REORGANIZATION OF THE VETERANS HEALTH
ADMINISTRATION
THURSDAY, APRIL 6, 1995
House of Representatives,
Subcommittee on Hospitals and Health Care,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to call, at 9:01 a.m., in room 334, Cannon
House Office Building, Hon. Tim Hutchinson (chairman of the subcommittee) presiding.
Present: Representatives Hutchinson, Smith, Bilirakis, Quinn, Edwards,
Tejeda, Gutierrez, Bishop, and Doyle.
OPENING STATEMENT OF CHAIRMAN HUTCHINSON
STATEMENT OF WILLIAM J. SCHULER, PRESIDENT, CEO, PORTSMOUTH REGIONAL HOSPITAL, COLUMBIA HCA
STATEMENT OF DANIEL H. WINSHIP, M.D., DEAN, STRITCH SCHOOL OF MEDICINE, LOYOLA UNIVERSITY OF CHICAGO
STATEMENT OF DANIEL SPAGNOLO, M.D., PRESIDENT, NATIONAL ASSOCIATION OF VA PHYSICIANS AND DENTISTS
STATEMENT OF LYNNA SMITH, PRESIDENT, NURSES ORGANIZATION OF THE VA
STATEMENT OF LOUIS JASMINE, NATIONAL PRESIDENT, NATIONAL FEDERATION OF FEDERAL EMPLOYEES
STATEMENT OF DAVID GORMAN, DEPUTY DIRECTOR, DISABLED AMERICAN VETERANS
STATEMENT OF TERRY GRANDISON, ASSOCIATE LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA
OPENING STATEMENT OF CHAIRMAN
HUTCHINSON
Mr. Hutchinson. This meeting will come to order--wherever the gavel
is--I will take an opportunity to bang that gavel when I get one. I would like to take
this opportunity to welcome our distinguished panels of witnesses who are taking time to
testify before our subcommittee this morning. I would also like to thank the leadership of
the American Legion and Vietnam Veterans of America who have submitted written testimony
for this hearing. I look forward to hearing each of your testimony on the Veterans Health
Administration proposed reorganization entitled Vision for Change , a plan to restructure
and decentralize current VA field operations. The proposal seeks to reorganize the current
4-region structure into 22 Veterans Integrated Service networks or VISNs. The primary
focus of the reorganization is to decentralize decision making authority to the field and
to organizationally flatten and remove management layers from central office. The VISN
structure was developed through a rather comprehensive process that included academics,
employees, hands-on managers, and most importantly, those who will be directly affected by
this process, the veterans themselves. I applaud Dr. Kizer for his leadership and his
willingness to consider divergent viewpoints on a very complex and very needed
undertaking.
In today's competitive health care market, our veterans deserve a health
care delivery system that is responsive to their needs, understanding that health care is
driven by local market conditions, I am very supportive of a structure that will afford
maximum management flexibility to those closest to the delivery of health care. In my own
district in northwest Arkansas, it will be very important to my veterans that planning and
budgetary issues be resolved at a level where they can feel that their input is most
meaningful and best understood. Understanding the enormity of this reorganization and the
inherent reluctance of bureaucracies to accept change, I want to extend my cooperation to
you, Dr. Kizer, and to your staff in this effort to focus VA's health care efforts on the
goal of placing patients first.
Over the years this committee has worked on a very bipartisan basis to
ensure that veterans' health care remains a priority. And as Chairman, I want to certainly
recognize the efforts of the Chairman of the full committee, Bob Stump, and all of the
contributions that he has made, as well as the long-time Chairman and now Ranking Minority
Leader on the full committee, Sonny Montgomery, in fostering this climate of
bipartisanship. Unavoidably, I will briefly leave the hearing at 9:45 to testify before
the Joint Economic Committee; and during my absence Mike Bilirakis--and Mr. Bilirakis will
be here a little later--will be chairing the hearing at that time. Now I want to thank
Mike for his willingness to do that. Once again, I welcome each of our witnesses, and I
look forward to each of their testimony.
Mr. Edwards, the ranking member of Texas, is unavoidably detained at the
White House this morning so we will forgive him, recognizing that priority. And so when
Chet gets here, we will give him an opportunity to give an opening statement.
I want to welcome Dr. Kizer, who will be our witness on the first panel.
And, Dr. Kizer, all of your written statement will be included in the record. And we would
ask you to keep your comments to 10 minutes or less so that each member of the
subcommittee will have an opportunity to ask questions.
STATEMENT OF KENNETH W. KIZER, M.D., M.P.H., UNDER SECRETARY FOR HEALTH,
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY NORA EGAN, COORDINATOR OF THE TRANSITION
WORK GROUP; JULE MORAVEC, Ph.D., DIRECTOR OF WESTERN REGION, VETERANS HEALTH
ADMINISTRATION
STATEMENT OF DR. KENNETH W. KIZER
Dr. Kizer. Thank you and good morning, Mr. Chairman and members of the
subcommittee. I am quite pleased to be here this morning to have an opportunity to discuss
my plan to restructure the Veterans Health Administration (VHA). I know how hard you are
working these days, and I appreciate your scheduling this hearing at this time. With me
today at the table are Dr. Jule Moravec, the Associate Chief Medical Director for
Operations, and Nora Egan, Coordinator of the team that has helped prepare the Vision for
Change document that specifies our plan for reorganizing the Veterans Health
Administration.
As you know, copies of the plan, Vision for Change , were sent to the
committee on March 17 of this year.
In brief, this reorganization is designed to improve the delivery of
health care to veterans, to improve the quality of that care, to increase the efficiency
with which we provide it, and to establish accountability for outcomes and bottom-line
results. I should also add that the reorganization plan is designed to retain or continue
those things in the system that are functioning well, as well as to complement our several
other statutory missions, in addition to providing medical care.
Perhaps the first issue that I would comment on this morning is: Why
change the Veterans Health Administration? There are a number of reasons that warrant
pointing out at this time.
First, technological advances, economic factors; the rise of managed
health care; and a variety of other forces all profoundly changing how health care is
delivered in this country. There has been a marked shift away from inpatient care and a
dramatic rise in ambulatory, or outpatient, care. Many complex medical conditions that
previously required hospitalization are now routinely treated at home or in outpatient
settings. This trend toward moving care into ambulatory settings, or at home, is going to
continue for some years to come. Indeed, I believe that it will not be all that long
before the traditional, general, acute-care hospital becomes a large intensive care unit,
taking care of only the sickest or most complicated of patients. Essentially all other
medical care will be provided in ambulatory settings, at home, in hospices, or in various
types of extended-care facilities.
The second reason why we should change the Veterans Health
Administration is that there have been a number of reports in recent years that have
concluded that structural changes--indeed, very fundamental structural changes--are needed
in the system. In the aggregate these reports have consistently found that VA needs to
become more flexible, more customer-focused, more decentralized, and more cost effective.
And finally, for a variety of reasons, there has been a fundamental
reanalysis of how government should function in recent years. The National Performance
Review and other activities are being undertaken to re-invent Government, to minimize
bureaucracy, to reward efficiency and innovation in government, and to empower employees
to make government work better for citizens.
Mr. Chairman, our plan for restructuring the Veterans Health
Administration will position our veterans' health care program to adapt to the
rapidly-changing, larger health care environment that we must function within. It will
improve customer service, and it should certainly improve the efficiency of our operation.
Moving to a few details, the foundation for accomplishing these changes
in the veterans' health care system involves the dissolution of the current hierarchical
central office, regional office and network structure that is currently in effect. In its
place we would create a federation of Veterans Integrated Service Networks supported by a
national headquarters. At this time, the plan calls for 22 of these integrated service
networks with each network including from 5 to 11 medical centers and various other VA
assets. The chart gives you a schematic depiction of what some of these other assets are,
including long-term care facility or medical centers, various clinics, vet centers, et
cetera.
The network boundaries have been established to preserve existing
patient-referral patterns; to include aggregations of patients and facilities that would
be needed to support a continuum of primary, secondary, and tertiary care; and to a lesser
extent, to be consistent with political jurisdictional boundaries such as state lines.
It is envisioned that these networks, or VISNs, will become the basic
budgetary and planning unit for delivery of veterans' health care.
As an integrated system of care, the new VISN structure will emphasize
the pooling of resources, the delivery of outpatient and primary care, partnerships, and
customer service. A premium will be placed on improved patient services, rigorous cost
management, process improvement and outcomes. Emphasis will be placed on the integration
of ambulatory care, with acute and extended inpatient services to provide a coordinated
continuum of care. Redundant administrative structures and processes will be eliminated.
And each layer or process in the new organization will be expected to add value to the
delivery of services in the field.
Each VISN Director will be assisted by a small staff of professional,
technical, and support personnel, the number varying with the size and complexity of the
individual network. Again, on the chart here you can see a schematic of basically how the
VISN will relate to the Office of the Under Secretary and to other components that I will
get to in a moment.
During the transition from where we are--or how we are organized at this
point to the new organization--we will continue to utilize personnel in the existing 4
Regional Offices as Support Service Centers, as you can see on the chart there. Expertise
in areas such as construction management, finance, planning and quality assurance will be
preserved to ensure continuity of operations while the regions dissolve and the VISNs
become operational.
Another structure you see on the chart there is the Management
Assistance Council. This is a formal structure that I feel is important to the functioning
of the organization. We intend to establish the Management Assistance Councils at each
VISN, these will be composed of both internal and external stakeholders, to ensure that
the needs of the patients, the communities, and others, are incorporated into our
decision-making process and that there will be a formal structure by which that input will
be attained.
Let me conclude my comments on field reorganization with some brief
comments on how we will achieve accountability in the more decentralized Veterans Health
Administration system that this reorganization plan would create. Concern about
accountability led us to devote an entire chapter of the plan to performance measurement
and assistance monitoring--although I would add that there was a lot more that could be
said, and that we could have written on that.
The cornerstone of the accountability system will be a performance
contract between each VISN Director and the Under Secretary's Office. Each contract will
cover three general areas: first, the systemwide tasks and needs that all VISNs will be
expected to complete; second, the VISN-specific service delivery and efficiency objectives
directed by Headquarters; and third, VISN-specific objectives developed by VISN
management. Performance contracts will include support of education and research, as well
as our fourth mission, emergency preparedness.
Key areas of focus for the performance measures will be patient
satisfaction, ease of access to care, the quality of care, and efficiency. Performance
measures will focus primarily on outcomes, rather than on processes, and will be selected
to allow for comparison to national and private-sector measures.
In summary, field units and senior managers will be held accountable for
measurable improvements to the veterans' health care system. The resulting efficiencies
should allow the Veterans Health Administration to invest in new ways of providing high
quality, efficient ambulatory, as well as inpatient, care to better meet the needs of our
veterans as well as to better meet their expectations.
Mr. Chairman, I would note that in an effort to move as expeditiously as
possible, we have begun to make preliminary plans for implementing the field
reorganization. These, of course, are subject to compliance with current law and input
that we receive as part of this hearing process. We are establishing a steering committee
to oversee the many activities that will be involved; and we are creating a number of
technically-oriented work groups that will handle detailed actions such as activation of
the VISNs, development of performance measurements, executive performance contracts,
employee education, resource allocation, and a number of other areas. We understand that
the 90 days in session provided to the Congress for review of the plan under the current
law--unless earlier legislative approval is provided--will be completed in late July or
early August of this year, depending upon the recess schedule of the Senate.
Let me conclude my comments with just a brief note on restructuring of
VHA's Central Office.
In order for the field reorganization to be successful, and for the
VISNs to be empowered to make appropriate operational decisions, headquarters must change
its focus from micro-managing operations to the critical role of governing and leading the
system overall. Offices in the future will be organized by function or product line,
whenever possible, rather than in the discipline-specific stovepipe nature that they
currently are organized. Headquarters must focus much greater attention, in the future, on
achieving systemwide quality improvement, information management, cost management, and
strategic planning.
Mr. Chairman, that concludes my general, introductory comments on our
plan to restructure the veterans' health care system. I certainly would be pleased to
answer any questions that you or any other members of the subcommittee have at this time.
[The prepared statement of Dr. Kizer appears on p. 60.]
Mr. Hutchinson. Thank you, Dr. Kizer. And, again, I appreciate your
efforts to address, I think, what all of us recognize as a need for reorganization and
better services at a more local decision-making level.
I have met, as I know you have, with many of the veterans' service
organizations, the veterans groups, and you have included their input in designing this
reorganization. Many of them express concerns about the relative autonomy of the VISN
Directors and were concerned as to what guarantees there might be to ensure that hospital
and VISN Directors would not arbitrarily eliminate specialized services because of the
high cost involved. Could you comment on the need to address that, whether any statutory
language might be needed to ensure and to guarantee the continuation of those specialized
services.
Dr. Kizer. Certainly, sir.
Of course, what really characterizes the veterans' health care system,
indeed the hallmarks of the system, are our specialized services. However, you cannot have
specialized services such as spinal cord injury and blind rehabilitation without having a
full-service complement of health care services to support those. It would really make no
sense for this system, though, to eliminate, to denigrate or to de-emphasize what are our
hallmark programs, and what characterizes us as a system. So, sir, I think that within the
organization there is widespread recognition that these programs deserve special
recognition and that they will continue to require that focus in the future. Yes, while
they are costly and often labor-intensive, and they would not be, quote-unquote,
competitive in the private sector, they are the essence of what the veterans' health care
system is all about.
So, one, I think that denigrating these programs would not be wise for
the system, and I think that our managers recognize how foolish it would be to do
something that would work to the detriment of the system such as undermining these
programs. Second, I would note that while we intend to decentralize, we certainly are not
abandoning our oversight responsibility. We have had this discussion with many of the
veterans' service organizations, as well as others. We recognize the need to develop
performance criteria and other measures that we can use to track these programs in a way
that will not only guarantee their ongoing survival and functioning, but which will really
improve the quality of service that is provided through these programs in the future. And,
third, I guess I would point out that there continue to be considerable provisions already
in the law for Congressional oversight of these programs that require notification of not
only the headquarters, but also Congress, if any such substantive changes are to be
undertaken at the local level. I recognize the concern, and perhaps nervousness, if you
will, that some entities may feel about this change anyway, I think it is very
understandable that they would have some anxieties. I think, if anything, what we hope
will come out of this is a strengthening, not only of the specialized programs, but the
system overall.
Mr. Hutchinson. Thank you, Dr. Kizer.
Mr. Quinn, you are recognized. We will be under the 5-minute rule, and
we will give an opportunity for a second round of questions if so desired. You are
recognized.
Mr. Quinn. Thank you, Mr. Chairman. And thank you, Dr. Kizer, for your
comments. I might mention also that I am a member of the Joint Economic Committee where
Mr. Hutchinson is going to testify so I will leave to hear his testimony. Maybe we would
save some time if we just stay here and traded, Tim, and we could all stay with all of you
this morning.
I read your testimony, Doctor, and appreciate your comments this
morning; and we have a meeting scheduled, I think, over here in the first part of May with
my veterans staff to talk about this and other matters. Just a couple of general
questions: I like the concept, first of all. I think it is a step in the right direction.
Just a question on the MACs, the big MACs as I called them when I read through here, the
Management Assistance Councils: Did I read it correctly that for each VISN there will be a
council to sort of advise? And you know the chart that you listed for the councils did a
pretty good job of including everybody, local officials, state officials, hospital
officials, and so on, and so forth. Do we envision a council for each of the 22 VISNs that
you are talking about?
