Witness Testimony of Michael E. Moreland, FACHE, Director, Veterans Integrated Service Network 4 Veterans Health Administration, U.S. Department of Veterans Affairs
Chairman Runyan and Members of the Subcommittee, it is my pleasure to be here today to discuss VA’s efforts to provide the best care possible to Veterans residing in Central and Southern New Jersey. Joining me today are Joseph Dalpiaz, Director of the Philadelphia VA Medical Center (VAMC) and Robert McKenrick, Director of the Philadelphia VA Regional Office (VARO).
I will begin my testimony by furnishing an update on how VHA and the Veterans Benefits Administration (VBA) collaborate on compensation and pension examinations, to include the scheduling of those exams. I will also review VHA services provided to New Jersey Veterans.
Compensation and Pension Examinations
VHA and VBA work together to deliver compensation and pension (C&P) examinations for Veterans. VISN 4 monitors and ensures access to these exams through dedicated staff that coordinate between VA medical centers and VBA regional offices. VISN staff also coordinate efforts related to the Integrated Disability Evaluation System (IDES) and provide additional resources when needed to VA medical centers. In the Third Congressional District of New Jersey, the vast majority of Veterans receive their C&P examinations at the Philadelphia VAMC, while a small number visit the Wilmington VAMC or a VA community-based outpatient clinic. In addition, VHA also coordinates some examinations through contract provider, QTC. This contract has allowed the Philadelphia VAMC to conduct additional clinical examinations. QTC has performed 38 audiology C&P examinations since November 2011. QTC conducts its examinations at sites closer to where Veterans live, including several locations in New Jersey.
At the Philadelphia VAMC, the current average wait time between when an appointment is scheduled and the date of the C&P examination is between 13 and 16 days. In February 2012, the national average was 25 days. The Philadelphia VAMC has made tremendous progress over the last 3 years in reducing the rate of patient no-shows for these exams, cutting the figure in half from 15 percent in FY 2009 to 7.5 percent in FY 2012. This is particularly noteworthy as the total volume of examinations conducted at the Philadelphia VAMC has increased over the same time period by more than 20 percent (18,718 examinations in FY 2009 and 23,132 examinations in FY 2011).
The Philadelphia VAMC implemented several process changes and increased staff capacity and proficiency in FY 2011. The facility has restructured all C&P clinical appointment profiles to better manage the increasing complexity of examinations requested and is scheduling C&P clinics on weekends and holidays to enhance capacity and convenience for Veterans. A new physician sharing program has one physician travel from the Philadelphia VAMC to the Philadelphia VARO to provide one-day turnaround service on priority cases that do not require an on-site examination. Leadership at the Philadelphia VAMC reviews C&P performance measures on a weekly basis and develops strategies as appropriate to implement corrective action when necessary.
One final innovation particularly helpful to Veterans of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) involves a revision to examinations conducted for traumatic brain injuries (TBI) to expedite the examination, thereby reducing the need for multiple reviews and simplifying the process for Veterans. Philadelphia determined that 70-80 percent of the Veterans presenting for TBI were not scoring well enough on their initial screen to avoid a second appointment with neuropsychology. Previously, this would require these Veterans to schedule a second appointment and return to the medical center at a later date. Philadelphia staff considered this a hardship for the Veterans, as a large number of the patients have a significant disability.
To address the issue, Philadelphia changed their process for providing the TBI exam. They worked with neurology service to hold appointments available for the days that Veterans were scheduled for their initial TBI exam. If the Veterans scored low and required the second appointment, they would be scheduled later that same day to complete the neuropsychology exam, without the need for a return visit. This process has shaved approximately 5-15 days off the exam completion time and eliminated the need for return visits.
