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Hearing on Healthcare-Recruitment and Retention.

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OCTOBER 18, 2007

SERIAL No. 110-55

Printed for the use of the Committee on Veterans' Affairs




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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



October 18, 2007

Healthcare Professionals—Recruitment and Retention


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Shelley Berkley


U.S. Department of Veterans Affairs, William J. Feeley, MSW, FACHE, Deputy Under Secretary for Health for Operations and Management, Veterans Health Administration
    Prepared statement of Mr. Feeley

American Federation of Government Employees, AFL-CIO, J. David Cox, R.N., National Secretary-Treasurer
    Prepared statement of Mr. Cox
American Legion, Joseph L. Wilson, Assistant Director for Health Policy, Veterans Affairs and Rehabilitation Commission
    Prepared statement of Mr. Wilson
American Physical Therapy Association, Jeffrey L. Newman, PT, Member, and Chief, Physical Therapy Department, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN
    Prepared statement of Mr. Newman
Association of American Medical Colleges, Richard D. Krugman, M.D., Chair, Executive Council, and Dean and Vice Chancellor for Health Affairs, University of Colorado School of Medicine
    Prepared statement of Dr. Krugman
CACI Strategic Communications, Jim Bender, Communications Services Manager
    Prepared statement of Mr. Bender
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
    Prepared statement of Mr. Ilem
National Board for Certified Counselors, Inc. and Affiliates, Kristi McCaskill, M.Ed., NCC, NCSC, Counseling Advocacy Coordinator
    Prepared statement of Ms. McCaskill


American Academy of Physician Assistants, statement
Miller, Hon. Jeff, Ranking Republican Member, and a Representative in Congress from the State of Florida, statement
Nurses Organization of Veterans Affairs, statement
Salazar, Hon. John T., a Representative in Congress from the State of Colorado, statement


"The Best Places to Work in the Federal Government—2007 Rankings," Veterans Health Administration Ranking Index Score, from the Partnership for Public Service and American University's Institute for the Study of Public Policy Implementation

Break down of the healthcare professionals hired within the last 9 months (particularly licensed professional counselors, (Monthly Distinct Employee for Non-Med Resident, GAIN, VHA (Occupation Name), requested by Chairman Michaud during the hearing

Post Hearing Questions and Responses for the Record:

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Jeffrey L. Newman PT, Chief Physical Therapy Department, Minneapolis VA Medical Center, and Member, American Physical Therapy Association, letter dated October 19, 2007, and response letter dated December 3, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Richard D. Krugman, M.D., Dean, University of Colorado Health Science Center School of Medicine,  letter dated October 19, 2007, and response letter dated December 4, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Jim Bender, Communications Service Manager, CACI Strategic Communications, letter October 19, 2007, and response from Deborah Lee, Project Manager, CACI, Inc., Strategic Communications Division, dated December 4, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Joseph L. Wilson, Assistant Director, Veterans Affairs and Rehabilitation Commission, American Legion, letter dated October 19, 2007, and response from Steve Robertson, Director, National Legislative Commission, American Legion, letter dated December 4, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Joy J. Ilem, Assistant National Legislative Director, Disabled American Veterans, letter dated October 19, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to J. David Cox, National Secretary-Treasurer, American Federation of Government Employees, AFL-CIO, letter dated October 19, 2007

Hon. Michael Michaud, Chairman, Subcommittee on Health, Committee on Veterans Affairs, to Hon. Gordon H. Mansfield, Acting Secretary, U.S. Department of Veterans Affairs, letter dated October 19, 2007

Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, Committee on Veterans' Affairs, to Hon. Gordon H. Mansfield, Acting Secretary, U.S. Department of Veterans Affairs, letter dated October 31, 2007


Thursday, October 18, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Brown of Florida, and Berkley. 


Mr. MICHAUD.  I would like to call the Subcommittee to order.  Members will be here throughout the hearing.  We will actually be having votes, as well as a journal vote, early, so we will try to start on time and recess if we are not done at that time.

Today, the Subcommittee hearing will be on issues regarding recruitment and retention of healthcare professionals within the Veterans Health Administration (VHA) system.  Healthcare professionals are VHA's most important resources in delivering high-quality healthcare for our Nation's veterans.

So without further ado, I request unanimous consent to have my full statement submitted for the record and any other Members when they return or come.

[The statement of Chairman Michaud appears in the Appendix.]