Dr. Kizer. That is correct, sir.
Mr. Quinn. So some of Tim's concern, which is a concern I shared and the
organizations mentioned to you and to us, about making certain that whether it is
Congressional oversight--which is a little bit removed in Washington, DC from the actual
operations--some of the concerns that the organizations may have could be discussed and
could be reviewed in the council.
Dr. Kizer. Absolutely. Indeed, that is one of the reasons why I am
including this formal structure, which would include representation from the veterans'
service organizations. These MACS would provide a forum where these issues could be
discussed at a very early stage. And if there are problems, they would be brought to the
attention of management and hashed out at that level. But the idea is to provide a formal
forum for stakeholder input to occur at the local level.
Mr. Quinn. And I think as important as the concerns early on would be
that ongoing that you mentioned. I mean, we need to walk before we run with this thing; I
think we would all agree. As the process evolves, there may be additional concerns that
the veterans' organizations--and they are going to need a place to air that. They are
going to need a place to have some feedback and some response, not only by calling their
local Congressmember or whoever it happens to be, but I think that local level of input is
key to all of it. So I will be looking with you at that as it evolves.
Thank you for your answer. There is no question that this is a change,
dramatic change. How much discussion--we are talking about late July, early August as a
possibility to be operating here; you think?
Dr. Kizer. As we have looked at all of the steps that need to be taken
internally, our goal is to have this system fully operational by October 1,
1995--concomitant with the new fiscal year, with the hope that we would be phasing it in
starting in the early fall--i.e, August or September.
Mr. Quinn. Okay. And how much discussion has gone on in the field, I
mean, at local VA Hospitals and some of the other assets that you talk about when you try
to get to these 22 VISNs? Is there communication back and forth with hospital directors
and staff out there already, and how much?
Dr. Kizer. Yes, sir, there has been considerable field involvement. Just
to give you some idea--when we floated some of these concepts out to the field last
November, we got about 1,500 pages of response back from our field facilities. With the
draft versions of the plan that were sent out, we got additional response. The plan has
been discussed in numerous different forums both in the field and in VACO. I do anticipate
also that we will, over the next several months, be making considerable efforts to
actually visit a wide array of these facilities, particularly ones where there may be some
potential problems, to see what we can do to facilitate the process from a headquarters
point of view.
Mr. Quinn. That is a good idea. I was at the Buffalo, NY center this
weekend and talked with our director on Saturday. And I think we are going to be
pleasantly surprised at those out in the field who want to help. And the reaction has been
somewhat positive so far. So thanks for your answers and your comments. I look forward to
working with you.
Dr. Kizer. Thank you. And I would just add also that the response that
we have gotten from the field overall has been very, very positive; they are chomping at
the bit to get going.
Mr. Quinn. Thank you, Dr. Kizer.
Mr. Chairman.
Mr. Hutchinson. Thank you, Jack.
Mr. Tejeda, the gentleman from Texas is recognized.
Mr. Tejeda. Thank you, Mr. Chairman.
Dr. Kizer, I want to commend you for stressing in your testimony the
plan's emphasis on outpatient care and primary care. You know, many Texans, many veterans
living in South Texas, have very little access to ambulatory care; and they have to drive
hundreds of miles to reach some crowded centers. Let me just ask you: What are your
thoughts on the prepared testimony of William Schuler of Columbia HCA, recommending the VA
to develop contractual relationships with private sector health care providers? Would such
a contract be cost effective for the VA?
Dr. Kizer. We would want to look at that and see what the specifics are
within the specific community that was involved. Under the scenario that we have outlined
here, what I would hope our managers would do would be to review the opportunities that
might exist, whether it be contracting with a private provider or using VA assets, or
using an academic affiliate, or contracting with a DoD partner, or whatever; look at the
cost; look at the access; look at the quality of care; look at the needs of the veterans
identified with the system, and a number of other things; and then come up with plans that
would work best to serve the needs in that specific community; and also involving entities
like the management assistance councils.
Mr. Tejeda. Just one other question: How will the new VISN Networks
affect VA medical research carried out at several facilities within one network? Will the
plan have a negative impact on individual VA medical facilities associated with some of
the universities within their--particularly on the medical research aspect of it?
Dr. Kizer. It is hard for me to envision how it would have a negative
impact. I do see the potentialk for some very--potentially--some very positive impacts and
some opportunities, particularly opportunities for our academic partners to look at
service-delivery issues and primary-care issues and some other things which historically
have often been hard for academic institutions to focus on because of the lack of a
partner that has a service-delivery network that would provide those opportunities to do
that type of research. So I see really no negative effects, and a number of potential
positive benefits to this.
Mr. Tejeda. Thank you very much.
Thank you very much, Mr. Chairman.
Mr. Hutchinson. Thank you.
Our good friend from Florida, Mr. Bilirakis, is recognized.
Mr. Bilirakis. Thank you, Mr. Chairman. I, too, want to welcome Dr.
Kizer and his colleagues with him to our hearing.
I have an opening statement and I ask unanimous consent that it be made
part of the record.
Mr. Hutchinson. Without objection.
[The prepared statement of Congressman Bilirakis appears on p. 51.]
Mr. Bilirakis. Thank you, Mr. Chairman.
Dr. Kizer, Mr. Tejeda brought up, of course, the point of research; and
I had not planned to get into that. But his point is well taken. And research, medical
research, is something that has always concerned me that there may not be adequate
coordination, if you will--that may be a lot of duplication of effort in all that. I am
sure that there is in all research. And that concerns me as far as the private sector is
concerned, NIH, our universities, et cetera, et cetera. So I guess the same thing applies
to VA research. And I know VA research is a good research. It is something we should all
be very proud of and should retain. So I am not really going to raise a question in that
regard, but I would hope that that is not going to be interrupted, maybe even enhanced, as
a result of your plan. But, you know, you do worry that when you have a splitting up like
this--which makes sense in general, as far as I am concerned--but when you have a split up
like this, does that mean that you have a chance of less coordination, if you will,
between the research groups.
Specialized services were brought up. And that is a subject close to my
heart. And I guess you answered it pretty well. But in terms of the medical center
directors, you know, the authority that they may have to reduce these services in order to
save money--I mean, part of the bottom line is obviously going to be important in our
lives for ever and ever. Will they have the authority to reduce those services to save
money? And they are very expensive, as you already indicated.
Dr. Kizer. Under this concept, the VISN Director, or the VISN, becomes
the basic budgetary unit, as opposed to the individual medical center. With this we see
some potential, real positive attributes for our specialized services. As we change our
focus from that individual institution to a population of veterans over a geographic area,
how we can pool the resources within that area to better serve the needs of the veterans
that are within that VISN catchment area and we actually can enhance, or potentially
enhance, those specialized services by changing the focus from what one institution can
do, to what five or six or seven institutions or medical centers combined with various
other facilities, long-term care facilities, and clinics, working in coordination can do
to actually enhance those services. So again, while I recognize the concern, I would go
back to the fact that these specialized services are the hallmarks and really characterize
the veterans' health care service. They are at the core of the system.
And I see some very good potentials for strengthening specialized
services and for making them better than what has existed in the past. And while I am
cognizant of those concerns, I do not think they are realistic concerns.
Mr. Bilirakis. Well, I appreciate it. I trust that it will work out the
way you intended in that regard. And as you have just said, they are the hallmark of our
VA system health care and health care system.
And really I use them; I have been contacted--maybe we all have--by the
press and by others regarding this idea of the VA health care system being eliminated and
veterans given vouchers to buy care in the private sector. And, or course, I find a lot of
fault with that. But certainly a part of that fault is the fact that the hallmark of our
system is these specialized services. And there is not any way they could get those same
specialized services in the private sector.
So, but let me ask you then your opinion--if I may put you on the
spot--regarding the voucher idea.
Dr. Kizer. Well, sir, I believe that we have the potential; and within 2
or 3 years, we will have the proof that the system that we are proposing will not only be
better than the voucher system but, I think it will be much better than any sort of system
that would be proposed or conceived of, such as a voucher system. I, frankly, do not think
that vendors are the way to go for veterans' health care. I think that we have tremendous
potential, to make the VA health care system the flagship health care system of the 21st
century. With some polishing, this somewhat raw diamond can indeed be such.
Mr. Bilirakis. So your thinking is that in spite of the budgetary
constraints that we not only have now but will continue to have, and the fact that we
are--certainly this committee is--going to be in the forefront of the eligibility reform
process which conceivably--and maybe hopefully--will bring in a larger number of veterans,
if you will, that you do not think that that might be part of our future, vouchers?
Dr. Kizer. I do not see that at this point sir. I do not rule out the
possibility that we may work in new ways with private sector entities. But as far as
turning the system over, vouchering it or whatnot, I really do not see that as a viable
alternative. I think that we can show quite well, and even more so in the future, that we
are not only more cost effective, but that we will provide better service than would be
achieved in such a scenario.
Mr. Bilirakis. Well, thank you, sir. Good luck.
Mr. Hutchinson. Thank you, Mike.
The gentleman from Illinois, Mr. Gutierrez, is recognized.
Mr. Gutierrez. Mr. Chairman, I ask unanimous consent to have my opening
statement put into the record.
Mr. Hutchinson. Without objection.
[The prepared statement of Congressman Gutierrez appears on p. 54.]
Mr. Gutierrez. Thank you, Chairman.
And thank you very much, Mr. Kizer, for being here. I just have one
question for you. It is apparent from your testimony that you plan to put a renewed
emphasis on outcomes and results. You are going to establish performance contracts, for
example. What are some of the criteria you are going to use to judge the performance of a
facility or a group of facilities, or even individuals? And is there any chance that we
would put a commodity on things like timeliness or efficiency? And when we do that, do we
end up creating a system that rewards quantity over quality? For instance, what happens if
we ask: How many patients did you see today? rather than: What did you do for each patient
to make them better?
Dr. Kizer. Thank you, sir. As noted in Chapter 4 of the document, we
have given various examples of those different areas and exactly the areas that you are
talking about. We would see timeliness as one of the areas that we would be looking at. We
also see quality of care, customer satisfaction, and a number of other things that would
be specifically looked at. I think that your concern is an appropriate one if you only
looked at a very narrow slice. But if you look at a comprehensive performance assessment
where, yes, timeliness is an issue; but quality is also measured; patient satisfaction is
also measured; efficiency is measured; complications are measured; and you put those
together, then you have a balance system where you are not just achieving quantity over
quality or the scenario that you had expressed.
I think that our approach is a very balanced approach. We have a number
of different menus that we can choose from as far as looking at performance measures. One
of the things that we would anticipate starting work on in the near future would be
developing those specific contract measures for the VISNs, looking at their performance
historically in these different areas, looking at the evidentiary base that we have in
these things that has accumulated in recent years, and then coming up with measurements by
which the management of the various VISNs would be held accountable.
Mr. Gutierrez. Thank you, Dr. Kizer. And the concern is simply that as I
have watched health care reform during the last--I do not know--maybe 10 to 12 years in my
own personal life, it seems like every time I get a health care provider, a new one,
whether I am working in the Chicago City Council or moving to Congress and have to change
health care providers, or they change, it seems like there is more of an emphasis on
efficiency but not really quality in terms of the doctors that you see and the
relationships that you develop with those doctors. And those medical institutions seems to
be simply saying: We are going to be more efficient. And more efficient has not exactly
meant better health care or more personalized health care--at least not in my own personal
life. And it has not seemed to work that way. So I want to make sure that as we look at
the health care system in the VA, that we maintain that kind of personalized health care
where people feel that they have a doctor, they have a relationship with the medical
institution.
Chairman Hutchinson, Thank you very much.
Dr. Kizer. Let me just add one brief remark, for your point is very well
taken. I think with the increased emphasis on primary care and ambulatory care that is
envisioned under this scenario that you will see the personal nature of care increase in
the future in the VA.
Mr. Hutchinson. Thank you.
And, Dr. Kizer, in reading the summary of the reorganization plan, I
know that one of the goals is to provide the best quality care as possible and to meet the
patients' needs. But there was one statement on Page 17, that troubled me, but I would
like you to expand on it. It says to be successful, the integrated health care system
requires management of total costs, a focus on populations rather than individuals, and a
data-driven, process-focus customer orientation. Well, it seems paradoxical to me that we
talk about total costs and populations rather than individuals, and then talk about
customer orientation.
I am wondering if each of the VISNs has, in effect, a kind of global
budget under which they operate? And if the goal then is going to be the management of
total costs, where does the the focus on the individual come? And how can we be assured
that the individual veteran will not be lost in the greater scheme of the budget?
Dr. Kizer. Indeed, I think that if you were to look at it purely as a
budgetary exercise, that might be a concern. But again, the business that we are in is
taking care of individuals. We can do that, I think, in a better way when we look at
populations and how we can serve the needs of the populations. But at the cornerstone of
that are the individuals. So the two really are not exclusive, or they are not
contradictory, because health care is basically a one-on-one business between a doctor and
a patient, a nurse and a patient, etc. And that is what will continue in the future. But
from a planning point of view, we are looking at managing it, so that how we can serve
more patients, and provide better care to those individual patients within the system. If
we focus on a population, a geographic area, then we can start to achieve some economies,
some efficiencies. We can start out-stationing facilities that make it more convenient for
the patient to get care in a way that has not been the case in the past in this system.
Mr. Hutchinson. Do you see that there would be more rationing of
medicine under the reorganization or less? And when you use the term protocol in the
reorganization plan, exactly how do you define the word protocol. And how does that fit
into the overall scheme of the reorganization?
Dr. Kizer. In the protocol, are you referring to political protocols?
Mr. Hutchinson. Yes. If you had a recipe that would be used.
Dr. Kizer. One of the things that many health entities have found useful
is defining clinical benchmarks, best practices, or clinical protocols--they go by a
variety of different names. And while that is not a specific recipe that everybody falls
into, if you can define those best practices or protocols for patients and, as a system,
you strive to use them, then experience outside the VA has shown them to have been
beneficial for individual patient care, the quality of that care and also the efficiency
with which that care is provided. Protocols help clinicians answer such questions as--Do
you have to get x-rays for this condition? How many times do you need to get a laboratory
test? And a number of other things. Depending on the condition that is under
consideration, what many health entities have found is that using best practices, or the
protocols, has improved the quality of care, as well as in many cases reduced the cost by
avoiding unnecessary testing that really does not have any value in making the patient
better.
Mr. Hutchinson. Thank you, Dr. Kizer.
The gentleman from Georgia, Mr. Bishop, do you have any questions you
would like to pose?
Mr. Bishop. Not at this time, Mr. Chairman.
Mr. Hutchinson. Okay, thank you.
Do any--okay, Mr. Doyle.
Mr. Doyle. Good morning.
Mr. Hutchinson. We will let you warm up and then come back to you. Do
any of the members have another round of questions?
Mr. Bilirakis. I have just a quick one, Mr. Chairman. I guess maybe it
is not all that quickly answered.
Construction: How would the new plan affect the construction plan in
terms of planning and that sort of thing?
Dr. Kizer. One of the tasks that I would expect our VISN management to
complete within the first year, would be to develop a 5-year, strategic plan for the
facility needs they might have in their service area. And then we would be looking at that
from headquarters. So that, without speaking specifically about any facility, would be a
planning process.
