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>> michigan has not had a physician on staff for at least two years. va has attributed to that, to the difficulty of recruiting physicians in rural areas.

while i understand that difficulty, i think va's overtly bureaucratic hiring process is a significant factor in its facility inability to recruit a physician for multiple years running. the amount of vrmc, the parent facility was unable to post the opening for a physician directly. instead, all job postings are filtered through a human resource office in milwaukee, wisconsin, several hours away in another state. facility job postings are one through the one office in milwaukee. what's more, despite repeated assurances by the officials that the department was actively recruiting for a position -- we call it the sioux in michigan i have yet to see a single advertisement for the position.

va employees retiring or hiring has risen every year since 2009. survey results ranked 18 of 19 large agencies overall, 18 of 19 ineffective leadership. 19 of the 19 in pay with the department's overall score last year as the lowest received since the report was published in 2003. when a va medical --?#

it was last year, secondary mcdonalds 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 with the top five occupations critical, officer, nurse, physical 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 direct directly. the primary care team is down to just one physician, two nurse practitioners, and one physician assistant. in addition, our county veteran services officers is concerned 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 health care has doubled and the va is working hard to meet the growing demand, but we still seem to be in a place that we're not fully staffed. i know that staffing issues facing ventura county are ones that can be found across the va system. i look forward to hearing how va is using the funding provided in the choice act to increase the department's work force 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 the first panel is john clifford president of the nurses organization of veteran affairs, the president of the national association of veterans

affairs physicians and dentists, the president of the veteran affairs physician assistant association, and jeff morris, director of communications, and external affairs for the american board of physician specialties, and dr. nickel, member and employee of the american medical association. ms. clifford we will begin with you. please proceed with your testimony. we allow everybody five minutes. there should be a little light there. when it's red, that means you're up. thanks. >> all right. thank you. chairman, ranking member, and members of the subcommittee. on behalf of the nearly 3,000 members of the nurses organization of veterans affairs, nova, i'd like to thank you for the opportunity to testify on today's important and timely subject, va staffing. as the department of veteran affairs undergoes system wide reorganization to include challenges of implementing the

veterans access choice and accountability act staffing must be at the fore front of the evaluation. i'm joan clifford here as the immediate past president of nova, a professional organization for registered nurses employed by va. no nova's focus is original issues and uniquely qualified to share views on va to efficiently recruit qualified health care professionals to treat our veteran patients. we're in the medical centers, community based outpatient clinics, 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 veterans, and we'd like to offer the following observations. we believe that the underlying issues reside in the lack of a strong infrastructure for human resources, insufficient nursing

education opportunities, and the complex application system mainly usa jobs that they use for hiring staff. vha is facing a shortage of corporate experience and inefficient staffing to support the multiple priorities required for hiring health care professionals. the complex hiring process with systems that do not interface lead to extended waits for job offers. at times this puts va back in the hunt for qualified candidates. limited knowledge of direct hiring process for registered nurses results in delays and policies for retention in centers centers contribute to delays. reclassification and downgrades of some occupations like surgical technicians who are brought in as a gf 7 level and downgraded to 5 are making it impossible to competitively retain and recruit. a lack of knowledge on how to

maximize locality pay log has resulted in inconsistent application of the law an obstacle to hiring and retention. nova asks the ceiling be increased to prevent depression between the grades in order to remain competitive. ensuring an infrastructure to sustain programs that producing nursing graduates who honor and respect the programs is vital. the office supported a wonderful rn residency program across some vas, but funds are limited. potentially impacting the recruitment of future hires who flock to the programs. the nurse practitioner residency program is currently a pilot requiring continued funding to pay for residents' stipends and infrastructure. nova believes it's a good investment as hiring pragse inging practitioners increases service and care nationwide. loan forgiveness programs help nurses defray the cost of education, if they work for vha

and support the va nursing economic partnerships is needed. an area of concern is the use of advance the practice nurses, which at this time is subject to state laws in which the facility is located. vha advocated full practice authority which results in all advanced practice registered nurses employed by the va to function to the full extent of the licensure and training regardless of the state in which they live and work. legislation has been introduced hr 1247, improving veterans access to care act of 2015 which is the model already practiced by the department of defense, health service, and public health service systems. nova together with other nursing organizations are calling on congress to support this legislation. this begins to address critical needs within facilities by improving wait times and access of care to all veterans. va employees over 90,000 nursing personnel, a third of the health