Mr. MICHAUD.  On the first panel today we have Jeffrey Newman, Chief Physical Therapist from the Minneapolis Veterans Affairs (VA) Medical Center, who is here on behalf of the American Physical Therapy Association (APTA). 

I want to thank you very much, Mr. Newman.  It is great to see you.  Once again, I did have a great opportunity to visit Minneapolis VA facility and was extremely impressed.

Also on panel one is Dr. Krugman, Chair of the Executive Council for the Association of American Medical Colleges (AAMC), and Dean of the University of Colorado School of Medicine.  I would like to welcome you, Doctor.

And also Kristi McCaskill, Counseling Advocacy Coordinator for the National Board for Certified Counselors (NBCC), Inc. and Affiliates.  I welcome you as well.

And fourth on panel one is Jim Bender, Communications Services Manager for CACI Strategic Communications.  I would also like to welcome you, Jim, today and look forward to all of your testimony.

And we will start off with Mr. Newman and work down the table.  So, Mr. Newman.



Mr. NEWMAN.  Mr. Chairman, Members of the Subcommittee, thank you for the opportunity to testify on the recruitment and retention of healthcare professionals who work in the U.S. Department of Veterans Affairs (VA). 

I have practiced as a physical therapist in the VA system for more than 30 years and for 20 of those years, I have served as Chief of Physical Therapy at the Minneapolis VA Medical Center in Minneapolis, Minnesota.

I come before you today as a member of the American Physical Therapy Association.  In my experience, I have seen the physical therapy profession advance to meet the changing rehabilitation needs of our patients.

The primary challenge to meet the rehabilitation needs of veterans is the recruitment and retention of physical therapists.  This challenge is compounded by two trends that increase the need for physical therapists, chronic conditions associated with an aging veteran population and the complex impairments associated with returning veterans from the conflicts in Afghanistan and Iraq.

In my remarks today, I will discuss the increased need for physical therapists in the VA, highlight current challenges with recruitment and retention, and make two specific recommendations to help meet these challenges and ensure our Nation's veterans the accessibility and availability to the physical therapist services they need.

These recommendations include the immediate approval and implementation of pending qualification standards and enhancements to current VA scholarship programs.

With more than 1,000 physical therapists on staff, the VA is one of the largest employers of physical therapists nationwide.  Physical therapists have a long history of providing care to our Nation's veterans.  In fact, our professional roots started by rehabilitating soldiers as they began returning from World War I.

Today physical therapists in the VA render evidence-based, culturally-sensitive care and have been recognized leaders in clinical research and education.  The need for high-quality rehabilitation provided by physical therapists has never been greater with the dual challenges of caring for the chronic diseases faced by aging veterans and the multifaceted profile of many of today's wounded warriors.

According to the VA, 9.2 million veterans are age 65 or older.  Among this aging veteran population, many have diabetes.  Physical therapists assist patients in regaining mobility and function lost due to diabetes and its complications as well as its prevention strategies.

Many of our Nation's recent veterans are facing unique injuries that require complex rehabilitation including spinal cord injury, amputee rehabilitation, and traumatic brain injury (TBI).

Physical therapists are a key part of the VA's polytrauma rehabilitation centers caring for TBI patients in Tampa, Palo Alto, Richmond, and at my facility in Minneapolis.

Minneapolis has had a TBI program with dedicated staff and TBI rehabilitation for over ten years.  We have physical therapists on staff who have received specialist certification in neurological, geriatric, and orthopedic physical therapy.

My specific clinical background is in amputation rehabilitation.  I have had the honor of caring for a generation of veterans and have been able to see the growing need for physical therapist services through the years.

The number one obstacle to both the recruitment and the retention of physical therapists to serve in the VA is the severely outdated qualification standards that currently govern the salary and advancement opportunities for physical therapists employed by the VA.

These standards have not been updated for nearly 25 years.  For example, the current minimal requirement to become a physical therapist is to graduate with a Master's Degree.  Approximately 80 percent of programs now are graduating at the doctoral level and pass a licensure test.

The current VA qualification standards have a minimal requirement of obtaining a Bachelor's Degree but do not recognize the Doctor of Physical Therapy Degree or DPT Degree programs.

The need for immediate approval of these revised standards is due to several factors.  First, the demand for physical therapy services is on the rise. 