However, perhaps more to your point, where I see the system going in the
future is toward becoming an outpatient-based system, looking at lease arrangements,
looking at joint venturing, looking at a number of other ways that we might get more
return on our dollars as opposed to necessarily building facilities ourselves. And what I
would hope is that our field managers would have the flexibility to look at what the needs
are, what those needs might be in the future, and how they could best serve those in the
most efficient way possible. And it may be that this can be best accomplished by situating
a small clinic or a larger clinic or a number of clinics, but I would see much less
emphasis in the future on traditional hospital construction.
Mr. Bilirakis. And they would be--their responsibility would be really a
recommendation responsibility, suggestions, recommendations to headquarters; and
headquarters would make the final decisions as far as any construction goes, and that sort
of thing.
Dr. Kizer. VISN Directors would have to come to VACO for projects that
are above limits that are specified. Projects below the threshholds could be done locally
subsequent to process of notification.
Mr. Bilirakis. I see.
Dr. Kizer. It might be possible to situate some small clinics or access
points.
Mr. Bilirakis. Sure.
Dr. Kizer. That made sense without----
Mr. Bilirakis. So they would have the authority----
Dr. Kizer. They would still have to notify us and----
Mr. Bilirakis. Sure.
Dr. Kizer (continuing). As well as Congress. But in many cases, when it
is being done within existing resources, they could do that, certainly.
Mr. Bilirakis. Thank you.
Thank you, Mr. Chairman.
Mr. Hutchinson. Thank you, Mike.
Do other Members have questions of Dr. Kizer?
I would recognize Minority Counsel, Mr. Ibson, for questions.
Mr. Ibson. Yes, sir. I would like to expand on the questions that the
Chairman asked you earlier, and related questions from Mr. Bilirakis. In responding to
their questions, you have expressed confidence that the integrity of specialized medical
programs would be preserved. I think, veterans' service organizations have very real
concerns regarding integrity of those programs. And I think those service organizations
may have raised those concerns because historically during periods of budget constraints
those programs sustained cuts. Given the confidence you expressed that those programs
would be protected, would you have any objection to legislation to ensure such protection?
Dr. Kizer. Recognizing that we are not talking about any specific
legislation, I can only comment in the abstract. I would hope that we would exhaust all
other means first before it were necessary to enact statutory changes. For example, one of
the things that has struck me about this is that some of the groups who have complained or
who have voiced, I think, some legitimate concerns about where some of these services have
gone, have never met with the directors, or met with them collectively, to try to work out
what the problems and solutions might be. It occurs to me that in the absence of having
that sort of dialogue, it would be premature to effect legislation. And certainly the
direction, the tack that I am taking, or would like to take, is that we explore all these
other common sense approaches, that we talk about this, that we work together to achieve
our common purposes, and that we reserve statutory mandates to when that is absolutely
needed.
Mr. Bilirakis. Would the Chairman yield just for a quick moment?
Mr. Hutchinson. Sure, Mike, you are recognized.
Mr. Bilirakis. Dr. Kizer, did you--have you read--the next witness is
Mr. William Schuler. He is President, CEO of Portsmouth Regional Hospital, Columbia HCA
system. Have you read his written testimony?
Dr. Kizer. I do not believe I was provided his testimony, sir. But I
have not read it, to answer your question.
Mr. Bilirakis. I would like to recommend, Mr. Chairman, that a copy of
that might be given to Dr. Kizer; and if he has any rebuttal or any comments regarding it,
he may possibly furnish to the committee in writing.
Mr. Hutchinson. The staff will provide Dr. Kizer a copy of the
testimony; and if you would give us a written response then.
Dr. Kizer. Sure. I would note that I have met with representatives of
Columbia HCA and have discussed where we are going and getting some of their thoughts in
the past. I do not know whether Mr. Schuler is aware of that or not.
(Subsequently, the Department of Veterans Affairs provide the following
information:)
Mr. William Schuler, President and Chief Executive Officer of the
Portsmouth Regional Hospital and Portsmouth Pavilion, Columbia HCA Healthcare Corporation
relayed the positive impact on his medical system after a corporate decision was made to
decentralize operational decision making. It was instructive to us as we restructure the
VHA healthcare delivery system. By decentralizing operational decision making we will
increase the autonomy of field management in making operational decisions.
First, Mr. Schuler's company is pursuing an organizational strategy
similar to what we have proposed for the veterans' health-care system. We believe this
reflects the understanding that health-care is fundamentally a local enterprise and larger
health-care organizations function best when operational aspects are decentralized.
Regarding the reference made in Mr. Schuler's remarks to a proposal that
would have VA contract with the Clinch Valley Medical Center (a Columbia/HCA hospital
located in Clinch valley, Virginia) to obtain certain services for veterans living in the
local area, I understand that the proposal is still being reviewed by the regional staff,
and a contract has not yet been approved. Further, I understand that the intent of the
proposal is to establish a VA clinic that would operate half days, Monday through Friday,
staffed with personnel contracted from the community. The clinic would provide an access
point for primary medical and psychiatric care only. All additional modes of care, other
than acute emergency, would be referred to the Salem VA Medical Center.
This arrangement is the kind of innovative arrangement with the private
sector that will be facilitated as a result of VHA's planned restructuring. This is an
example of the ``virtual organization'' referenced in Vision for Change . I applaud
Columbia/HCA's interest in contracting with the VA to improve veterans' access to care,
and I envision many other opportunities for sharing with the private sector in the future.
Mr. Bilirakis. Thank you.
Mr. Hutchinson. Thank you, Mike.
Do any other Members have questions?
Dr. Kizer, I want to thank you for your time. I thank you for your
effort in this reorganization plan. We appreciate it very much. We will excuse you at this
time.
Dr. Kizer. Thank you, sir.
Mr. Bilirakis (presiding). We will ask the second panel, Mr. Schuler,
President, CEO of Portsmouth Regional Hospital in Portsmouth, NH, representing Columbia
HCA.
Mr. Schuler, I welcome you to this hearing, very important hearing, and
would ask you if you would try to keep your oral remarks to 5 minutes, or as close thereto
as possible. But obviously your entire written statement is a part of the record. So if
you do not mind the gentleman being in front of you, if that will not bother you, I would
appreciate if you would start. Take your time, sir. Please start, Mr. Schuler.
STATEMENT OF WILLIAM J. SCHULER,
PRESIDENT, CEO, PORTSMOUTH REGIONAL HOSPITAL, COLUMBIA HCA
Mr. Schuler. Fine. My name is Bill Schuler. I am a----
Mr. Bilirakis. I have been corrected. It is 10 minutes, rather than 5
minutes. We do 5 minutes in Commerce. Sorry. So you have 10 minutes, apparently.
Mr. Schuler. Okay. Thank you.
My name is Bill Schuler. I am a former U.S. Marine Corps Infantry
Platoon Leader, a Vietnam veteran. I did receive a Purple Heart and a Bronze Star as a
Marine Officer in Vietnam. And I am pleased and honored to appear before this subcommittee
today.
I am presently--currently president and Chief Executive Officer of
Portsmouth Regional Hospital and Portsmouth Pavilion. As President and CEO, I am
responsible for all internal and external services at the 144-bed medical surgical
facility and the 65-bed psychiatric hospital in Portsmouth, NH, where both facilities are
located. We have approximately 900 employees, 125 members of our medical staff, and a
$75-million-plus budget.
Portsmouth Regional Hospital and Portsmouth Pavilion are both owned and
operated by Columbia/HCA Corporation, based in Nashville, TN. Pending a planned merger
with another health care company, Columbia will own and operate more than 315 acute care
and psychiatric hospitals, more than 100 ambulatory surgery centers, and dozens of home
health agencies in 35 States and 2 foreign countries.
In 1944--1994, Columbia employees and facilities provided more than $1
billion in uncompensated and charity care; and the company paid more than $1.2 billion in
local, state, and Federal income taxes.
I am pleased--taxes--I am pleased that this subcommittee is seeking
information from the private sector as the veterans' health system reorganizes. And I
appreciate being part of that process.
Columbia has been an agent of change sweeping in health care. The
company's strategy is to have local management make nearly every key decision regarding
the operation of that hospital. Local managers are responsible for all personnel
decisions, for local marketing programs, for negotiating and signing local contracts, and
for establishing and requesting our own levels of capital funding. The corporation is now
a service entity to these hospitals, helping my hospital become a stronger local
competitor. The corporate offices negotiate national purchasing contracts, suppliers with
suppliers, to reduce significantly the cost of supplies to my hospital. The corporate
office is also responsible for operations and installation of computer information
services which help track financial data and ease the paper flow burden at the hospital on
the hospital employees and are instrumental in tracking medical outcomes that enable us to
measure and improve the quality of our care. Finally, the corporate office is responsible
for capital formation, which it does by issuing shares of stock or borrowing in public
debt markets.
The decision to decentralize has provided my hospital and community with
many benefits. But make no mistake, the decision was based on how to best compete and
survive in today's rapidly changing health care environment. As many of you know, hundreds
of hospitals have closed over the past 5 years. More than 10,000 hospital beds were taken
out of service in 1994.
In my view, this type of local autonomy is suited to the veterans'
health system. Having just listened to Dr. Kizer's proposals, I was encouraged by the fact
that the VA is beginning to take a look at decentralization; and I think it is a good move
on their part. As this subcommittee examines the restructuring of the veterans' health
system, I would like to make some other suggestions as well.
I believe this is an ideal time for the veterans' health system to
expand contractual relationships with private-sector health care providers. This will
enable the VA to use the excess capacity in the private sector to provide improved
ambulatory access to veterans, especially to elderly and chronic patients with limited
ability to travel. I am pleased to learn of a public/private initiative in Virginia that
may offer future alternatives to the VA veterans who seek to restructure and reform itself
to better serve both veterans and taxpayers.
Veterans living in a rural area around Richlands, VA now must travel
2\1/2\ hours to the nearest veterans hospital, which is in Salem, VA. Clinch Valley
Medical Center, the local hospital, which is owned and operated by Columbia/HCA, has
excess capacity of 42 percent. The management of the Salem VA Hospital has agreed to
contract with Clinch Valley Medical Center to provide certain services to veterans living
in the area. This experiment will likely demonstrate the cost-effectiveness of public and
private partnerships in the provision of health care to rural areas of declining
population.
In this agreement, the VA will contract with a local internist, nurse,
and secretary. The hospital will lease an on-campus site to the VA. And the hospital will
provide necessary ancillary services, such as diagnostic procedures and pharmacy, to the
clinic for service-disabled veterans. Once the success of this phase has been established,
the local hospital hopes to expand the program to include elective procedures and
emergency care for service-connected and nonservice-connected veterans.
In brief, I believe this arrangement will ensure that area veterans
receive consistently high quality care delivered locally and efficiently on a timely
basis. In my opinion, it does not make sense for the Veterans Administration to compete
with organizations such as Clinch VAlley Medical Center. Clinch Valley pays taxes,
provides jobs, and delivers quality care to patients regardless of their ability to pay.
It makes sense for them to work together. I know this proposal will come before the
appropriate Appropriations Subcommittee, and I encourage its passage.
By decentralizing the authority of VA centers, local administrators can
make decisions like these to contract with regional private hospitals to provide veterans
with care they need in their own communities. It makes sense for the VA; it makes sense
for private sector hospitals with excess capacity; and most importantly, it makes sense
for veterans.
And speaking as a veteran, and not as a health care professional, I
would like to receive my care in my community when I become ill, just as Medicare and
Medicaid patients can. I recognize that this change is dramatic and cannot come quickly,
but I encourage you to lay the groundwork for that change now. I believe these hearings
can lead to that process and other veterans--and I and other veterans seek. So I thank
you, Mr. Chairman, for the opportunity to address this subcommittee.
[The prepared statement of Mr. Schuler appears on p. 63.]
Mr. Bilirakis. Thank you, Mr. Schuler. Well, Mr. Schuler, you are a
veteran; and I commend you for your service to this country. You may know that the
veterans have been very zealously guarding separate veterans' health care over the years.
The mainstreaming--I think that is the right term; is it not--that is something that they
really have not really been willing to accept over the years. I realize that over the
years some things may be changing. Ideas and thoughts may be changing because of budgetary
constraints and maybe some common sense and that sort of thing. But in your experience,
whether you have had personal experience, or whether you were talking about other
Columbia/HCA Hospitals or other private facilities, has this idea been welcomed by the
veterans, the privatizing; if you will?
Mr. Schuler. I--I believe so. There was a discussion here of vouchers.
My personal opinion, not as a hospital CEO now but as a veteran, is that a voucher system
basically puts the power into the hands of that individual veteran. If, in fact, the
veterans' services and hospitals provide the finest quality of care and accessible and
easy for them, then I believe veterans will use that. And by the way, I do not think--I am
not one that thinks that the voucher system should close the VA system at all. I think it
simply puts the power into the hands of that individual veteran to let him make a choice.
If, in fact, the veterans hospital or health care service in that area is, as Dr. Kizer
mentioned, one of the finest there is, the veterans will clearly use it. And if, in fact,
it is not, you have a choice for the veteran to get that care elsewhere. And to me that is
the benefit I see of the vouchering and decentralization. I think the decentralization
concept which Dr. Kizer had mentioned--and as I was listening to it--was really a very
good start. It really puts decision making closer to where the tire hits the road. As a
former Infantry Platoon Leader, one of the early examples I got was that the decisions
made closest to where the action was was usually the best decision making. And it seems to
me that the VA is moving in that direction, and I would encourage that type of----
Mr. Bilirakis. Well, all right. Let me sort of play Devil's Advocate,
because that is really what I am trying to do. All right if the situation determines that
most of the veterans in a particular area do not find the services at the VA as adequate
as maybe they would maybe a private facility and switched over, you were basically
probably leading up to closing down that facility. I mean, you are not going to keep it
open if there is hardly anybody to serve, which maybe based on what you say is maybe what
should take place. But then we get to the specialized care. And they are the only ones who
could offer that particular specialized care. So do you envision maybe sort of a
two-tiered type of a voucher system where there would be veterans facilities for
specialized care would somehow be preserved in spite of the fact that maybe the
others--and I should not maybe even be going into this because I do not mean to put
anybody in fear of closing down health facilities. But I guess that is the real world, and
it is being talked about, and we better explore it.
Mr. Schuler. I--again, as a veteran, along those lines, I would think
once decentralization occurs and it becomes more market driven, I would have the
confidence that some of these veterans hospitals in areas can begin to dramatically
improve their services. It becomes competitive. They have a vested interest in developing
a highly competitive, high quality product. And I think that would result somewhat from a
voucher system.
I think what you may see is a consolidation of some of these specialized
services that may allow veterans to maybe more cost efficiently consolidate these services
and make it more accessible to other veterans and improve the quality of it. I would not
dismantle the veterans system, by any means. But I would think potentially a voucher
system and public/private partnerships would make the veterans systems presently more
competitive and more motivated encouragement to become more attractive to those veterans
who now have that voucher ability to get their service anywhere. And I view that as a
system that could become more competitive and better for the veterans and better for the
VA.
Mr. Bilirakis. I would hate to be a party to something like that that
did not work out. We may as well never run for re-election.
Well, it is something--that is something that is part of our real world.
It is being talked about. And I do not see any large amount of interest among the members
of the Veterans' Committee thinking towards that end. But at the same time, we should be
open minded. And people like your opinions, and people like you.