care work force. nova believes there's no greater times to have representatives at the table as va reorganizing the way it provides care and services to america's heros. improvements and careful review of the process of downgrades across va, increased training and locality pay law, revising the cap on the pay schedule to eliminate complexion and establish a more user friendly p lily application process goes a long way towards correcting the challenges vha faces with staffing. we thank you for the opportunity to testify and pleased to answer any questions from the committee. >> thank you very much ms. clifford. doctor, please, go ahead. >> mr. chairman, we've submitted a written testimony, and i would ask if you have that enter into the record, i'll try to keep my few comments here fairly brief. thank you for having us here,

and thank you to the distinguished members of the committee for having us here. we certainly appreciate it. i'm here as a practicing physician with more than four decades with the va, and i'm here also as the president of the national association of va physicians and dentists usually referred to as napd. i'm a veteran, serving two years of active duty in the united states public health service. the national association of va physicians and dentists is a 501c nonprofit organization committed to improving the system and ensuring the doctor-patient relationship is maintained and strengthened. i appear today in pursuit of that purpose. this year is napds 40 th year. we believe key means of enhance enhancing veterans is to employ the best physicians and

dentists. it is essential for physicians to be involved in decisions requiring delivery and quality of health care. during my many years with the va i witnessed if changes of the va. some good, some not so good. i've had the opportunity to meet nearly all the secretaries of the va over the last 40 years. get to know several of them very well. a few i've seen as patients. i believe all of these individuals have been good people and all of the best intentions. i'm sure secretary mcdonald who i also met with also has good intentions. notwithstanding good intentions of the good people, however, the role of the physician within the system as a leader of medical care has greatly diminished over this same period. today, most physicians and dentists feel like their opinions are neither helpful nor requested. at many centers, physicians and dentists are no longer even

considered professionals, but referred to, simply, as workers. these observations come from the members, va doctors dentists, and men and women who want to help improve veterans' care. in the late 19 60s and 70s, centers were led by directors who were physicians. today, very few centers have physician directors. the position called the va under secretary of health was known as the chief medical director. at the time, there was a direct line from the chief of staff at the medical center to the chief medical director. issues of the delivery and quality of medical care were raised and addressed by medical professionals. today, chiefs of staffs report to a clinical specialist at the centers. in more recent times there's been a strong movement to eliminate the need to have a

physician in the role of undersecretary of health. would it be wise or possible to run the defense department without generals and admirals in leadership positions? we are not saying there's no role for nonphysicians in the administration of hospitals or medical care but sayings, however, medical judgment should be based on years of observation and patient care. physicians are bloated with additional duties more appropriate for non-physicians like typing, follow-up calls patient reception and preparation. similarly, it's not cost saving nor first time to have physicians routinely escort parties from waiting rooms to examine rooms and having them help patients get undressed. there is a growing trend to add nonphysicians and a concern that a veteran is never seen or treated by a physician while in the va health care system. veterans are seen by nonmd doctors without ever realizing they have not seen a medical

doctor. we believe this is dangerous for patients, family and it may also raise ethical issues. the va's currently considering a change in its nursing handbook under the proposed handbook, no longer physician oversight for the process of sedation in providing operation room anesthesia by registered nurse. the proposed change provides no guarantee this provides safer patient care. additionally, lpns with little to no psychiatric experience take the place of psychiatrists during counselling and assessments in some departments. 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 hear simple straightforward 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, is there someone there to help me? do my doctors and nurses spend time explaining things so that 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 focused on access to care this is 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 removedcolin screening because there's not accurate number of physicians or an operating room.