Second, the increased need for services provided by qualified physical therapists in the VA due to aging veterans and meeting the complex needs of our soldiers returning from Iraq and Afghanistan. 

Third, the outdated qualification standards also limit the ability of a physical therapist to advance within the VA system once they have joined.  The current standards do not recognize physical therapists that achieve specialty certification such as those needed in the polytrauma centers.

Fourth, it has been at least six and one-half years since the VA first recognized that the standards needed to be updated, yet no revisions have been implemented.

In addition to the immediate approval and implementation of revised qualification standards, I recommend enhancements to the current VA scholarship programs to help in both recruitment and retention.  Many new graduates are concerned with a high amount of student loan debt. 

I had the opportunity to serve on the Committee to review scholarship program applicants in the early 1990s when the VA had a very successful scholarship program to attract new graduates.  That scholarship program provided an incentive to serve right out of school, whereas the new program is poorly advertised and cumbersome.  We are in need of better incentives to pull more graduates into the VA system.

In closing, APTA recommends the immediate approval and implementation of the qualification standards for physical therapists and the investigation of options to enhance current programs offering scholarships, loan support, and debt retirement for physical therapists choosing to serve in the VA.  This will assist in both the recruitment and retention of physical therapists to meet the needs of our veterans of today and tomorrow.

Thank you, Mr. Chairman, for this opportunity.  I would be happy to answer any questions from you or other Committee Members at this time.

[The statement of Mr. Newman appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Newman.



Dr. KRUGMAN.  Good morning.  And thank you, Mr. Chairman, for the opportunity to testify this morning on the retention and recruitment of health professionals at the VA.

My name is Richard Krugman.  I am Dean of the University of Colorado School of Medicine and Vice Chancellor for Health Affairs there.  We are affiliated with the Denver VA Medical Center and the Rocky Mountain Veterans Integrated Service Network (VISN) Network 19.

I am also Chair of the Association of American Medical Colleges and Member of the VA Dean's Liaison Committee of the AAMC which is a not-for-profit representing 126 accredited medical schools, 107 of which are affiliated with VAs and nearly 400 major teaching hospitals and health systems including 68 medical centers.

We would like to thank the Committee for your support of the VA appropriation in 2008.  Your leadership resulted in the House's passage of $36.6 billion for VA medical care and $480 million for VA medical and prosthetics research.  This funding is crucial to the continued success of the primary sources of VA physician recruitment and retention, namely academic affiliations, graduate medical education (GME), and VA research.

While the VHA has made substantial improvements in quality and efficiency, the veteran service organizations cite excessive waiting times, delays as the primary problem in veterans' healthcare.

Without increases in clinical staff, the demand for healthcare will continue to outpace the VA's ability to supply timely healthcare services and will erode the world-renowned quality of VA medical care.

Concerns about physician staffing at the VA come at a time when the Nation faces a pending shortage of physicians.  Recent analysis by the AAMC's Center for Workforce Studies indicates the United States will face a serious physician shortage in the next few decades.

Our Nation's rapidly growing population, increasing number of elderly Americans, an aging physician workforce, and a rising demand for healthcare services all point to this conclusion.

The VA has been the first to respond with plans to increase its support for graduate medical education.  Under the GME Enhancement Initiative, the VA plans to add an additional 2,000 physicians for residency training over five years.  This will restore VA funded physicians to approximately 11 percent of the total GME physicians in the United States.  The expansion began in 2007 when the VA added 342 physicians.

The smooth operation at the VA's academic affiliations is crucial to preserving the health professions workforce needed to care for our Nation's veterans.  The VA's AAMC Dean's Committee meets regularly to maintain an open dialogue and provide advice on how better to manage our joint affiliations.

The VA has consistently recognized that there is room for improvement.  As such, the AAMC looks forward to working on other matters of concern.

As medical care shifts to more satellite-based outpatient approaches, graduate medical education needs to follow suit.  This strong shift to ambulatory care at multiple sites requires a similar locus of change in medical training.

The dispersion of patients to multiple sites of care makes more difficult the volume of patient contact crucial to medical training.  Similarly, faculty diffusion makes it more difficult as well.

This is not exclusively a VA problem.  And one of the key points I would like to make is that the issues faced by VA physicians are precisely the same that we as deans of medical schools face in recruiting and retaining faculty in the current economic environment in this country.

Another concern at both VA and non-VA teaching hospitals is the growing salary discrepancy.  This discrepancy continues to be a concern and it is increasingly difficult to recruit residents and students to our programs.