Mr. Schuler. I think you need to be open minded in terms of where you
could go. Would I recommend that tomorrow? Probably not. But I think the decentralization
and reorganization of the veterans is a good step in a direction that makes it more
competitive and the ability to develop those kinds of quality services that Dr. Kizer was
talking about. And if, in fact, they are successful in developing a more decentralized,
quality-driven service that is, as he said, one of the diamonds in the rough in health
care delivery, then I think, frankly, a voucher system would fit into their needs because
people would love to go there. I might even want to get my care there. And if they are
not, you have provided an avenue for veterans to seek care elsewhere.
Mr. Bilirakis. Well, thank you, sir.
I will turn now to the ranking member of the subcommittee, Mr. Edwards
of Texas.
Mr. Edwards. Mr. Chairman, thank you very much. And I will be brief. I
have no questions at this point. I would like to submit my opening statement if I could in
writing for the record.
Mr. Bilirakis. No objection.
[The prepared statement of Congressman Edwards appears on p. 56.]
Mr. Bilirakis. The opening statement of Mr. Edwards will be part of the
record of this subcommittee.
Mr. Edwards. I just want to say I apologize for being late. I would like
to say I just forgot to move my watch ahead an hour this weekend, but we had a meeting of
Southwest House Members, Democratic Members, at the White House this morning. So we were
keeping Presidential time this morning, Mr. Chairman.
Mr. Bilirakis. And that explains your tardiness.
Mr. Edwards. That is correct. So thank you very much. And I know we have
a lot of other witnesses, and I will wait to listen to those.
Mr. Bilirakis. Thank you, sir.
Mr. Tejeda . No questions.
Mr. Bishop. Thank you, Mr. Chairman.
Just a couple of brief questions, very brief. I am intrigued with the
idea of the voucher system and decentralization from your point of view, particularly in
areas that are underserved for veterans. Access is a problem in a number of areas in the
country for veteran services. And I could see the decentralization to the extent that
vouchers would be allowed so that veterans could utilize local facilities such as yours
rather than have to travel 3 or 4 miles to a veterans hospital.
On the other hand, if there is a veterans facility available, it has
been my experience in talking with veterans, that they enjoy the esprit de corps and the
camaraderie of meeting with veterans who have similar backgrounds and experiences while
waiting for their services. And to some extent that has a therapeutic effect. And they
would choose if they had a choice to get that care at a veterans facility as opposed to a
private facility because they know that they will be able to talk with other people who
have similar backgrounds and concerns and who may have even similar problems.
I want to commend you for the innovative idea but also express the
concern that the Chairman expressed that we do not want to put veterans hospitals out of
business. But I think that it is a very, very innovative idea for utilization of vouchers,
for example, in contracting with local hospitals for the provision of services when
veterans are not located where there is access. Because I have a lot of complaints in my
district that we do not have a convenient veterans hospital for veterans medical services.
And many times they have to go from Georgia to Tuskegee, Florida or from South Georgia to
Atlanta, which is a great, great deal of inconvenience. The veterans' service
organizations do a fine job in trying to assist in providing transportation, but it can
really be a lot of wear and tear on a veteran to make that long trip. So I just want to
thank you for that. And I just note those comments in the caveat.
Mr. Bilirakis. Thank you, Mr. Bishop. Mr. Doyle.
Mr. Doyle. Thank you, Mr. Chairman.
Mr. Schuler, thanks for your testimony this morning. I represent a
district in western Pennsylvania with one of the highest veterans populations in the
country, and we have 3 VA hospitals in my district. I have met with all of the directors
in those hospitals and toured them. And they have been asking for this decentralization.
They want the flexibility to be able to make some decisions locally. So I think many of us
are welcoming Dr. Kizer's Vision for Change plan. And it is good to hear someone in the
private sector to opine that it is a step in the right direction. Thank you for your
testimony.
Mr. Bilirakis. I am going to do something a little unusual, if I may.
Mr. Bishop, your veterans who now have to travel such long distances to
get health care and in spite of the fact that transportation is being provided for them or
efforts are being made towards that end, how would they feel if the VA contracted with
private facilities in the area as is being done in some areas of the country as Mr.
Schuler shared with us? How would they feel about something like that?
Mr. Bishop. That is a very interesting question, and I certainly will
want to explore that. But what I have gathered from the conversations with the veterans'
service organizations has been that they would prefer a separate veterans' health care
system, specifically designed and specifically targeted for veterans, probably because of
the esprit de corps and the common background and experiences and the camaraderie that
they have when they pursue those services. And then they get to exchange those ideas and
information during the course of their visits and their travel to and from. So I do not
know. And I think that it certainly would be a worthwhile survey for the VA to determine
what the attitudes of veterans would be toward that.
Mr. Bilirakis. That is very important. I know I would ask Mr. Schuler at
this point how much of this contracting out is being done; do you know? I mean, you know,
to what extent?
Mr. Schuler. I am really not aware of it. I am just aware of that one
incident in Richlands. I believe there are others. And I think, again, the distance, the
access issue is probably a good start to see if that works and get feedback from those
veterans involved.
I agree there are veterans who would prefer to get--who have the
camaraderie--although frankly, there are a lot of veterans who do not have to use the
system who are using our hospitals. We are in an area where there is a military base, a
concentration of veterans, and I have to admit we share stories now at the local level as
well and services. And I, again, I think the voucher system--if, in fact, the veterans
feel strongly about that--you have simply empowered them to do that.
And I have no--I do not think the veterans system would go away. I think
there is a use for it and a need for it in these particular areas where a 2\1/2\ to 3 hour
drive could wear somebody down, especially depending on the amount of care that they need,
that that sometimes can be a significant benefit to them that they are not wasting 4 to 6
hours in an automobile. But they are, in fact, able to use that more productively in their
lives. And so that may be an excellent example where a decentralized VA can negotiate
these things, get immediate feedback from their veterans in that area. And it is a good
starting point for people to begin to gauge whether----
Mr. Bilirakis. In these outlying areas.
Mr. Schuler (continuing). In these outlying areas. It is, again, Clinch
Valley in Richlands, VA is probably a good point that ought to be measured and surveyed
after a while and find out how these veterans feel about that.
Mr. Bilirakis. Great.
Mr. Bishop, I know you are chomping at the bit. There is something you
wanted to add.
Mr. Bishop. No. I just think that that is a very interesting subject
that ought to be explored through surveying veterans' attitudes toward it. I have heard
lots of complaints at hearings with this very subcommittee across my district and Atlanta.
The veterans complain about having to travel long distances and how inconvenient it is
when they have to do that, particularly when they are ill to start with. And it is a
burden on families. It is a burden on them in terms of time, and it physically has wear
and tear on them. So it certainly should be an option.
Mr. Bilirakis. I agree with you. I think we better be open minded to it,
maybe try to find out more about it. I do not know, maybe with the demonstration projects
in areas such as Richmond and maybe your area and whatnot might be a good idea.
Mr. Tejeda, Mr. Edwards, any further questions of Mr. Schuler?
Thank you very much, sir. We appreciate your coming here today and
sharing your expertise with us.
Mr. Bilirakis. The next panel, we would like to invite them up at this
point. Dr. Daniel Winship, who is the Dean of the Stritch School of Medicine, Loyola
University of Chicago; Dr. Samuel Spagnolo, President of the National Association of VA
Physicians and Dentists; Lynna Smith, President of the Nurses Organization of the VA; and
Louis Jasmine, National President, National Federation of Federal Employees, welcome.
We have 10 minutes. Your oral testimony, your prepared statement,
obviously is made a part of the record. We will start out with Mr. Winship. Doctor?
STATEMENT OF DANIEL H. WINSHIP, M.D., DEAN, STRITCH SCHOOL OF MEDICINE,
LOYOLA UNIVERSITY OF CHICAGO; ACCOMPANIED BY DANIEL SPAGNOLO, M.D., PRESIDENT, NATIONAL
ASSOCIATION OF VA PHYSICIANS AND DENTISTS; LYNNA SMITH, PRESIDENT, NURSES ORGANIZATION OF
THE VA; LOUIS JASMINE, NATIONAL PRESIDENT, NATIONAL FEDERATION OF FEDERAL EMPLOYEES
STATEMENT OF DR. DANIEL H. WINSHIP
Dr. Winship. Good morning, Mr. Chairman and members of the subommittee.
I am Dr. Daniel Winship, Dean of the Stritch School of Medicine, Loyola University of
Chicago. I am pleased to present the testimony of the Association of American Medical
Colleges, as you consider the proposed reorganization of the Veterans Health
Administration.
AAMC represents the 125 accredited United States medical schools; nearly
400 major teaching hospitals, including 74 VA medical centers; over 90 professional and
academic societies; and the Nation's medical students and residents. Together, the members
of the AAMC work together to improve the Nation's health through the advancement of
academic medicine.
I personally have devoted my professional life to research and academic
medicine, having held appointments at several medical schools and hospitals within the
AAMC's membership. In addition, I have cared for veteran patients in 4 medical VA medical
centers, directed a VA medical center, and served in VA central office.
Currently, I am an attending physician at the Edward Hines, Jr. VA
Medical Center, with which Loyola University is affiliated. The Hines VA, you may know,
was the first VA medical center to affiliate with a school of medicine. Back in the 1940s,
VA medicine suffered from bureaucratic constraints, a shortage of physicians, and a less
than sterling reputation.
As thousands of veterans began returning home from the second World War,
President Truman signed a 1946 law that allowed VA hospitals to enter into affiliation
agreements with accredited medical schools. Affiliations helped staff VA hospitals with
top-notch medical school faculty physicians, residents, and interns, and provided medical
schools with new venues in which to educate young physicians, including military doctors
returning home to seek specialized training.
These affiliations have allowed VA to achieve its goal of affording the
veteran a much higher standard of medical care than could be given him with a wholly
full-time medical service. Today, nearly 10,000 VA clinicians have academic appointments
with one or more academic institutions; and a similar number of faculty from these
academic affiliates care for veteran patients and teach residents and students at VA
medical facilities.
Contrary to popular belief, the VA medical system offers veterans
excellent health care and a range of specialized services that many veterans desperately
need but might not find elsewhere.
VA medical centers consistently score well on the reports of the Joint
Commission for the Accreditation of Hospital Organizations, comparing favorably with their
private sector counterparts. A 1992 U.S. News and World Report article on AIDS cited four
VA medical centers among the facilities that offer the finest AIDS care in the United
States. The vibrant VA health care research program, based on the health care needs of
veterans, attracts top physicians and scientists to VA careers and contributes positively
to the quality of medical care received by patients in affiliated VA medical centers.
Since 1982, VA has also been required by law to serve as a backup to the
military medical system during war and other national emergencies. During the Persian Gulf
War, many VA medical centers developed contingency plans to treat casualties in concert
with their academic partners. The Hines VA and Loyola University, for example, crafted a
plan that would have used my institution's entire specialty structure to provide medical
care for wounded soldiers. These cooperative efforts in support of military medicine are
particularly vital since the number of beds operated by the military has declined from
80,000 to 16,000 over the past 25 years.
VA also plays a major part in educating today's physicians. In 1994, VA
supported more than 9,100 medical resident positions, or close to 10 percent of all the
residency slots in the country, and over 33,000 medical residents from affiliated
institutions rotated through VA facilities. More than one-half of the Nation's physicians
have received some part of their training in VA facilities.
After nearly 50 years of close partnership, academic medicine cannot
envision an educational environment that does not somehow include VA. Severing or even
diminishing the symbiosis that has benefitted both parties is particularly unimaginable
when one considers that many VA medical centers are situated on the same grounds or
located in the same building complexes as their affiliated medical schools.
Academic medicine looks forward to working with VA and the Congress in
reinventing VA to face the challenge of caring for the Nation's veterans while adapting to
changes in the health care environment and marketplace. The proposal before you is an
important first step toward transforming VHA into a more comprehensive, responsive, and
efficient medical system. Secretary Brown, Under Secretary Kizer, and their colleagues in
Washington and in the field should be commended for tackling the awesome task of
reorganizing the largest integrated medical system in the United States.
The AAMC and its member institutions will continue to support VA's
efforts to provide the best possible care for our Nation's veterans. We are concerned,
however, that the reorganization proposal mentions only in passing VA's missions to
educate health professionals and conduct health research. We would like to think that the
reorganization can strengthen, rather than imperil, the arrangements between VA medical
centers and schools of medicine that are essential to the high quality of care provided to
veterans by VA.
Under the proposed reorganization, basic budgetary and planning
responsibilities would shift from individual medical centers to the VISNs, which would
coordinate health care for eligible veteran beneficiaries in defined geographic areas.
This move carries potential ramifications for the long-standing
relationships between individual VA medical centers and their academic partners. For
instance, the proposed shift in planning responsibility from the VA medical center to the
VISN signals the potential for dramatic changes in the role of Deans Committees.
Every medical school that conducts medical education programs in
cooperation with a VA medical center must organize and nominate a Deans Committee, subject
to the approval of the VA medical center director. These Deans Committees are composed of
medical school deans and senior faculty members from appropriate medical school
departments and divisions. The Deans Committee has a primary advisory responsibility
regarding all aspects of a VA medical center's education and research programs. These
committees also nominate faculty and trainees from the medical school for appointments to
meet VA's staffing needs.
Under the reorganization plan, each VISN would establish a management
assistance council to assure input from VHA's internal and external stakeholders. The plan
foresees a role for VHA's academic affiliates as consultants to these councils, providing
recommendations regarding the operating of and planning for the VISNs. Although we believe
the close interaction between VA medical centers and affiliated medical schools warrants
involving academic medicine and other important stakeholders as more than simply
consultants, we also realize that adding representation from every conceivable external
interest would make these councils rather unwieldy.
Notwithstanding this concern, the AAMC appreciates VA's interest in the
views of its partners, and we believe these councils would provide an avenue for the
dialogue and constructive collaboration that is essential to the success of the
reorganization.
The interplay between the VISNs and the Deans Committees within each
network will almost certainly create tensions that will buffet the affiliations. Since
each proposed VISN would also incorporate more than one VA medical center with a strong
academic partnership, the reorganization plan harbors the potential for additional
conflicts within the VISNs themselves. I believe VA and academic medicine should work
together to create a structure through which the VISNs can work with the Deans Committees,
either individually or through consortia, to devise systems for staffing VA facilities,
educating students and residents, and conducting health research in the best interests of
veterans and each partner. As the subcommittee considers the reorganization plan, the AAMC
would welcome the opportunity to discuss this issue further.
We understand the need for VA to restructure its health care system to
provide health care to its patients more effectively and rationally. Medical schools and
nonfederal teaching hospitals with educational and research missions are also beginning to
form integrated networks and to incorporate ambulatory and community-based service points
into expanded continuums of care. However, as VA reinvents itself, the directors of the 22
VISNs must take care not to sunder unnecessarily the ties between individual VA medical
centers and medical schools. I believe that VHA headquarters should provide the field with
national policy, direction, and oversight to ensure that the benefits of these
affiliations are preserved and enhanced.
In my view, the transformations in health care delivery that are
spreading across the country present VA and academic medicine with new possibilities for
cooperation that would benefit both partners and, ultimately, the veterans we serve. For
instance, VHA, medical schools, and teaching hospitals can join together in finding ways
to enhance primary care education and to provide students and residents with more
experience in outpatient settings. These types of collaborations between VA medical
centers and academic medicine would make sense for both partners, providing academic
medicine with new educational opportunities and helping VA improve veterans' access to
health care by promoting appropriate delivery systems. Together, medical schools and VA
can implement necessary changes, yet protect what is good in the current system.
