whole process down that we would be better off following the practices of private industry in terms of hiring.

is that a fair assessment for nurses? >> i would say so. it's very complex, lots of steps in the process from the human resources side and that is what causes -- >> so for the nurses, it's unlike the physicians, the problems are predominantly within the human resources department and their rules hiring doctors you go through human resources but have to go outside of human resources as well? yes and yes? >> i'm not sure i understand the question about going outside. so dr. spagnola testified that for longevity, in terms of hiring physicians it's within the human resources department but they also have to go outside of the human resources and i presume be interviewed by other physicians or other departments and i'm just wondering, for nurses, is the whole hiring process within the human

resources department? >> the nurses -- the nurse manages, the supervisors look at who they want to hire and then done by human resources. >> and the same for physicians? >> i can't tell you how many human resource officers i've seen go by in 40 years. but every new director that came to our facility in the last 40 years has said my number one priority is to fix hr. it's never been fixed. >> mr. spagnola, your testimony was shocking when you said sometimes veterans have medical appointments for care and leave not knowing that they did not see a physician or medical expert of any kind. that's pretty shocking testimony to me. and then when i hear some of the obstacles around a physician

assistant and the shortage there, it's -- i'm not sure what to say except we have a lot of improvements to make. but do you think that's a common occurrence where a veteran comes for an appointment for medical services and never sees a physician? >> was 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 clothes and reception -- patient reception, et cetera, how did that happen? how did those responsibilities become the responsibilities of the physician? is it just 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 that when i was the chief of staff a number of years ago i used to say to our hospital director when he would come in and yell at me and say our docs are not seeing enough patients, there was nobody in the clinics to assist the patient. they have one exam room. they have to get the patient, they have to help get the patient undressed, they have to see the patient and they be they have to write a note usually on the computer nowadays, they have to help the patient get dressed and then escort the patient out of the room. how many times can do you that when you have no other help? you have nobody to help input date data into the computer, you have no one to request drugs into the computer. you're basically doing the physician, the secretary the receptionist. it's very difficult to be

efficient. not that the physicians don't want to be efficient. 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 nationally 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 of 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. figure hey, maybe we better hire

another practitioner and we did. 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 nk those who serve ank those who serve nk those who serve ank 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 hired 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 him 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. but i wanted to serve an underserved area. 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