In recent years, the funding for VA medical and prosthetics research has failed to provide the resources needed to maintain, upgrade, and replace aging facilities.  Many VA facilities have run out of adequate research space.  And, again, the recruitment of physicians who are interested in research and education and the support of those interests will be critical to retaining a VA workforce.

The AAMC recommends an annual appropriation of $45 million in the VA's minor construction budget dedicated to renovating existing research facilities to try to replace at least one outdated facility per year.

Mr. Chairman, Members of the Committee, thank you for the opportunity to testify on this important issue.  I hope my testimony today has demonstrated that the recruitment and retention of an adequate physician workforce is central to the success of the VA's mission. 

The extraordinary partnership between the VA and its medical school affiliates coupled with the excellence of the VA medical and prosthetics research program allows the VA to attract the Nation's best physicians.

Over the last 60 years, we have made great strides toward preserving the success of these affiliations and with our hard work, I am confident that this success will continue.

Thank you.  I would be happy to answer any questions at the appropriate time.

[The statement of Dr. Krugman appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Doctor.

Ms. McCaskill?


Ms. MCCASKILL.  Mr. Chairman and Honorable Members of the Veterans' Affairs Committee, I appreciate the opportunity to present testimony regarding the need for additional mental healthcare providers in the VA.

My name is Kristi McCaskill and I am the Counseling Advocacy Coordinator at the National Board for Certified Counselors.  I possess a Master's Degree in Counseling from the University of North Carolina at Chapel Hill. 

For the past few years, I have worked with professionals who have been certified by NBCC as they explain their qualifications to prospective employers, public, and legislators.  I, too, am certified by the NBCC and understand the value of counseling and counseling credentials.

NBCC is the Nation's premier and largest professional certification board devoted to the credentialing of counselors holding Master's level or higher degrees.  These counselors must meet standards for the general and specialty practices of professional counseling.

Founded in 1982 as an independent, nonprofit credentialing body, NBCC provides a national certification system for those counselors and administers the Ethics Code for those counselors.  Currently we have more than 42,000 active certificates living and working in the United States and in over 40 countries. 

NBCC and licensed professional counselors are pleased with the passage of Public Law 109-461.  This legislation explicitly recognizes licensed professional counselors as healthcare providers within the Veterans Healthcare Administration.

Unfortunately, it appears to us that despite the passage of this law, licensed professional counselors still have a very limited role as mental health providers in the VA in the nearly ten months since the law was enacted.

Our veterans have unprecedented needs and these needs deserve to be met.  Nationwide there are over 100,000 professional counselors licensed to practice independently and this number is growing.

In addition to completing rigorous degree programs, professional counselors must document supervised, professional practice, pass a national counselor examination, submit a professional disclosure statement, and keep current their professional education.

Following licensure, these individuals provide quality mental health services to citizens.  Counseling treatment comes in many forms and deals with problems such as stress, anxiety, depression, divorce, death, post traumatic stress disorder (PTSD), and other psychological or behavioral disorders common among our veterans.

Congress has passed a law recognizing counselors as eligible to provide mental health services within the VA.  In addition, a sufficient number of skilled professionals are available to provide these services.  The VA and Congressional leaders must find a way to ensure that skills offered by counselors are readily available to meet the increasing mental health needs of our citizen heroes.

NBCC stands ready, willing, and able to assist in this effort.  Thank you for your time to speak on such an important subject.

[The statement of Ms. McCaskill appears in the Appendix.]

Mr. MICHAUD.  Thank you.

Mr. Bender?


Mr. BENDER.  Mr. Chairman and Members of the Subcommittee, thank you for inviting CACI to contribute to the discussion on healthcare recruitment and retention.

CACI has been instrumental in the advancement of recruitment marketing, research, and strategy and practice for more than 15 years.  Our clientele include the National Security Agency, the National Guard Bureau, the Corporation for National and Community Service, and the Veterans Health Administration.

My name is Jim Bender and I am one of the architects of the VA Nurse Recruitment Pilot Study I will address today.

In February of 2006, in response to the "Veterans Health Programs Improvement Act of 2004," VHA's Healthcare Retention and Recruitment Office (HRRO) contracted with CACI to conduct a pilot program to test and recommend innovative recruitment methods for hard-to-fill healthcare positions.