Based on my experience as a physician and an administrator, I believe
that the proposed reorganization, although an important first step, should not be
considered a panacea by this subcommittee. As the subcommittee discusses the future of VA
health care, it should also consider reforming the convoluted and dysfunctional
eligibility criteria to allow VHA to provide a comprehensive range of care to all eligible
veterans; allowing VA to retain third-party collections; urging appropriators to provide
adequate funding for VA medical care and research; and allowing VA medical centers to
treat non-veteran patients, as long as the high quality of care for eligible veterans is
not compromised and VA is reimbursed properly for all care provided to non-veterans.
Thank you for allowing me to present the views of the Association of
American Medical Colleges today. I would be pleased to answer your questions.
[The prepared statement of Dr. Winship is on p. 69.]
Mr. Bilirakis. Thank you very much, Dr. Winship. Dr. Spagnolo.
STATEMENT OF DR. SAMUEL SPAGNOLO
Dr. Spagnolo. Thank you. Good morning, Mr. Chairman and members of the
subcommittee. My name is Samuel Spagnolo, and I am here today as President of the National
Association of VA Physicians and Dentists, better known as NAVAPD. For the past 20 years,
I have served as the Chief of Pulmonary Diseases at the Washington, DC VA Medical Center,
having come here after finishing my training at Harvard and the Mass General Hospital.
I have also been for the past 20 years, serving as the Director of the
Pulmonary Division at George Washington University; and I am currently Professor of
Medicine at George Washington University.
With me today are two of my colleagues. They are sitting behind me, Dr.
Rhonda Lee Travaglino-Parda, who is Chief of Plastic Surgery at the Washington VA and Dr.
John Burton, Chief of Dental Service at Columbia, SC; and we hope they will have an
opportunity to answer your questions.
I thank you for the opportunity to comment today on the recent proposal
to restructure the Veterans Health Administration. We come before the Committee today to
address what we believe is the single most important issue facing VHA. That is maintaining
and improving the quality of patient care for our Nation's veterans.
At the outset, let me emphasize that NAVAPD does not oppose change in
the VA system. On the contrary, continuous change is necessary to meet the needs of any
dynamic business or organization. The VHA must now contend with ongoing changes affecting
the demands for its services, such as an aging veteran population, a marked decline in
inpatient and acute care, and major shifts in the geographic locations of veterans, to
mention a few. The VHA must address these issues in a timely and effective way without
compromising quality health care. Therefore, it is not whether the VHA changes, it is how
it changes that concerns us.
We applaud the VA for proposing to eliminate unnecessary bureaucratic
layers in the management system and shifting operational decisions to the local level. The
concept of decentralization is not inherently bad, provided the new structure
significantly involves doctors in the management process.
Before I address our concerns, I want to stress that NAVAPD seeks to
continue a constructive dialogue with the VA and Congress as we debate this reorganization
plan. As always, we stand ready to answer any questions and to work with the VA and
Congress.
We would also like to briefly point out that the reorganization plan
fails to address the difficult issue of simplifying veterans' health care eligibility
criteria. Without knowing who our patients are and what they need, how can we effectively
plan for their care? We know there is a Bill recently put forth before the House, and we
urge Congress to address this important issue before any attempt is made to reorganize the
system.
NAVAPD has four areas of concern, and let me briefly tell you what they
are. We are concerned that quality health care is not the focus of reorganization.
Although the plan endeavors to address the quality of health care, its primary goal is
managed care, now commonly known as best value care, as the plan states. Let me quote from
the plan: The new VISN structure places a premium on improved patient services, rigorous
cost management, process improvement, outcomes and best value care.
Congressman Hutchinson, I think, has already addressed this. The plan
goes on to say that an integrated health care system requires management of total costs; a
focus on populations rather than individuals; and a data-driven process-focused
orientation, which is a long sentence.
I am personally aware of managed care organizations where patients are
scheduled in 8-minute intervals. I do not consider that quality care. When you restructure
a system as unique as the VA administration health care system, the question really should
be: What is best for the Nation's veterans, not: What is the best value for the VA system?
We are concerned that managed care will effectively--adversely affect the quality of care
delivered, especially in specialized services.
For example, NAVAPD has consistently taken the position that the VA
should improve patient care by creating centers of excellence. These centers would provide
treatment, research, postgraduate education in special areas, such as organ transplant
perhaps, early diagnosis of cancer, cardiac surgery, spinal cord injury and
rehabilitation.
To accomplish this goal, there must be a strong commitment at the
management level. There must also be significant input from doctors.
Let me just digress for a minute. As a physician, I am acutely aware
that the ultimate responsibility for my patients' care rests with me. I am trained to make
decisions on the quality of care that my patients receive. All of you know, the practice
of medicine is centered around the doctor/patient relationship, and decisions about
treatment must be based upon the professional judgment of the doctor. This relationship
must not be compromised by managed care. I ask you: Under managed care, who is the
patient's advocate? Who will protect clinical outcomes? Furthermore, courts have
consistently upheld my accountability in the doctor/patient relationship. Who is
accountable in a system that inserts a non-medical administrator into that relationship?
Now, this leads me to my second point. NAVAPD is concerned that under
this plan, doctors will not have substantial decision-making authority regarding the
development and implementation of administrative policies within each VISN. The plan
proposes that each VISN be headed by a director, who would be expected to have expertise
in medical management, finance, budgeting, planning. There is no mention of expertise in
patient care. If a doctor cannot advise the VISN director as to the clinical outcome of
decision, and if that advice does not carry real authority, then the doctor has no real
input into the management process.
Policy decisions made without clinical justification will fail and will
have serious adverse impacts on the quality of patient care.
Our third concern is that the plan's main emphasis on decentralization
of authority will adversely impact the quality of patient care. By the year 2010, our
information is that one third of all veterans will reside in six States: California,
Pennsylvania, Texas, Florida, Arizona, and New York. What does that mean for facility
management, staffing, expansion and the allocation of technology resources? It is not
clear to NAVAPD how the new VISN management structure will address the allocation of these
resources among the VISNs and what criteria will be used in the allocation of these
resources.
Finally, one of NAVAPD's primary goals has always been to improve
patient care by maintaining special medical expertise within the system. The VHA must
adopt policies that are aimed at retaining senior, experienced personnel and recruiting
new quality doctors.
This reorganization plan fails to address how the VA would modify
academic affiliations and resource opportunities for doctors. The opportunity to be
actively involved in medical education and research has long been one of the most
attractive features in employment. I personally have trained nearly 100 lung specialists.
In this important opportunity for growth and professional development,
if that is closed off to VA doctors, you can rest assured that senior physicians and
dentists will leave and the recruitment of new, high quality doctors will suffer.
Let me summarize our position. First, the focus of any reorganization of
the VHA must be the quality of health care for veterans and not managed or best value
care. Second, physicians and dentists should be directly and effectively involved in
management decisions affecting patient care. Third, decentralizing management functions in
the VHA should not negatively impact resource allocation. And finally, the reorganization
should maintain specialized medical expertise in this system.
Mr. Chairman, that concludes my remarks. Thank you for the opportunity;
and I, along with my colleagues, would be more than welcome to answer any of your
questions.
[The prepared statement of Dr. Spagnolo is on p. 76.]
Mr. Bilirakis. Thank you so much, Doctor. Ms. Smith.
Ms. Smith. Thank you, Mr. Chairman. I would like to introduce myself. I
am Lynna Smith, a nurse practitioner at the American Lake Veterans Affairs Medical Center
in Tacoma, Washington. As president of the Nurses Organization of Veterans Affairs, I am
testifying on behalf of Nova, and I speak for the more than 40,000 professional nurses.
It is an honor and a privilege for me to represent NOVA here today and
to testify on the Veterans Administration's Reorganization proposal. This testimony will
focus on the effect of this on veterans' health care and on nurses. NOVA strongly supports
the Veterans Health Administration and an independent health care system providing a full
range of services enhanced by education and research programs benefitting both veterans
and the Nation. The VHA functions in concert with major trends in the health care
profession and reflects those changes in its care of veterans. NOVA also supports the
recognition--reorganization goal to transform the VA into a responsive, decentralized,
customer-driven organization providing high quality, cost-effective, accessible service
for all veterans. NOVA applauds Secretary Brown for his leadership in this undertaking.
NOVA is also committed to providing quality health care for the veteran.
We believe that the health care must shift from the illness/cure model of care to a focus
on the wellness/health promotion model. NOVA asserts that an increased utilization of
nurses as primary providers will promote accessibility and quality care, that the
increased use of nurses as case managers will decrease fragmentation of health care, that
research-based clinical practice will promote increased standardization of health care and
promote quality of care. That education and training will assist nurses in moving toward
ambulatory care, hospice or home care and long term care settings.
The following comments are on components or reorganization. In
September, 1994, the Nursing Program's Board of Directors initiated an organizational
structure to support decentralization by providing opportunities for grass roots input in
policy development and decision making. The Board includes chairs of five constituency
centers: Clinical, Administrative, Research, Education, and Informatics. Task forces with
representatives from nationwide VA have been developed to work on elements of the
strategic plan.
This innovative program has generated interest and enthusiasm from all
levels of nursing service. As with all programs, outcome measures need to be tracked. For
example, an Advanced Practice Advisory Group was appointed in 1994 and subsequently
aligned with the Clinical Constituency Group. The Advanced Practice Advisory Group guided
the development of a new directive related to establishing prescriptive authority for
Advanced Practice Nurses, Clinical Pharmacy Specialists and Physician Assistants. This
Group has also begun the development of Scope of Practice guidelines for Advance Practice
Nurses and has initiated identification of issues and information necessary to create a
national database for Advance Practice Nurses in the VA. NOVA strongly commends these
innovative programs as essential for nursing in the VA.
In late 1994, the VA announced each medical center can now realign Chief
Nurses to the position of Associate Director for Nursing Services Patient Care Services.
This realignment positions our nursing services to assume a greater scope of
responsibility and accountability for the governance and operation of each VHA medical
center.
NOVA applauds Nancy Valentine, the Assistant Chief Medical Director for
Nursing Programs and the Task Force on Reorganization of the Chief Nurse with the support
of Secretary Jesse Brown and Deputy Secretary Hershel Gober in achieving this NOVA goal.
The Veteran Integrated Service Network restructuring proposal would
abolish the VHA's current 4-region system and replace them with 22 VISNs. These VISNs will
allocate resources among the medical centers and use contract services with the private
sector as well as sharing agreements with the Department of Defense. NOVA believes this
reorganization will lead to an increased quality of care as well as cost managements. NOVA
recommends that nursing representation be at the VISN level.
NOVA also supports the goals of the recent organizational integration in
which 16 VA medical centers were realigned into seven facilities. This allows for
expansion of services to veterans and the improves the management of the VA's network of
health facilities. This integration is commendable and, in our opinion, exactly what the
VA needs to accomplish.
However, at one or more facilities, this process appeared very abruptly,
with both staff and veterans voicing feelings of uncertainty about their programs and
health care. The process of integration, which should have begun prior to merger, must now
begin. Issues of concern include communication with the veteran consumer and the hospital
staffs about this integration process; continuity of health care programs; consolidation
and integration of information systems; and integration of clinical services. NOVA
recommends that these integrated facilities be monitored to ensure the achievement of the
stated goals, and that the veteran consumer and the staff of the various clinical programs
within these facilities have representation in this process.
NOVA continues to have significant concern regarding veteran eligibility
issues and access to care. For example, in Tacoma, Washington, there are three new private
health care plans actively marketing veterans.
One of my veterans that I see, after attending one of these sessions
stated to me: The plan sounds too good to be true. He decided to return and hear the
presentation a second time, and subsequently, signed up for the plan. He selected a family
doctor, believing that he will receive total health care, including medications in
exchange for his medicare deductible and a $5 visit co-pay. There was a proviso with his
plan, though; and that was that he was not to receive health care from any other provider,
including the VA.
NOVA believes that eligibility reform is critical to a viable VA. Unless
the reorganization plan includes simplification eligibility reform, those veterans,
especially those less than 50 percent service connected, may well go elsewhere for their
health care.
Our country has a responsibility for the men and women who have put
their lives on the line and made our country and the world a safer place. Veterans deserve
quality, efficient and effective health care. This is the VA challenge. NOVA is committed
to working with the VA and with Congress to achieve this goal.
In closing, Mr. Chairman, NOVA would like to thank you and this
subcommittee for your work with the legislation to amend Title 38 to exempt full-time
professional nurses from restrictions on remunerated outside professional activities. This
regulation has long been an issue for NOVA members, and we are truly grateful for your
support.
Thank you.
[The prepared statement of Ms. Smith appears on p. 83.]
Mr. Bilirakis. Thank you very much, Ms. Smith. Mr. Jasmine.
Mr. Jasmine. Thank you. Good morning, Mr. Chairman and members of the
subcommittee. My name is Louis Jasmine. I am the president of the National Federation of
Federal Employees. On behalf of the National Federation of Federal Employees, otherwise
known at NFFE, I appreciate the opportunity to appear before you today to offer our
comments on the plan to reorganize the Veterans Health Administration.
NFFE represents over 150,000 fellow employees throughout the country. I
would like to take a moment to reaffirm the commitment of all NFFE VA employees to
constructing a VHA that is more responsive and provides high quality health care to those
individuals who have given so much to this Nation, the veterans. NFFE has wholeheartedly
embraced the VA's call to put veterans first and is willing to work with the VHA as it
restructures its health care delivery system to put patients first.
I must say also that NFFE applauds the VHA for developing a
reorganization plan that is correctly focused on systematic changes intended to improve
service delivery rather than on a massive job cuts intended to provide only monetary
savings. In today's cut and slash reform environment, this is certainly a refreshing
change and we want to applaud you on that.
As you know, you already know the current, the proposal for
reorganization which is going to transform the current field operations to 22 Veterans
Integrated Service Networks, or VISN. What is more important to NFFE is the--that in the
reorganization plan, that it would lead to a net reduction of 157 FTE positions. NFFE is
certainly pleased to see that VHA intends to achieve these reductions through the use of
reassignments, early retirement, and special placement initiatives instead of the more
draconian reduction-in-force, one thing that we all really do not like to see as a means
of reduction. And we certainly want to applaud you for taking these steps at reducing the
number of FTEs.
While NFFE is generally supportive of the VHA's reorganization plan, we
do have a few concerns. Leading the list in the potential impact is the plan on the
labor-management partnerships in the VHA. As you may know, many VA facilities already
have, or are in the process of completing, a partnership agreement with resident employee
unions. These partnership agreements envision accountability at the facility level. The
partnership may be undermined if the facility management is required to defer to the VISN
director instead of being able to reach an agreement with its partner at the station.
Throughout the Federal Government, partnership agreements have shown by working together
Federal workers and management can dramatically improve the quality of service while
reducing costs. The VHA reorganization plan should reflect the success of this philosophy.
As I travel through different parts of the country visiting VAs, those
that have partnerships, and certainly those partnerships have worked toward improving
quality service and reducing cost; and I think the reduction of cost and money is the
bottom line throughout this whole operation and your reorganization plan.