At the Wilmington VAMC, the average wait time for a C&P examination is between 10 and 14 days. The Wilmington VAMC conducts all C&P examinations on-site, and is exploring options that would use telehealth to conduct certain types of examinations at community-based outpatient clinics in New Jersey and Delaware. The Wilmington VAMC has seen an even greater increase in the number of C&P examinations conducted between FY 2009 and FY 2011 than the Philadelphia VAMC, growing by more than 33 percent (4,902 examinations in FY 2009 and 6,553 examinations in FY 2011). The Wilmington VAMC no-show rate has remained fairly constant and is currently at 10.8 percent for FY 2012.
The Wilmington VAMC has also improved its processes. It has added staff in C&P clinics to allow greater flexibility in patient scheduling, including evening and weekend hours. The facility has identified a new C&P physician leader who works with the Philadelphia VARO on pending issues and to support collaborative problem solving. Wilmington VAMC is also looking at opportunities to support the Dover Air Force Base and the Philadelphia VARO as part of the IDES process. Finally, the Wilmington VAMC is exploring ways to increase the use of telehealth to conduct behavioral health C&P examinations at any of five community-based outpatient clinic locations this fiscal year.
Both the Philadelphia and Wilmington VAMCs use a proactive, patient-centered approach to scheduling appointments by contacting patients and establishing appointment times that are as convenient as possible for Veterans. These facilities also make reminder calls to Veterans prior to their scheduled appointments to reduce the no-show rate. VA has established a national benchmark of 30 days for a cumulative average processing time for these examinations, and in each month of FY 2012, both the Philadelphia and Wilmington VAMCs exceeded the national benchmark (25-day average at Philadelphia and 20-day average at Wilmington). This represents a significant improvement for the Philadelphia VAMC, which had an average processing time of almost 35 days in FY 2010. The vast majority of examinations conducted also pass all quality indicators for sufficiency and consistency between the available medical evidence and the examination report. Since FY 2009, the insufficiency rate at both Philadelphia and Wilmington was at or below 0.5 percent. VA’s national benchmark for this figure is 1 percent, with a smaller figure being better.
VISN 4 Overview: Central and Southern New Jersey
Veterans Integrated Service Network (VISN) 4 consists of 10 VA medical centers and 43 community-based outpatient clinics (CBOCs), 17 Vet Centers and one rural mobile clinic, which serve 104 counties throughout Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. Almost 455,000 Veterans are enrolled in VA’s health care system in VISN 4, and more than 318,000 unique Veterans received health care in VISN 4 during fiscal year (FY) 2011. Between FY 2010 and FY 2011, we saw modest growth in the number of Veterans using VISN 4 for health care, despite a slight decline in the total number of Veterans enrolled. VISN 4 employs 13,144 people and has a total operating budget of $2.44 billion.
In close proximity to the Southern New Jersey Veteran population, VA and VISN 4 operate medical centers in Philadelphia, PA and Wilmington, DE. As evidence of the accessibility of our inpatient services, 86 percent of urban Southern New Jersey enrollees live within a 60-minute drive of these facilities, while 100 percent of rural Southern New Jersey enrollees live within 90 minutes or less of these facilities. Approximately 82 percent of Veteran enrollees in Southern New Jersey live in urban areas, with the remaining 18 percent considered rural. The VA standard is that 65 percent of Veterans meet that level of access, which indicates that VISN 4 exceeds the current guidelines. To provide convenient outpatient care in Southern New Jersey, Philadelphia VAMC operates CBOCs in Gloucester County and Ft. Dix in Burlington County, as well as an annex clinic in Camden County. Wilmington VAMC serves New Jersey area Veterans at CBOCs in Northfield in Atlantic County, Vineland in Cumberland County, and Cape May in Cape May County. VISN 3 operates other VA facilities in New Jersey as well. Counseling, outreach and referral services are also provided to Veterans in the Southern New Jersey area in Vet Center locations in Philadelphia (two sites), Ewing, Lakewood, and Ventnor.