From a pool of 17 pilot site applicants, the North Florida/South Georgia Veterans Health System was chosen as the pilot location.  The system's unique recruitment challenge was finding nurses with enough experience to fill higher level nursing positions. 

Our objective going into the North Florida/South Georgia System was to test methods to enhance effectiveness in four key areas.  Number one; employer branding and interactive advertising strategies; number two, internet technologies and automated staffing systems; number three, the use of recruitment, advertising, and communications agencies; and, number four, streamlining the hiring process.

Subsequently the study was divided into two distinct operations.  One was focused on recruitment marketing with a goal of increasing the number of qualified applications coming into the system.  The second was business process reengineering with the goal of decreasing the administrative time between application receipt and job offer.

An abundance of anecdotal evidence suggests that VA loses good candidates because of the lengthy boarding process.

The program was conducted over 60 days beginning February 5th, 2006.  All activities were monitored and measured to evaluate the results.

On the recruitment marketing side of the operation, the findings were exceptionally optimistic.  The recruitment marketing campaign generated 10,261 inquiries into nursing positions for experienced nurses.  An inquiry was defined as a response to recruitment advertising or similar communications outreach.

Of those inquiries, 115 candidates submitted applications.  Most impressive was the percentage of applicants uniquely qualified to fill the advertised positions.

During March of 2006, the only full calendar month of the study, the number of applicants for nursing services who passed the initial screening process increased by 83 percent over the month prior from 12 applications to 22 and 300 percent over the trailing five-month average from 7.4 applicants to 22.

The recruitment methods that garnered these results included a strategy based on the principles of employer branding and market segmentation in addition to vigorous use of interactive media and internet technologies which delivered the highest return on investment of any media in the study.

The pilot program recommendations embraced these methods and further suggested the use of database marketing, relationship building, especially with the student population, employee referral programs, budget modifications, and improvements to organizational communications.

On the business process side, the results were equally optimistic.  A comparison of current hiring processes to what-if scenarios revealed that a small number of process changes could significantly accelerate the time to hire.

The process changes that would actualize these what-if scenarios include the delegation of approval authority for routine recruitment activities, the implementation of an automated recruitment and management work-flow system to eliminate delays in paper-based, mail-in processing, and several modifications to standard processes that build delays into the system.

We at CACI believe healthcare recruitment at VHA is both strong and spirited.  HRRO, in addition to the exceptional staff and leadership at the North Florida/South Georgia System, embraced this project with enthusiasm and sustained intellectual vigor.

Since the pilot's conclusion, we have seen continued movement toward the methods tested in the pilot project including increased use of targeted e-mail communications, expanded use of on-line job postings, and greater promotion of employee referral programs as well as a persistent hunger for new, progressive ways of engaging healthcare professionals.

In closing, thank you once again for the opportunity to present CACI's conclusions on the Nurse Recruitment Pilot Study and thank you for the opportunity to contribute to the continued health and welfare of our country's veteran population.  I look forward to your questions.

[The statement of Mr. Bender appears in the Appendix.]

Mr. MICHAUD.  Thank you.

I would like to thank once again all four panelists.  Great testimony.  And I will have a lot of questions.  But at this time, because of the vote, we will recess.  We should be back shortly.  As I understand it, there is only one vote.  So if you can hold your thoughts and get ready for the questions, I will try to drum up more Members to be here so that they can ask questions.

Do you have a question right now, Ms. Berkley?


Ms. BERKLEY.  I am not going to be able to come back.  We also have the swearing in of the new Member afterwards and I think many people are going to be down.  I was requested by the Speaker to be there.  Can I just very quickly? 

I want to thank you for being here and providing us with your testimony.  I represent Las Vegas and that is the fastest growing area in the United States with the fastest growing veterans' population.

We are in the process of building at the very early stages a huge VA facility, hospital, long-term care facility and outpatient clinic.  We have trouble recruiting as it is healthcare professionals.  I do not know what we are going to do to staff those buildings, particularly with the influx of new veterans coming to the Las Vegas Valley.  So it is a tremendous challenge for me and that is why I especially appreciate your thoughts on this issue.

Mr. MICHAUD.  And there is no Member of the Committee that fights diligently for VA facilities as well as VA employees than Congresswoman Berkley.  I really appreciate your efforts.

So with that, we will recess for the votes.  Thank you.


Mr. MICHAUD.  I would like to call the hearing back to order.  Once again, I apologize for the interruption because of the journal vote.