Another concern is the potential for micro-management of the medical
centers by the VISN directors. In the 1980s, the regions were too large and contained too
many medical centers for Regional Director to manage human or fiscal resources
effectively. The danger in the present plan is that the VISNs are small enough for the
VISN Director to micro-manage the medical centers; and this is a concern that the unions
have, NFFE has. To avoid this problem, the VHA should emulate some of the Nation's largest
private sector multi-hospital systems, which basically allowed the medical center director
the freedom to locally manage the human and fiscal resource departments, but also make
them accountable for their actions. And we think the committee should look at that, as
well.
Finally, in conclusion, Mr. Chairman, I would like to reaffirm that
NFFE's commitment to reform the VHA so that it provides our Nation's veterans with a
health care delivery system that is both effective and of high quality. NFFE believes that
this proposal has the potential to realize this goal as long as it is adjusted to reflect
the success of labor management partnerships and safeguards are added to ensure that local
directors are allowed to manage effectively. The local directors having that autonomy and
that authority is the key to successful relationships.
That concludes my testimony, and I would like to thank you for allowing
me the opportunity to come before you today.
[The prepared statement of Mr. Jasmine appears on p. 89.]
Mr. Bilirakis. Thank you, sir. Thank you for your input. Mr. Hutchinson
has just come in. But Ms. Smith, Mr. Hutchinson introduced the piece of legislation that
you referred to. But you gave me credit. So I guess I am going to have to seriously
consider co-sponsoring it.
Ms. Smith. Thank you.
[Laughter.]
Mr. Bilirakis. I am always impressed with the fact that even though
during these veterans hearings--this does not really take place in too many other
committees when the VA is usually asked to testify first--in other committees, when you
ask basically the administration to testify first, or early on, they usually get up and
leave after they are done testifying. But I am always impressed that the VA always has a
representative here to hear the rest of the testimony. Ms. Egan--and there may be
others--but I know Nora Egan is here, and I appreciate very much, and I know the others
do, too. You got an earful, particularly from Dr. Spagnolo. I would very much appreciate
it if you would--you know, your time is wasted if you do not go back with those inputs to
Dr. Kizer and to the others.
Dr. Spagnolo, when this was all being worked out, was there not any
coordination done with your group? Was your input not requested? Did the VA not work with
your people?
Dr. Spagnolo. There were one or two phone calls made, but not on a grand
scale, Mr. Chairman. We would like to have had a little more input, but we are certainly
willing and able to give as much input now as we can.
Mr. Bilirakis. Well, the cow is now out of the barn.
Sir, I commend you for being so very concerned about the quality of
medical care. As you say, in your opinion, you do not think enough emphasis has been
placed on that insofar as this plan is concerned.
Are you sort of being cautious in your concern that the quality of
medical care might be adversely affected or do you feel confident that it will be
adversely affected under this system?
Dr. Spagnolo. No, I think I am more concerned that it could be, and I do
think that--I am all for restructuring and simplifying the bureaucracy, which I have been
in it for many years. But I think we can improve quality of patient care if we put some
trust in those people who are making those quality decisions, such as the doctors and the
nurses and the dentists. And I do not see enough of that happening. I have watched the VA
over 20 years, longer; and I have watched the separation between the administration and
the providers get wider and wider and wider.
Mr. Bilirakis. And you feel that it is getting wider yet?
Dr. Spagnolo. And I feel that, you know, a lot of people have a lot of
criticisms about the VA health care system; and I feel that you have got to put the
providers back--let me borrow a phrase from a, perhaps, a famous senator who said: We feel
we have been pushing this train for a long time. We would like to have an opportunity to
help lead this train. That is really what I am asking.
Mr. Bilirakis. That certainly does appear to be reasonable.
Dr. Spagnolo. And I think, as a partnership in this reorganization
matter, with real input by physicians, nurses, dentists, and all the practitioners, I
think we can deliver quality care. But I am a little concerned about this new phrase, best
value and managed. I am very concerned about what that means.
Mr. Bilirakis. Ms. Smith, you have devoted your life, obviously, to
taking care of people in need, and yet you have said some good things about the
reorganization. But Dr. Spagnolo does not oppose it, either. Do you sort of agree with him
in the fact that maybe there has not been enough emphasis on quality of medical care?
Ms. Smith. I feel--I agree with him that there needs to be professional
medical nursing input in order to keep the system whole, but I also believe that there has
to be a business administration. In order for the VA to survive, we have to have a
business aspect to it. That is what this is all about. The VA is such a special group, all
of the things that have been talked here today--talked about here today, the veterans'
camaraderie, the special problems that veterans have related to so many of the events in
their lives related to the military, I believe that we have to preserve that; but we have
to do it in the economy. And if it takes a CEO to maintain some business aspects in order
to bring more income in and to get more money into health care providers to take care of
those veterans, that is what is essential.
Mr. Bilirakis. Are there not doctors out there or nurses, I mean,
practitioners who also can serve? I realize the reputation of doctors. My son is one of
them; and I am here to tell you, when it comes to business--but there must be people out
there that could serve, basically, both functions.
Ms. Smith, I commend you for your candidness. You are quite right. I
think, the real world is we have got to worry about the bottom line, unfortunately. But at
the same time, we do not want to hurt the quality of medical care in the process. Can both
not be done, in your opinion?
Ms. Smith. Can a medical or a nurse do both?
Mr. Bilirakis. Yes.
Ms. Smith. I believe so.
Mr. Bilirakis. You believe so, right. Dr. Spagnolo?
Dr. Spagnolo. Absolutely, and here is one.
Mr. Bilirakis. Right. And I plan to go to Dr. Winship.
Dr. Spagnolo. And Dr. Kizer, who was here earlier who is a physician. I
think there are plenty of physicians who are good managers, and I think the VA should also
start a management program for physicians.
Mr. Bilirakis. That is a good point. I wish they had started one when my
son was still training through the VA.
Dr. Winship, do you have any comments regarding particularly Dr.
Spagnolo's testimony?
Dr. Winship. Yes. I would echo Dr. Spagnolo's concerns, but I do not
believe that the VA is headed, necessarily, in the direction of plummeting health care. I
think a lot of what is going on now and, in fact, the heart of this program is not just to
save money, but also really and truly to improve health care. I have long thought,
personally, that decentralization of management of VA medicalk care would be a great
benefit and would allow more bang for the buck, if you will, to get decision-making out
there where it is really being done. So I think it is not only possible, I think it is
likely, and I think there is a strong focus on that in the plan. But at the same time,
because it will represent a major change, a sea change in the way VA has done things for
many, many years, I think much care has to be given to paying close attention to what the
VA is there for; and it is first to take care of patients, the veteran patients. All the
other things feed into that, but that is Job One.
Mr. Bilirakis. Thank you. Well, I think my time has certainly has
expired. On my behalf and the behalf of the committee, I commend you for your courage in
saying basically what comes from the heart.
Mr. Edwards?
Mr. Edwards. Thank you, Mr. Chairman. And thank you all for being here
today. I want to express my special appreciation for your lifetime career commitment,
providing better care for veterans. Veterans are getting better care today because of what
all four of you have done in your careers and I want to thank you for that.
Dr. Spagnolo and Dr. Winship, both of you, in fact, all of you touched
on the issue of eligibility reform and I would like to focus on that and how that ties
into this reorganization plan. Now, the mantra in Washington today is decentralize. I
think generally that is a good concept, but there is a reason we do not just send block
grants back to mayors and county commissioners and governors and say: Spend this on
Veterans Programs as you would like. There is a reason for that; and the reason is that we
want a certain standard of guarantee care to be given to veterans, so I do not favor full
decentralization of veterans programs.
It seems to me, what we need is a balance between decentralized
management and some local flexibility in making management decisions. But we need some
centralized goal settings. What are the standards? What is the care we want to ensure that
all veterans receive wherever they are in the Country, regardless of local managers'
personal views on issues.
I guess, kind of a vague question or concern I might have about
reorganization before you have eligibility reform is that you then have localized
decisions about who is eligible for care. And there is no standard at all about the kind
of care, the kind of criteria we use in determining care for veterans.
Dr. Spagnolo, you said we ought to have eligibility reform before we
have this management reform. I do not know if that is one of the concerns you might have,
but I would like to hear from you and Dr. Winship since you focused on eligibility reform.
Is it essential that we have eligibility reform before this management reform? Or is it
preferable? Or if we do not have eligibility reform first, is it something that we ought
to be concerned about? Could there be some problems resulting from that?
Dr. Spagnolo. I will defer for a moment to my senior person on my left,
but also, if time permitted, would appreciate a comment from one or two of the people that
I brought with me that are very close to the eligibility issue, Dr. Parda and Dr. Burton,
please.
Dr. Winship. VA has been functioning for quite a long time with its
current eligibility mix. Whether eligibility reform ever takes place or not, a lot can be
gained by carrying out the plan. I think in terms of management structure, in terms of
flexibility, in terms of providing the potential, I think we have the potential for
providing better care for the veterans even if eligibility reform did not happen. So I
certainly do not think it has to happen before reorganization can take place.
On the other hand, I believe that one of the most dysfunctional things
about VA system is its eligibility criteria. It is a non-system that has been cobbled
together over decades of this rule and that rule and the other. What really needs to
happen, I think, for good care for veterans, is to define the population of veterans that
the system needs to care for and then care for them. Give them all the care that they
need. That seems to be a very simple prescription, although I understand it must be very
difficult to make that happen because it has not happened.
So I think those can go along in parallel; and I think if this plan gets
put in place before reform, eligibility reform, that is okay. But I do think that
eligibility reform ought not to be taken off the books. I think it is terribly important
for the future of the system for that to occur.
Dr. Spagnolo. I would agree that perhaps they can go hand in hand. I
think if you do reorganize and you have not done eligibility, we are going to be in for a
lot--just as much confusion as we have. And I know, my colleagues who do plastic surgery,
and they are trying to fix a knee, and they are not permitted to fix the foot because the
foot is not the service connected part, but it has something to do with making the knee
better. The only way to get that done is you have to admit the patient. And I am sure that
if Dr. Burton could speak for himself, could tell you all kinds of problems that he has in
the dental service with the same phenomenon.
So it is getting back to providing quality care for the individual
patient. I would like to see both issues on the table because I think the organization
plan will have less chance of succeeding unless you do something with eligibility. Whether
you narrow it or broaden it or whatever you do, you have got to simplify it.
Mr. Edwards. Could I ask, along those lines, and Ms. Smith, Mr. Jasmine,
if you would also like to comment on this on either my first question or my last question
here. Several of you referred to your concerns--Dr. Spagnolo, you specifically on
maintaining specialty care if we change this system as suggested. What do you specifically
recommend that we do to guarantee under this new reorganization that we maintain
commitment to specialty care, specialized care, for veterans?
Dr. Spagnolo. Are you asking me?
Mr. Edwards. Yes.
Dr. Spagnolo. Well, I think we should continue to do some of the things
we are already doing. I am a strong proponent of organizing some of these specialty
centers and making them the best they are in the world. Perhaps that would be able to
shrink some resources from some other areas where they may not need to do that, and you
could funnel them into these specialized cares. I do not think you should lose that. And I
think you should continue to, although I think the focus has got to be on primary care. I
am a great proponent of primary care. But you still have to have the backup of specialty
care to go along with primary care; and I do not think you should begin to jettison that,
which I have already seen little bits of that already happening. I think you have to have
a balance between them both.
Mr. Edwards. Do you think we need Federal standards despite this
decentralization--Federal standards saying that you have local management flexibility, but
you cannot reduce specialized care in certain areas? Do you think we need that kind of
protection?
Dr. Spagnolo. Well, I tend to be less of a--setting up a lot more laws,
but there has got to be some sort of assurances. I am sort of more--the fewer laws, the
better, the happier I am. But I do think there has got to be a balance. Somebody has got
to put in some criteria for balance.
Mr. Edwards. Thank you.
Mr. Bilirakis. Thank you, Chet. Are you done?
Mr. Edwards. Yes, unless Ms. Smith or Mr. Jasmine wanted--I did not want
to cut them off. If you wanted to comment or agree with the comments made, you can.
Ms. Smith. I want to say that I agree with that. I think there has to be
some mandate to maintain the specialty centers or the specialty programs that are
particularly, have been developed, for the veterans.
Mr. Edwards. Thank you.
Mr. Jasmine. I have been in the VA system for a little over 10 years as
a social worker; and I can relate to many of the issues that my colleagues to the left
here address, but I do feel that primary care as well as specialty care should be in here
somewhere because oftentimes VAs are in facilities where--again, I heard just prior to us
coming up, they have got--a gentleman was talking about the length of time that a veteran
has to travel to receive services.
Oftentimes, I mean, this whole process is to look at improving care.
Rather than sending someone across the state to receive services, then it would be nice to
have that service right there; and then the VA can specialize in those various areas. How
it is done, I leave that up to the physicians and the administrators; but I can relate to
that, being a social worker and in the system for a long time and having to develop
transportation resources so that veterans can get to one place to another and oftentimes
the places are so far apart, the veteran would have to spend the night in order to get the
services. So I am in agreement in that and with that.
Mr. Edwards. Thank you. Thank you, Mr. Chairman.
Mr. Hutchinson (presiding). Thank you, Chet. Mike has left, but I wanted
to thank him for sitting in for me; and I want to thank the panel. Now, I did not get to
hear your testimony, but I have surveyed each of your testimony a little bit and scanned
it and appreciate the lines of questions that Chet and Mr. Bilirakis had as well.
I think some of the debate that I have been hearing about how
prescriptive the Federal role should be and how many mandates we should have in
association with the reorganization really parallel the debate I think the Congress has
gone through in giving more authority to the States because we time and time again ran
into the concern that if you give too much authority locally, well, it is not going to be
used correctly and how much should we prescribe from Washington. I think I would agree
with Dr. Spagnolo that in general, I trust them more than I trust us in making the right
decisions.
Dr. Spagnolo. I am glad you said that.
Mr. Hutchinson. But there are some legitimate concerns; certainly in the
area of specialized services and the overall impact of the reorganization.
Dr. Spagnolo, one--when Dr. Kizer testified, I cited for him part of the
Vision for Change in which in defining integrated health care systems, it states that it
requires management of total cost to focus on populations rather than individuals. I think
that I have discerned that that is one of your concerns, that there might be a shift away
from the individual toward the focus on populations.
When I asked Dr. Kizer about that, basically he said that he thought you
could have a management of expenditures and costs and a reduction in overall spending or
control of spending, at least, and at the same time improve the quality of the health care
for the individual veteran. I am interested in your evaluation of that.
Dr. Spagnolo. I do not disagree with that as a principal. I think there
sure are places where we can save money and improve services, but I get a little bit
concerned about the total management approach from some of the organizations in the
private sector.
I am always completely assured that their focus is on quality of care.
And I think everybody in this room knows what quality of care is. That is very hard to
define. But I think when you see it, you know it. I am not sure that seeing a patient, one
patient every 8 minutes is really quality of care. That may be efficient delivery of a
service, but I am not sure that is quality of care. That is what I am concerned. I have
spoken with Dr. Kizer about this, and he is certainly concerned that we have to be careful
about that arena.
Mr. Hutchinson. Do you see the reorganization that he has proposed as
exacerbating that risk?
Dr. Spagnolo. I think it is going to make that one of our major concerns
that we have really got to not lose sight of. I think it would exacerbate that risk, but I
think if it is done--again, I keep coming back to the partnership. Let us talk to the
people that are in the trenches and have them have some input into this.
Mr. Hutchinson. Okay. Dr. Winship, if you could, in a sentence, tell us
the one great risk or the one great concern that you might have regarding the impact that
the reorganization would have upon VA's relationship with medical schools.