this is thecourse of care not just the initial visit. it's best facilities operating under a common umbrella. there's standards at every facility that appear to be different. there must be unification, simpleness to achieve efficiency and common outcomes. when you see one va, you've only seen one. in this regard we've seen no recent operational structural changes to increase the physicians in the va. changes announced by the current secretary are not consistently implemented in local facilities perhaps because the leaders have not understood that these changes are mandatory. >> doctor you have to like, clean up your time here. >> i'm one sentence left. >> okay, good. >> 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 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 sub committee. we thank you for examining the issue of overcoming barriers to more efficient and effective staffing. veterans should never be shortchanged in medical care. recruiting qualified and skilled physicians to work within the health system is needed now more than ever. what many do not know is that physician politics as well as existing discriminatory practices of the american board of medical specialties are keeping excellent physicians out. what is indefensible is that they are not denied because of their training, education, or

experience. these highly skilled physicians are denied employment boiesased on choice of board certification. there's discrimination going on in the administration. a veteran himself, a green beret beret, member of special forces, leading medical treatment of 400 of the special forces. he wanted to work at the va applied for seven physicians and was never called for arian interview. this was not due to the training. he graduated from the university of alabama medical school, residency training in radiation oncology oncology, and in addition to the medical medical medical profession, he has an attorney. the only thing that prevented him from working was his choice in certification. he chose each position required ab certification only. he chose adps. because of the choice he's

denied the opportunity to take care of his fellow veterans. we are here to ask the va to cease discrimination of physicians, and behind discrimination is the fact people do not understand what board certifyication is a choice, and indicator that they mastered the skills in the chosen specialty. currently, there's three recognized multicertifying body bodies, specialties, and american board of physician specialties. abms largest of the three, made up of 24 bodies making many believe they are all different entities, and this structure hid a monopoly that they established, making many believe they are the only ones. ab a abms is not the only. there are others that exceed the standards. in fact, this is the only one of the three to have received an independent affirmation of the

high standards of the exams through a review process. since 1994 they have approached the department regarding these discriminatory staffing issues creating barriers to hiring field physicians. each time they protect the monopoly and respond they had no plans to recognize anyone else. in 2011, they returned to the administration to stop the discrimination and further explain we were a part of the current standard of certification. they again refused to see the issues. all these discussions were led by undersecretaries of health and dr. karen sanders, all board certified by the same organization keeping abms and other skill physicians out. urn the g.i. bill, they reviewed and approved by the u.s. department of veterans affairs yet, they stated to us that it does not mean they have to accept it. the va reimburses board

certification, but will not recognize it for hiring or promotion. board certification is not a requirement, that is left to the discretion of the local v.a. however, this has not been the case. according to the usa jobs, there's over 1,000 open physician positions. most discriminate by requiring abms/ama only, leaveing the need to fill many positions. kansas city va sets a good example of this providing a higher level of care.physicians but they create a hostile work environment and ultimately discriminates them. they are not here today because they feared loss of their jobs. we wish to contribute to solutions to ensure veterans receive the highest quality of care. director from the office of the va needs to be in place that creates antidiscrimination policy defines board

certification, and goes beyond acceptance of acceptance, and job listings should not require one board over another, and a quarter reporting structure be developed with institutions report on applications received, hiring physicians, and boards identified identifying individuals accountable for the oversight. all done in the similar manner as corporations are required to identify hirings. this allows for a transparent process and centers will be held accountable. thank you, again for the opportunity. we look forward to working with you to improve hiring practices in the discrimination. most importantly our veterans' health, safety, and care must be placed before physician poll sicks and egos of a few. it is what they deserve. >> thank you, mr. morris. mr. silva you're up next. >> on behalf of the entire

membership association we appreciate the invitation to provide testimony before you today. the profession has a special unique relationship with veterans. the pa profession came in existence in the 1960s. due to the shortage of the physicians in the united states the first graduates of the duke university program in 1967 were four navy hospital foreman. it's the single largest employer of pa's in the country with 2,000 working in the va system. they provide cost effective high quality health care working in hundreds of medical centers and outpatient clinics. a quarter of all primary care patients are treated and seen by p.a. 32% are veterans including myself. i'm a former navy hospital foreman. the report of january 2015 conducts a determination of the va occupations with the largest