Once again, I want to thank each of you for your testimony this morning and have several questions.

If you look at last year, Congress passed the "VA Benefits Healthcare and Information Technology Act of 2006" (P.L. 109-461) authorizing the recognition of licensed professional counselors within the VA system.

What specifically can licensed professional counselors offer the VA?  And my second question are licensed professional counselors capable of taking care of patients with severe problems such as PTSD and psychiatric disorders? 

Ms. MCCASKILL.  Thank you.

Licensed counselors are specifically trained in the provision of mental health services and they are experienced in dealing with people that are going through crisis.  They can provide services from screening all the way through individual work, group work.  They can do assessments.

We do these kinds of things for private citizens in the States where they are licensed and we are just looking to be able to do it for the veterans, for our returning heroes.

As far as those dealing with the very severe things like psychosis, we do not do medicine.  We are not medical doctors, but we have worked cooperatively with other professions like psychiatrists or general physicians as they provide the medical treatment and we provide the counseling.

In fact, research has shown that when you do the two of them together, they are very effective in providing help for people going through severe difficulties.

Mr. MICHAUD.  And do professional counselors receive evidence-based training?

Ms. MCCASKILL.  Yes, they do.  The core coursework is what I mentioned a moment ago.  They also have to have supervised experience before anybody becomes licensed.  And in all 49 States that license counselors, the only one that does not is California.  That State has legislation pending at this time. 

But all 49 States use NBCC examinations.  These examinations are based on research done in the field of counseling on a routine basis so that the exam does accurately reflect the profession and the current developments.

Mr. MICHAUD.  Great.  Thank you.

And as we heard in testimony earlier as far as recruitment and retention and the healthcare professionals shortage that we currently have not only within the VA system but in private sector as well, what type of tools do you think would be most effective in recruiting and retaining a high-quality workforce, particularly in rural areas?  Do you see more of a problem in rural areas versus urban areas?  I guess I would turn it over to Dr. Krugman.

Dr. KRUGMAN.  Interestingly, Mr. Chairman, we are facing in this country now what we faced back in the late 1960s, early 1970s when I started my faculty career and that is a real workforce shortage, particularly in rural and under-served areas.

And in the Rocky Mountain region, we have VA facilities in rural areas.  Grand Junction, Colorado, is one hospital and others.

There is good evidence that the recruitment and retention of professionals to under-served areas can exist if we provide portions of their training in those institutions, in those areas if we work to develop loan repayment and other types of programs that can attract people to those areas and to go to the head of the pipeline, if we recruit people from rural and under-served areas to come into our health profession training programs.

There is 30 years of work done by the Area Health Education Center's programs in this country and in Colorado, we have one.  And it works.  The VA in Grand Junction as well as a VA facility in southeastern Colorado are part of our Area Health Education Network.

We send students on rotations.  We have them trained there.  After we have taken them from those areas, we try to give them incentives to go back.  And we keep them engaged in teaching because we know that is the best form of continuing education for any professional.

If you have a student who wants to be like you, they will push you to keep learning and, in fact, will help you learn more.

So I think the tools are there.  The question is, can we get it done at a time when these programs, most of which were funded on the public health service side under title 7 are under severe budget pressure?

I think we do not have to reinvent the wheel.  We just need to pay attention to what we had to do 30 years ago and do it again better.

Mr. MICHAUD.  You had mentioned, Doctor, that part of the problem, and it is true, that when you look at higher ed, they do not have the slots available for students who want to go in the healthcare field. 

What do you recommend that we do to encourage people to go into the field, as far as helping higher ed out, specifically in rural areas?  Do you think a grant program or more collaboration between the VA and higher ed facilities in the rural areas would help?

Dr. KRUGMAN.  I think clearly recruitment and retention and scholarship and loan deferment programs targeted toward students from rural and under-served areas who want careers in medicine can work. 

It is similar to what the National Health Service Corps has done again on the public health service side, similar to what the Armed Forces has done with its scholarship program that pays students to come into health professional training in return for which they are expected to provide four to eight years of service.

I think if students can be attracted into a VA model program that will pay for their higher education and health professional training in return for which they do their graduate medical education and then serve in VA facilities for a particular period of time. 

The experience in the Armed Forces is that once you have put in eight to ten years, the retirement benefits are such that your retention is far more likely than if you do not have any hook at all.