Dr. Winship. The one great concern I have is inadvertent dissolution of
some very important and complex ties between academic medical centers, medical schools,
and VA medical centers.
Mr. Hutchinson. Okay.
Dr. Winship. We do not want that to happen.
Mr. Hutchinson. Okay. Now I would like--and with this, I am going to end
my questioning--but I would like to start with Mr. Jasmine, and if each one of you would
give me your evaluation of whether the reorganization plan in general--I know each one of
you have specific concerns and you have expressed them in your testimony--but in general,
whether it will benefit and help the VA system, hurt the VA system in general, or whether
it is just another reorganization and a reshuffling of the cards again.
We will just kind of go through and let you answer.
Mr. Jasmine. I hope it just is not a reorganization and shuffling, but
I----
Mr. Hutchinson. In the Arkansas legislature, that happened all the time.
We would reorganize and nothing different would happen.
[Laughter.]
Mr. Jasmine. I think overall that it would help the VA system. As I
stated throughout my statement, the major concern that I have is that partnership stay
intact, that partnership and the philosophy of partnership not be lost in the
reorganization. And what is key to partnership is those directors at those individual
sites having the ability and the autonomy to deal with those and deal with managing the
human--management resources area and the budgetary.
I think without the director having those kinds of authority, that it
can affect the overall operation of the reorganization as well as affect the effectiveness
of partnerships. Partnerships is one of the key elements, I think, that can make this
reorganization more functional.
To answer your question: Yes, I do think that overall it is good for VA.
Mr. Hutchinson. Thank you. Ms. Smith?
Ms. Smith. I have been around a long time; and I know when we moved from
28 districts to four regions, and now it is back to the 22 VISNs, I think that what is
different about this organization or reorganization is that there is a business component
to it. I think that is a very important element. As we had talked about before, I also
believe that there has to be professional nursing and physician input to make sure that
this remains patient-centered, veteran-centered. But I think it is a good plan.
Mr. Hutchinson. Thank you.
Dr. Spagnolo. I am going to give you a 50/50 analysis. I think, unless
there are some major changes in the way it is structured, it may not succeed. We may just
be reshuffling chairs.
Mr. Hutchinson. All right. Dr. Winship?
Dr. Winship. I believe very strongly that this reorganization plan will
be positive for the VA, and I believe that it stands the best chance of any of those
reorganization plans which I have seen over the last couple of decades to, in fact, be
more than just rearranging the deck chairs on the Titanic.
[Laughter.]
Mr. Hutchinson. Three out of four. We did pretty good there.
I appreciate your candor, really. I think I can, with confidence assure
you that reorganization moving forward will not in any way prohibit or prevent or preclude
what this Congress will do on eligibility reform and that eligibility reform will be
addressed forthwith.
Thank you very much. Mr. Bishop from Georgia, you are recognized.
Mr. Bishop. Thank you very much, Mr. Chairman. I appreciate all of your
testimony. I had to step out for a moment and did not hear Mr. Jasmine. But I was
particularly interested in Dr. Spagnolo when you talked about quality of care. I think
that is what we are all basically concerned about. How do we deliver the best quality of
service to our veterans through the veterans' health system with the proposed
reorganization and the decentralization? You recommend very strongly the specialty care
centers and that there be an emphasis placed on that? Would that then be compatible with
providing vouchers or providing the primary care in the locales or the residents of the
veterans?
Dr. Spagnolo. Yes, I think so.
Mr. Bishop. If they are not close to a VA hospital, or if they are close
to a VA hospital, that the VA hospital shift their focus to specialty care and really
emphasize that and then let the primary care be done pretty much close to home? Then they
only have to go away from home with it is really, really, really called for?
Dr. Spagnolo. I agree. I see no problem with that.
Mr. Bishop. Economically, do you feel that that would be a better use of
the VA resources as opposed to competing on the primary care as well as the specialty care
levels within the health care system?
Dr. Spagnolo. I think you might look at that as a way of saving some
costs.
Mr. Bishop. I would like to hear the reaction to that from Dr. Winship
because you have a particular aspect of academic medicine and the relationship between the
academic as opposed to research in the VA, but also the nurses and the social work
perspective. I would like to hear the reaction to all of that from all four of you.
Dr. Winship. Shall I start?
Mr. Bishop. Yes.
Dr. Winship. You know the VA has had a mechanism for doing what amounts
to vouchering for quite a long time. It really has a fair amount of flexibility and has
for years in terms of being able to provide care locally, where VA care was not available,
or to develop sharing agreements or contractual arrangements where they were important. I
think, to that extent, what I see in this plan will help that and will help the success of
the plan. So I do not see any real conflict.
I think the conflict comes as one says: Well, we will simply do away
with the system, and we will not voucher out all of this care to all the veterans. I think
that is fraught with a lot of difficulty. But to work out an arrangement that would be, I
think, cost effective, but first of high quality, is certainly something that needs to be
looked at.
Now, whether it would be more cost effective to do that--if that is the
question--that simply has to yield to analysis of the specific situation, the specific
locale, and so forth. One of the things that is happening in academic health centers, as
well as in VA, is this move toward primary care and delivery of more care in that fashion,
rather than just being bastions of tertiary care and specialization and
superspecialization. The VA is heading in that direction; we are all heading in that
direction.
I think we can do that together; and the future holds for us to be not
only delivering more care out there in the community than in the hospital-based program,
but to delivering our educational product out there as well, and doing our research there.
I think the future holds all that and we can do that collectively together.
Ms. Smith. I believe that you have to have primary care. I am a primary
care provider, and I work in research But you have to have the two working together. If
you separate them, you are going to run into a lot of difficulty getting care for the
person with the specialty program. At our place, we have a blind rehab. And if those
patients become ill or whatever, they are not followed regularly, they are going to end up
in the hospital. Even when they are in the specialty program, there has to be an
outpatient component to see them.
At the VA--at our VA, we have divided our primary care component into
teams where there are physicians, nurses, practitioners, clerks, into different teams; and
every patient is assigned a team. This team--this patient then has a primary provider, but
should that primary provider not be available, there is somebody else who can see him and
will know his problem.
Also, if they have a problem and their medications have run out, in the
past, they used to come through a walk-in clinic, long, long lines, long waiting time.
Now, they just call their team; and those prescriptions are taken care of. They do not
even have to come in. This has really cut down on waiting lines.
We need to look at these sorts of programs and evaluate them and use
this material. Primary care and specialty go hand in hand. To separate them would be
doing, I think, a disservice to the veteran. It would be fragmenting their care.
Mr. Bishop. Mr. Jasmine?
Mr. Jasmine. And so, but being a social worker, I am right in the
middle. And you are looking at the problems that if yo try to separate primary care from
special care--I just see that that work can go hand in hand. And I kind of agree with the
Members here.
Dr. Spagnolo. If I might just add from maybe the last 2 seconds, the
shift toward primary care, though, does not necessarily require total reorganization of
the VA. And the shift toward primary care means a lot of different things to a lot of
different people. We are going to be training many physicians over the next few years, and
I am sure you would agree to deliver things as internists and primary care doctors they
were never trained to do before, that is going to take a long time to get that effect. The
kinds of changes that you are suggesting are occurring already. That is a better way of
organizing the outpatient and providing services. But again, that really does not require
total reorganization of the VA. Any individual VA hospital could have done this 10 years
ago. But we still do not want to lose sight of the fact of having the people that are
providing the care involved in how we make those decisions, bottom line.
Mr. Hutchinson. Thank you, Mr. Bishop.
Do any other Members have questions of the panel?
Well, then I will thank you very much for your testimony and your time
this morning.
Mr. Hutchinson. And if Panel No. 4 would please come up.
And I would ask of the committee unanimous consent that the statements
of the American Legion and the Vietnam Veterans of America be included in the record.
Without objection. So ordered.
[The statement of Vietnam Veterans of America appears on p. 109.]
[The statement of The American Legion appears on p. 104.]
Mr. Hutchinson. Panel 4 is David Gorman, Deputy National Legislative
Director of the Disabled American Veterans; Terry Grandison, Associate Legislative
Director, Paralyzed Veterans of America.
Thank you for your patience in waiting around until Panel 4. We
appreciate your willingness to be a part of the hearing here today. Mr. Gorman, we will
let you go first. You are recognized.
STATEMENT OF DAVID GORMAN, DEPUTY DIRECTOR, DISABLED AMERICAN VETERANS;
ACCOMPANIED BY TERRY GRANDISON, ASSOCIATE LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF
AMERICA
Mr. Gorman. Thank you, Mr. Chairman. I am going to try to be very brief.
Let me say at the outset, though, that the DAV supports the concept and the framework that
has been embodied in Dr. Kizer's plan in his Vision for Change . I think what I would like
to do--we recognize that as this is the transition, hopefully implementation----
[Sound system interference.]
Mr. Hutchinson. This is an unscheduled witness.
[Laughter.]
Mr. Gorman. That concludes my testimony, Mr. Chairman.
[Laughter.]
Mr. Gorman. But, seriously, I think that as hopefully the VA is allowed
to move into this transition, this change in the way that they deliver health care and
they manage their health care delivery system, many issues that have been thought of
already--and I am sure dozens, if not hundreds that have not been thought of already are
going to crop up. And they are going be addressed in a way that is professional in nature
by the cadre of dedicated and talented VA employees.
If I could, Mr. Chairman, let me--I would like to digress from my
written statement and simply try to address some of the issues and concerns that we have
heard this morning. Although there have been a number of them, I would like to concentrate
on just a couple.
I would think first that from reviewing the plan and hearing Dr. Kizer
and having been briefed on it and being somewhat involved, that it is not really just
another reshuffling of the charts on a piece of paper nor the chairs on a ship. Rather, it
is really, as Dr. Winship alluded to, it is really the first meaningful effort that has
been made, I think, that has a chance of succeeding and putting the VA on a track toward
being able to provide care on a contemporary basis.
I think there is a statement in the plan that sums up the way that this
is proposed real well. And that is to think globally and act locally. I think act globally
can be done from VA Central Office or Headquarters, as they would like to call it in the
future, to manage their system. But I think, also, that even within each VISN the global
aspect of delivering health care is necessary. And it is going to be there. And the local
flexibility that is going to be delivered to the individual medical centers and facilities
is going to be so very crucial to it, toward delivering that care.
The special programs, we have been involved for a long time. The DAV
has, for one; and I know PVA has been involved for an awful long time on this issue. I
want to take issue with one thing that Dr. Kizer said. And that is that the people who
have complained or voiced concern about the special programs have not really met with any
of the service directors. That may be true. I can say categorically that as far as we are
concerned, that is not true.
Going back to 1984 when a reorganization of prosthetics and prosthetics
sensory aid was initiated, we were involved, as was PVA, very actively. In the late '80s
we were involved in a transition of that reorganization in an intimate way with the VA.
They brought us into the picture. In June of 1990, your counterpart on the Senate side
conducted a hearing that was very fruitful; and it really changed the way the prosthetics
services were delivered.
And even today, the DAV, the PVA and the Blinded Veterans Association
are actively involved on an advisory committee, not only for guiding prosthetics, but also
other special disabilities. I think the concern that has been thrown up about these
special programs has really been a--if I could call them--bad apples within the system
have taken and really robbed, if you will, prosthetic funds that were meant for that
purpose and done other things with them.
That has caused a lot of fury, as is should have. And it caused really
the situation that we are in today where the VA has to do the things they do to sort of
fence and protect these funds. It would be our hope, at least from the DAV's perspective,
that the plan, the VISNs, to move forward would alleviate that. It would be out of the
performance measurements and part of the input that Dr. Kizer foresees coming out of his
management councils or advisory councils at each VISN would have an eye on that. And it
would not be done. It is not in the best interest of, certainly, the veterans, nor the VA
for that kind of thing to happen.
We are somewhat confident that with a careful eye, that that is going to
be taken care of. The issue of access that Mr. Bishop and others have referred to, if you
cannot--if you have got the best facility in the world with the best providers, it does no
good if you cannot get to them. I think this plan addresses that in a meaningful way by
setting out parameters where VA can expand into the community and can have points of
access in the community where veterans can come to. Maybe not for all of their care, but
certainly as a point of access, they might be able to be taken care of in that center. And
if not, they can be referred as a built in patient base in a medical center.
The issue of vouchers, I will not pretend to speak for the other
organizations, but I can say that--safely--the issue of mainstreaming I think this voucher
discussion may evolve into has been one that has been around for a long time. It really
started in some depth back when Dr. Kussis was Chief Medical Director in the early 1980s.
It was opposed by virtually everybody. It is not a good idea. The VA is too good a system
and has too many dedicated people within it. It provides good quality care to veterans,
and it is a national asset. Any talk or discussion or thought of doing away with that as a
system would meet from all the energy that our organization could muster.
However, having said that, there are opportunities to provide not
vouchers but fee basis, which VA is into now, and contractual medical care in the
community where veterans cannot access the VA, both from an issue and a standpoint of
access of the system if they are too far away from a medical center and when VA cannot
provide the care because they do not have the expertise of the specialties.
I would--I think, Mr. Chairman, with that, I would wrap my testimony up
and say again that it is--I think I should also recognize that a lot has been said--before
I conclude this morning--about eligibility reform. Can you put one before the other? And I
think perhaps this kind of an effort that Dr. Kizer and VHA is putting forward now is one
that should not wait. It can be done. I do not think it can be done independent of
eligibility reform totally. Eligibility reform remains in our minds and our views the most
critical, crucial issue facing VA today and has been for some time. The organizations have
put together a--which I am sure you have all seen and have laying around--this red booklet
Partnership for VA Health Care Reform, put together by 10 of the service organizations.
The Independent Budget, which has been released and is on the Hill; and you all should
have a copy of it and hopefully you have looked at it as far as the medical care aspect
talks about what needs to be done.
There is a plan out there. If that is done, I think it can not only
improve care to veterans, it can make the lives of VA much easier. I do not think the VA
eligibility clerks could be any more confused in the future than they are right now as far
as veterans eligibility for care. And that sometimes drives veterans away from the system.
So there are a lot of things that can happen, a lot of things that are
happening. This is one very first bona fide effort to step forward and make the system
better than it is today, better for veterans, better for VA, and certainly better for the
American taxpayer.
With that, Mr. Chairman, I will conclude. Thank you.
[The prepared statement of Mr. Gorman appears on p. 93.]
Mr. Hutchinson. Mr. Grandison, you are recognized.
Mr. Grandison. Thank you. Good morning, Mr. Chairman, and members of the
subcommittee. On behalf of the Paralyzed Veterans of America, we appreciate this
opportunity to express our views regarding the Veterans Health Administration
reorganizational proposal.
Mr. Chairman, while PVA supports this effort by the VA to streamline its
management structure and enhance the efficiency of the veterans' health care system, it is
important that we do not lose sight of the VA's primary health care mission. The VA has
historically focused on addressing those medical requirements of veterans which are
related to their military service. For PVA's members, those services have been provided by
the VA system for spinal cord injury and dysfunction care. For other veterans, the VA has
created unique programs focusing on the health care requirements of amputation, PTSD, and
long-term mental health services.
As the VA's restructuring is assessed, it is extremely important that
these core, specialized services are given special consideration. It is essential that
these specialized services are recognized as being the cornerstone of the VA's health care
mission. PVA believes the VHA's reorganizational proposal is one of many steps that must
be taken to carry the VHA into a new and vital future. PVA is also cognizant of the fact
that a missed step along the way could have disastrous implications for disabled veterans.