staffing shortages required by the veterans choice act. they determined edd vas were critical on the list compared to all others. according to the work force planning of 2015, next year in 2016 37% of pas are eligible to retire. this work force will result in approximately loss of 1.15 million veteran eligible patient care appointments, next year 2014 pa had the biggest loss rate more than any other occupation deemed difficult to recruit and retain. utilizing the act of 2015 va reports no plans to recruit new pa positions, setting goals to hire physicians and nurses as not including the p.a. work force. some are not posting for them at

all under the veterans choice act. of the total postings national for p.a.s, there's only 83. this eliminated 50 % of applicants, and they do not pose for pas, there's a message that veterans should not and cannot apply even though military pas have higher levels of experience in front line battlefield care. the discrepancy between civilians and va is a recruiting barrier. there's three types of providers that provide care. physicians, physician assistants, and nurse practices practitioners practitioners. they are mandated nearly. pas fall under a special salary rate, but this was not mandate

yearly. the work succession plan the facilities report reasons they cannot hire vas because they cannot compete. they can convert and pay them pursuant to the law, but the va refused to follow the steps to resolve problems and the recommendation is congress should legislate and mandate the va under secretary for health include pas. for the education debt reduction program, vapa is concerned that the use of incentives is the discretion of the hiring physical and is not standardized across the system. during 2013, only 44 physician assistants received $319,000 in scholarships. compared to $705 receiving awards totally over $11 million in support of np and np programs.

they must advertise in all va vacancy announcements so applicants are aware of the debt reduction reduction, and move the program application process for accountability nationally since this is not a facility funded, but a va funded program. next would be independent care technician, the itt program known as the grow your own program. to assist returning veterans to have targets partnerships, this shall appoint program directors to coordinate educational assistance necessary to be a liaison so they follow the footsteps to be pas. for recruitment, move all direct patient care to the recruiter work force and in conclusion members, as you strive to assure that veterans receive timely access to quality health care and demand accountability into the va health care system we strongly urge the full committee

to review important roles of the pa profession and ensure the va take immediate steps to address the current problem on a national level and not leave it to the local facilities to address the program as the oig report shows. this profession moves up the list on critical occupation, and this was born from the military and we need to continue the special relationship. on behalf of the membership association, i really appreciate this opportunity to testify before you here today and ask for the help in supporting the nation's veterans. >> thank you. >> yes, sir. >> chairman and ranking member and members of the subcommittee i appreciate and welcome the opportunity to speak on behalf of the medical association. i commend the subcommittee for its focus to assist and direct the veterans administration to effectively and efficiently recruit and retain qualified

medical professionals and improve access to quality health care in the va. i'm a member and director of young physicians at apma. i'm also a practicing pediatrist maintaining without compensation va appointment. i'm before you today representing apma and the medical profession. while i do not represent va, bring with me firsthand experience and knowledge of hiring practices within va and knowledge of the widespread disparity between physicians and other va physicians. mr. chairman, when the va's qualification standards were adopted in 19 76 i was not yet born. this contrasted with physician providers at the time and far cry from medicine as it is today. unlike 39 years ago current

education is vastly expand, and then residencies were few and not required. toad, they are comprehensive three year surgery residencies to satisfy all graduates with 77 positions held within the va each requiring completion of a broad curriculum e quitble to residency train ingtraining. they are appointed as medical staff, and many serve in leadership roles within the institutions. many of my dreegs have full admitting privileges responsible for emergency and trauma calls. the skill and scope of today's physicians has grown from the practices before i was born. because of this, they recognize today's physicians and tricare recognizes us as licensed practitioners. that's today's pediatrist. we have to understand today's

veteran. veteran patients often plagued by issues are ailing have more core morbid disease, and poor health status compared to their non-veteran counter parts. the patients increase burden of diabetic foot ulcers and amputations and documented in the written step testimony almost 2 million veterans are at risk of amputation with underlying diabetes and nonheeling foot ulcers. the veteran population is far more complex to treat than patients in the private sector as a whole. we provide a cost savings to va and role of the veteran quality of life. as part of the disciplinary team pediatrists manage parties in the scope of practice and include the same administrative