Specific to the Third Congressional District of New Jersey, VA provides care to Veterans in Burlington and Camden Counties through services available at the previously-mentioned VAMCs in Philadelphia, PA, and Wilmington, DE, as well as the CBOC at Ft. Dix in Burlington County, and the annex clinic to the Philadelphia VAMC in Camden County. According to data published by the Joint Commission, a national hospital accreditation organization, these two facilities perform as well or better than their local private sector counterparts in all metrics for which there is sufficient data for comparison. In Ocean County, the majority of Veterans receive care from facilities located in VISN 3.
An estimated 61,000 Veterans reside in Burlington and Camden counties. In FY 2011, 19,455 Veterans from Burlington and Camden Counties were enrolled in VA’s health care system. For that same time period, the medical centers in Philadelphia and Wilmington treated 5,586 unique patients from Burlington County and 5,721 from Camden County.
VA has established a standard that 70 percent of Veterans have access to primary care within a 30 minute drive of their residence. VISN 4 surpasses this requirement in Burlington County, where 94 percent of total enrollees live within 30 minutes of primary care, and in Camden County, where 100 percent of Veterans have this ready access. In VISN 3, approximately 90 percent of Ocean County Veterans have access to primary care within 30 minutes.
The Philadelphia VAMC is an acute care, teaching hospital, providing comprehensive patient care services, including primary care, tertiary care, and long-term care in areas of medicine, surgery, psychiatry, rehabilitation, neurology, oncology, dentistry, and geriatrics. A wide range of specialty care services are offered to Veterans at Philadelphia, such as substance use disorder treatment; mental health care, including evidence-based treatment for post-traumatic stress disorder (PTSD); hemodialysis for Veterans with kidney disorders; skilled nursing home care; respite care; Home-Based Primary Care; laser surgery; and other intensive care programs. High-tech diagnostic services such as computerized tomography (CT) and magnetic resonance imaging (MRI) complement the treatment modalities. In May 2012, the medical center will open an outpatient dialysis center for Veterans, and already operates a Women's Health Clinic providing primary and gender-specific specialty care to female Veterans. The facility’s 240-bed Community Living Center serves the metropolitan Philadelphia area and provides extended care, rehabilitation, psycho-geriatric care, palliative care, and general nursing home care to area Veterans.
Philadelphia also operates several Centers of Excellence, including:
- The Mental Illness Research, Education and Clinical Center (MIRECC), which focuses on improving the identification of substance abuse and other mental health problems in Veterans;
- The Center for Health Equity Research and Promotion (CHERP), which works to reduce disparities and promote equity in health care among vulnerable groups of Veterans; and
- A Parkinson’s Disease Research, Education and Clinical Center (PADRECC), one of six such facilities that strive to improve care for Veterans suffering from Parkinson’s disease and other related movement disorders.
The acute care facility in Wilmington, DE is a teaching hospital that provides a full range of patient care services. Comprehensive health care is provided through primary care and long-term care in several areas of medicine, including surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and extended care. Wilmington VAMC also provides comprehensive primary care for women Veterans.
VHA and VBA are a strong team providing a full range of benefits and health care to Central and Southern New Jersey Veterans. VBA and the Philadelphia VA Regional Office, together with VHA and VISN 4, strive to furnish Veterans with timely and accurate compensation and pension evaluations. VISN 4 is committed to ensuring access to comprehensive health care through primary, acute inpatient, and long-term care in areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and extended care. Mr. Chairman, this concludes my testimony. My colleagues and I look forward to answering any questions you may have. Thank you.
 See The Joint Commission, Quality Measure Set Comparison between Wilmington VA Medical Center and Christiana Care Hospital, July 2010-June 2011. Available online: http://www.qualitycheck.org//Consumer/SearchQCR.aspx. See The Joint Commission, Quality Measure Set Comparison between Philadelphia VA Medical Center and Pennsylvania Hospital, July 2010-June 2011. Available online: http://www.qualitycheck.org//Consumer/SearchQCR.aspx