VA needs to clearly demonstrate that it has the commitment and
capabilities to adjust to the change in health care environment. In particular, special
care must be taken to nurture and protect those services developed to meet the unique
needs of the veterans with spinal cord dysfunction and other veterans requiring VA's
specialized services. VA's spinal cord injury and dysfunction care system affords veterans
access to a complex comprehensive mix of health care services not readily available in the
private sector.
Providing all aspects of necessary medical and rehabilitative services,
the VA incorporates acute, sustaining, and long-term services of veterans who experience
spinal cord dysfunction. The VA's SCI system brings together a range of medical
specialties necessary to address the lifetime requirements of veterans with spinal cord
dysfunction.
Mr. Chairman, if the VHA is to preserve the unique quality and integrity
of spinal cord dysfunction medicine as well as other specialized programs, then VHA must
outline in greater detail the management structure that will ensure system-wide integrity
in the context of a decentralized administration. To ensure this end, PVA recommends an
organization that would do the following: One, protect the resources essential to sustain
strong, specialized service programs; two, develop clinical practice guidelines for
specialized programs such as spinal cord dysfunction medicine and develop standards of
care; three, monitor performance and quality; four, enforce the coordination of funding,
policy, standards, and quality assessment to ensure dependable access and high quality
care for veterans within the service network.
While the need for structural change is acute, the cure for VA's
long-term success and viability will depend on the following initiatives: eligibility
reform, maintenance of VA's core mission of providing specialized services, guaranteed
funding for the provision of care--provision of health care services, and retention of
non-appropriated funds. These changes will provide the VA health care system with the
instruments it needs to provide efficient and quality health care to our Nation's
veterans.
Mr. Chairman, PVA will support the reorganization of VHA. We will assist
in the process in any way we can to ensure the quality of VHA's program for spinal cord
injury and dysfunction, so vital to our members well-being and sustainment. PVA will also
insist on excellence in other specialized services for blinded veterans; veterans in need
of prosthetics; for those in need of special mental health services, such as PTSD. Like
us, these veterans depend on VHA for services that cannot be matched by for-profit
providers.
Mr. Chairman, that concludes my testimony. Thank you.
[The prepared statement of Mr. Grandison appears on p. 96.]
Mr. Hutchinson. Thank you, Mr. Grandison, we appreciate that. And we
certainly appreciate the contribution of both of your fine organizations and look forward
to working with you on the issue of eligibility reform as we see reorganization
implemented.
Now, one of the recurring concerns that we have heard is the issue of
specialized services and whether under reorganization there could be any erosion of
resources and support for those specialized services. And I understand that is of
particular concern to your organization.
Mr. Gorman, if I understood you correctly, you felt that there is no
need for Congressional action or statutory language to protect those resources, that you
will have adequate input as the reorganization is implemented to ensure that. And, Mr.
Grandison, I am not sure--I want both of you to comment on this in just a moment--I know
you emphasized that in reorganization there should be a protection of resources. Do you
feel that you will have input in the implementation of the plan sufficient to ensure that
kind of protection, or does Congress need to do anything?
And let me stop--or start with Mr. Gorman, and let both of you comment
on that.
Mr. Gorman. I would be hopeful that Congressional action is not
necessary. I would not--I do not think that we would recommend that right now that you all
of a sudden take a large chunk of funds for the special programs that have been identified
and say you set those aside and fence those. I think in a lot of ways that may restrict
the flexibility that is needed to manage health care in general.
However, having said that, the issue of specialized services, as I tried
to say, has always been near and dear to us. I am a user of specialized services, as is
Terry, and a lot of members of our organizations. If they are somehow, because it is a
nonprofitable cohort of veterans to treat--if all of a sudden a VISN director or a medical
center director says I can better use these funds over here and not use them for their
intended purpose or not use them to take care of the veterans that actually need them,
then we have got a problem.
I think our focus now is that I think we have to go into this with two
premises: one, a good-faith effort on the part of the VA to do the right thing; and two,
to keep an eye on the process. And I think that we have been doing that through a variety
of ways, particularly the Prosthetics and Special Disabilities Advisory Committee that the
VA has established.
And I think that your role is so very crucial and so very important--and
has been over the years--to keep a look on and an eye on these various programs and see
what has been happening to them. But without any evidence--and I think you need to
strengthen and really drive home continuously that these things are the very essence and
the fabric of why VA was created many, many years ago to take care of the war wounded and
their rehabilitation. And these kinds of special programs and services are very crucial to
that. We can never lose sight of it.
Mr. Hutchinson. Thank you.
Mr. Grandison. Mr. Chairman, I guess I would address this question by
first looking at Title 38 in regards to spinal cord dysfunction medicine. Title 30 makes
no substantive provisions for protection and for the on-going future of spinal cord
dysfunction medicine. In the context of a VISN scenario, as Mr. Gorman stated, spinal cord
dysfunction medicine as well as other specialized programs will be especially vulnerable
to budget and program manipulations. Without statutory protection, there is no way that
PVA can be assured that there will be a viable future for spinal cord dysfunction
medicine. I will give an example to illustrate: Five SCI beds were recently closed at the
West Roxbury VA. These closures were done at the regional office level. These beds were
closed without PVA's consultation, and there is no statutory obligation to come before
Congress with plans to close SCI beds. So we are very concerned about that, and so we are
looking for some assurances. We would also like to thank Mr. Edwards for introducing his
legislation, which does make greater protections for specialized programs. We would like
to thank him for including that language in his Bill. And we would like the opportunity to
work with you to make it even stronger. Although good-faith promises and good-faith
efforts are all well and good; but when it comes down to the actual dollars and cents and
making tough decisions, our membership cannot afford to just wait and rely on that. We
need more than that. Because, again, our members' future medical care depend substantially
on SCI medicine's viability.
Mr. Hutchinson. I think Dr. Kizer's point was that it would be very
short sighted and counterproductive for local directors to divert funds because that is
the strength of the VHA. This is one of the unique services and that that in itself would
be a strong disincentive for them to diminish the role of the specialized services. I
would think also that your organization, if you have adequate input during the
implementation stage, that for us to act now might really be counter to the whole goal of
decentralizing.
Mr. Grandison. I agree in context with Dr. Kizer's statement. Yes, it
would be counterproductive to the system. It would basically compromise the whole VA
health care system, in that regard. But, again, there must be assurances because, spinal
cord dysfunction medicine is a high cost and labor-intensive program. A VISN director
faced with making certain budgetary decisions may view spinal cord dysfunction medicine as
a ripe target for reduction in program services. This is a chance that PVA and other
disabled veterans should not have to face. And as I said earlier, in Title 38 there are no
substantive protections that Title, to protect spinal cord dysfunction medicine. We need
strong legislative language in line with Mr. Edwards' legislation.
Mr. Hutchinson. Okay. Thank you.
Mr. Gorman. If I could, Mr. Chairman, just one other comment. It is sort
of on the other side of the coin. I think, too, that it is very important that when you
have these kinds of specialized programs like spinal cord injury service, for example, and
probably the best example, you have to have that concurrent with an ongoing viable acute
care program. You cannot have the two isolated from each other. So it is okay to get a
real strong assurance that they are going to have and SCI center. But on the other hand,
when they take away the acute care capabilities, it does you very little good to have the
SCI. So I think there is a whole, integrated piece of the puzzle that you have to have
here. I think that is a big part of it.
Mr. Grandison. And I certainly agree with that. They are integral to
each other.
Mr. Hutchinson. Thank you.
Mr. Edwards. Thank you, Mr. Chairman. I will be very brief. And I
apologize for leaving. The Texas delegation is having a photograph taken at 11:45, and I
do not want to hold up the entire delegation. This is certainly far more important
substantively.
I just will be brief in my comments in saying that I hope you will do
two things. One is as this reorganization is put in place, I hope you will pay special
attention to whether there is a good enough information system in place so that we will
know if specialized care--and we will know quickly--if specialized care is being
compromised. I think you are right to be concerned when managers are faced with limited,
finite resources. And the kind of constituencies you represent, the veterans you represent
are very high-cost care recipients in many cases. And it will be tempting for a manager,
not out of ill will, but out of pragmatic decision making to just slowly erode those
specialized services. So the first thing we have got to be sure of is that there is an
adequate, timely information flow. And I hope you will take a look at that.
Secondly, we are just beginning this process. But I know that the
Chairman, Chairman Hutchinson, is pushing very quickly to have eligibility reform on the
front plate, front burner, and in high gear with this committee. He is putting together
legislation now, and I am going to be supportive of his legislation, work with him. My
Bill is kind of a first step. And let us get the debate on the table. But as we work
together on a bipartisan basis with him and Mr. Stump, I hope you will work with us and
help us put language in that eligibility reform bill that does protect specialized care. I
think if we do not have some direct protections over time, not through ill will but just
local management decisions, we are going to see the specialized care erode. And I think
that would be a real tragedy. And I think that would be a first step toward eventually
losing the unique role of the VA health care system. So please work with the Chairman and
me on that. We look forward to working with you.
Thank you, Mr. Chairman. And I apologize for walking out before the end
of the hearing.
Mr. Hutchinson. Not at all. Thank you, Chet.
Did you want to make any comment on Mr. Edwards' statement?
Mr. Grandison. Well, PVA would definitely look forward to working with
Mr. Edwards and you, Mr. Chairman, to effectuate a viable change in the health care
system. We look forward to it.
Mr. Gorman. I think that the effort that was put forth last year in
trying to get this committee reporting on a bill that was--that treated VA and veterans so
very, very well in the area of eligibility reform and how services would be delivered, I
think hopefully that effort is going to carry over and we can all work together toward
that common goal which I think we all recognize and share. I look forward to it.
Mr. Hutchinson. Mr. Bishop.
Mr. Bishop. Thank you very much, Mr. Chairman.
Let me say how much I appreciate Mr. Gorman and Mr. Grandison's
testimony. I was interested. You did comment on the issue that arose earlier regarding the
attitude of veterans toward decentralization and having local service and vouchers as
opposed to getting treatment, primary care, from the VA facilities. I would like to hear
from both you and Mr. Grandison again on that as there is some thought probably outside of
this committee in Congress, some of the budget-cutting committees that are more concerned
with trying to streamline the services, the health care services, that veterans are
getting. And they would like to perhaps see a voucher system which would ultimately either
eliminate, greatly reduce, the primary care that is being provided by the VA system and
make the VA compete with other health care providers. And the survival of the fittest is
sort of the attitude out there. But it seems to me that my concern from the veterans that
I represent, many of whom do not have access, they have distance problems in getting
primary care as well as specialized care, assuming that we hold onto the primary care in
veterans hospitals where they exist. But in the areas where veterans do not have access,
do you feel that this decentralization would be aided by the use of vouchers and
contracting of services in local communities with other health care providers to serve the
needs of veterans in their communities so that they do not have to endure tremendous
travel burdens that many have to endure now?
Mr. Grandison. Mr. Bishop, in regard to spinal cord dysfunction
medicine, it poses a very delicate question because spinal cord dysfunction medicine
cannot operate efficiently without the backup of primary care, tertiary care system.
Spinal cord dysfunction medicine's lifeblood and viability is predicated on that backup.
So in that view, we cannot see how veterans with spinal cord dysfunction can get
consistent medical care, the close nexus between VA's tertiary care system spinal cord
dysfunction centers must continue.
Also, even if vouchers were to be used, particularly in the case of
spinal cord dysfunction medicine, there would be no way to monitor the performance and the
outcomes and quality of care, efficiency, and even access that the veteran with spinal
cord dysfunction will receive from one VISN Network to the other. We would find fragmented
and compromised, a breakdown in the whole specialized service regarding spinal cord
dysfunction medicine. We do not see an operable way for vouchers and specialized programs,
such as spinal cord dysfunction, to operate in a harmonious way.
Mr. Bishop. But I assume that that is not the case with primary care,
though, for the veteran that does not have the need of the special, highly specialized,
services of spinal cord dysfunction but just the general internal types of things that all
of us will eventually need if we continue to live.
Mr. Grandison. The veteran who has a spinal cord injury or spinal cord
dysfunction, there is no provision within the proposal with how that veteran will receive
access to the spinal cord injury center outside his VISN or even within his VISN area, if
the distance is very remote. So there has to be some kind of mechanism even within this
proposal to provide a referral mechanism to get that spinal cord dysfunction veteran to
that particular spinal cord injury center.
But there is no viable option in the private sector regarding spinal
cord dysfunction medicine because there is no private sector facilities that provide the
care that VA spinal cord injury centers provide. Again, spinal cord injured veterans are
not only dealing with the spinal cord and paralysis, but they also have problems with
kidneys; they have problems with the bladder; they have problems with skin ulcers; they
have respiratory problems. So our injuries are not necessarily confined or different from
a veteran who may have an amputation, but still it is the holistic approach to caring for
that veteran and the tertiary backup is needed.
Mr. Gorman. If the concept in which you talk about a voucher, if I
understand it correctly, is to give to a disabled veteran--VA give to a disabled
veteran--a piece of paper that entitles that veteran to, say, $1,000 worth of health care
in the private sector. If that is the definition that you use to frame your question, then
I would say it is not a good idea. Then what you do is you disenfranchise that veteran
from the VA system, and the veteran becomes the indemnifier of that care. If that is the
case, you might as well do away with the VA and do what Medicare does, just pay for the
care.
There are too many good things the VA does to do that. I use the VA
system; and quite frankly, I would be very apprehensive, if not scared, to be given a
voucher like that to go to the private sector. No one has convinced me, number one, that
the VA care is inferior to the private sector. No one has convinced me, on the other hand,
that the private sector can take care of my general medical needs and my specific medical
needs adequately. And I do not think they can, to be frank with you. I am an amputee, and
I have been using the VA for 25 years, and I am satisfied with it. I would not like to go
to Dr. Jones cold and present him with my problem. He may be an excellent physician, but I
do not think he understands my problem with my knees.
Again, once--sometimes once you let a contractor or low bidder, which
perhaps the voucher system would be, and it may be good for the life of that contract,
which could be short term, maybe a year. At the end of that year, what happens when that
provider comes back to the VA and says: I am going to continue to take care of your
veteran, but not at the cost I did last? So you have no control, as Terry says, either
with the quality of the care, which is more critical as far as we are concerned, or the
management and cost of the care.
In your scenario that we are trying to get to is: When a veteran is so
distant from VA and there is no VA identity there in the community, should that veteran
have to travel X number of miles to the VA to get care. And the answer, I think is: No, he
should not have to or she should not have to. The VA has a very vital ongoing fee-basis
program where they do that on a monthly basis. The veteran is allowed, if you will,
without question to use X number of dollars to purchase care from a--I am blocking the
word I want--from a provider that has already been approved by VA.
If the need is for more care, for more dollars to purchase more care as
they need it, that can be approved by the VA on an ongoing basis. But there is that
monitoring system in the process. But I think to simply hand the voucher and the dollars
to the veteran does not do the veteran any good. It may, in fact, do the veteran a lot of
harm.
Mr. Hutchinson. Thank you, Sanford.
I want to thank Mr. Gorman, Mr. Grandison and all of the witnesses today
for their contribution to the hearing.
This hearing is adjourned.
[Whereupon, at 11:58 a.m., the subcommittee was adjourned.]
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