responsibilities as any other unsupervised specialty. despite work responsibility, there exists a marked disparity in pay and recognition of physicians in the va. the authority has minimal experience and lack board certification. the majority of the new hires separate from the va within five years. i'm speaking to you from personal experiences i am one of the majority. i entered the va without board certification with less than five years experience and gained experience earned board certification, and 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 parties in my local facility without compensation i testify to the profound disparity. legislative proposals to amend

title 38 in the physician and dentist pay band has been submitted by the director of services annually for the last ten years and these proposals have been denied every single year. as for several requests for a fix, dispete written letters of support. five years ago, apma leadership made this issue a top priority. since then we've alerted the va to the knowledge of the issue, and in response, former undersecretary created a working group with whom we participated in several meetings and recently received acknowledgement of the need of a legislative solution to address the issue. in closing, i would like to state that oftentimes we find that the simplest solution is the best. i come before the committee today to respectfully request that congress help the va and patients by passing legislation to recognize physicians and

surgeons in the physician and dentist pay ban and changing the law to recognize pe die try for the advancements made and contributions made in the care of the veteran population will resolve recruitment and retention problems for the va and veterans. mr. chairman members of the subcommittee, thank you, again rs for the opportunity. this concludes my testimony. i'm available for questions. 6 6>> i have to start with ms. clifford clifford, bringing up something that is pertinent here. how long is the average hiring process take? how long is that time? talk a little more about the difficulty and getting people because they take a job

somewhere else while the process is ongoing. >> right. it's variable and goes anywhere from two to six months or more in some places. it's a very complex process. first, most places it'll 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 format to be posted on that, and then we wait and get the certification of who applied to the position, and then they have to go through all the other processes we have like equip which is the background check -- >> so two to six months in order to get hired? the least amount of time is two months? >> two months would be considered a good hire, a quick hire. >> in the private sector it does not take two months. they are hired at the local hospital, i mean, in my experience do you have any

experience with numbers on the private sector? >> that is krengt.correct. it comes to the point where candidates say i have another job offer you know, how quickly can you tell me whether or not i can have it? they probably have to give notice to the other job so it's another month to make the job over to get them in the door. >> can you comment on the same question on the physician side of things? there's a lot of trouble with the qualifications or making sure the person's background is right and getting that right, but how does that process work in the va from your experience? >> takes up to a year to recruit a physician. i heard of it taking longer. i also run the care department that is usually a year before we can hire a therapist to get through all the processes and

get them in. working with hr is near impossible. >> this is done through the hr department then? the physician hires as well? >> well, the hl -- it's more than just hr. it is approved by committees, chairman, and hospital directors, and it goes back and forth. it just takes forever. >> now doctor you mentioned the pediatrist problem in the va, and the va that i worked at, the pediatrist was one of the busiest providers in surgery clinic and had a hard time keeping the pediatrist there long enough to do all the work he had to do. what's the the difference in pay? not paid as physicians? explain that to me more. >> it is on a different pay

scale. unofficially, i'm 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. >> well that would explain why it's difficult to recruit. [ laughter ] right? do you have anything to add on that recruitment and difficulty in hiring question? >> i would agree. it takes a long time takes six weeks on the private sector max. whereas in the va system it's up to six months. >> expand about your you know, my concern about -- when i worked at the va was the fact that you know, doctors were not involved with the making the decisions and departments that actually involves how the patient care is delivered.

you were 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? 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 in the facility to know what was really going on, you find out quickly what was working and what was not working. you need to empower some of the nurses. you need to empower the physicians. 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. i yield. >> thank you, mr. chairman. i know that the secretary of the va is really trying to make transformation at the va and i 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 longevity of hiring people within the va, it is the rules that our -- 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 for nurses? >> i would say so. there's a lot -- it's very complex, a lot of steps in the process from the human resource side, and that's what causes a lot of the problems. >> so, for the nurses, unlike the physicians, the problems are predominantly within the human resources department and their rules, hiring doctors, you go through human resources but you have to go outside of human

resources as well? >> yes. >> yes. >> yep. >> yes, and yes? >> i don't know that i understand the question of going outside. >> so, doctor testifying -- when longevity for hiring inside the human resources department, but they have to go outside 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 nurse manages and supervisors make the decision of who to hire. captions copyright national cable satellite corp. 2008 captioning performed by vitac