So I think there are models out there that the VA can take advantage of.  And the AAMC and academic medical centers which already have these networks around the country would be delighted to collaborate in that effort.

Mr. MICHAUD.  And, Mr. Newman, do you want to add anything to that?

Mr. NEWMAN.  Thank you, Mr. Chairman.  I do.

Within the VA system, within the VA system network, we have community-based outpatient clinics in rural communities in Minnesota and I would think that this same situation applies in your home State.

We have plans underway in Minneapolis to add physical therapy clinics to some of those community-based outpatient clinics or CBOCs as they are called within the system.  I think that is a great way to get the rural communities involved, to get the care to those veteran patients that can stay closer to home.  They do not have to travel miles to come to our facility in Minneapolis and they can get that quality of care locally.

To do that, recruitment and retention standards and the passage of those would go a long way in attracting qualified physical therapists to come to the VA to work in those community-based outpatient clinics.

Mr. MICHAUD.  And I would like each of you to comment.  When you look at the healthcare professionals shortage we currently have nationwide and when you look at what is happening with the war in Iraq and Afghanistan, particularly men and women who are coming back to their home State that might not have a job waiting for them, or they lost their job, or just cannot make ends meet because the job does not pay enough, do you think this is a great opportunity where we can help address the healthcare professionals shortage we currently have in the system by focusing maybe first on providing slots for the men and women who served this country in the healthcare area?

We will start with Mr. Newman and work down.

Mr. NEWMAN.  Mr. Chairman, great question.

Two good stories for you on that particular issue.  This past summer, we had a decorated Iraqi veteran come back to Minnesota, come back to going back to school at the University of Minnesota, and has a great interest in physical therapy. 

He has come to me.  He has come to our facility as a volunteer and has performed admirably within the clinic setting working with our polytrauma patients, working with our other veterans who are coming to our clinic for physical therapy.

Just Tuesday, before I came on to Washington, D.C., I had another Guardsman from Minnesota who served two years in Iraq who has a degree in biochemistry.  He has an interest in physical therapy.  He is going to begin volunteering for us in our clinic with hopes in going back to school using his benefits as an active-duty soldier to become a physical therapist. 

I think that is a tremendous asset for our physical therapy clinic and for our VA setting.  It goes a long way in working with our polytrauma patients and our polytrauma patient families.  They have been there.  They have served.  They can be in the clinic answering questions, working with our young veteran population.  It goes a long way in rehabilitating these veterans.

Mr. MICHAUD.  Those are great stories.

Dr. Krugman?

Dr. KRUGMAN.  I would concur that any individuals who have experienced healthcare on the side of being a patient who then want to come into any of our professions are likely to have a perspective and an empathy that would be welcome in the health professions provided they have had a good experience themselves.

Mr. MICHAUD.  Great.

Ms. MCCASKILL.  I would also echo the same comments.  NBCC has been looking and is planning on trying to do an institute where we work with people to develop a specialty certification for those people who want to provide services to military personnel and returning veterans.

We know that the military life is somewhat different.  We know that there is some stigma attached to getting help, especially mental health service help.  So that is part of the reason why we have been looking at additional things that we can do to help people.

So people that have gone through it and have that awareness and understand the life of military and what they have gone through, I think, have a very deep respect and can help those who are having a hard time when they come back.

Mr. BENDER.  Mr. Chairman, the question is really beyond the scope of my expertise.  I will say we have engaged in a number of communication campaigns reaching out to those transitioning out of the military on behalf of VA, those transitioning out of the military to encourage them and to tell them about the opportunities of employment at VA.

Mr. MICHAUD.  Let us focus a little bit on what your expertise is.  I have a question on your organization which conducted a nurse recruitment pilot study.  What would you say were the biggest lessons learned from this pilot study?   I believe it was in an urban area?  Have you done any studies in rural areas, and, if so, what were the differences, if any?

Mr. BENDER.  The area is the Gainesville, Lake City area in Florida.  The difference between conducting the type of recruitment marketing that we do from an urban area to a rural area is not at this point going to be extreme.  In other words, the difficulty level is not going to go up a number of notches.

Prior to the internet, it was a little bit different because of the penetration of media within certain areas.  Obviously, you know, in a city, you have a large number of options and other places, you do not.  So the difficulty of taking the message, the good message about VA to the people is not a tremendous concern right now. 

Getting back to the study, and there is a relationship between the two here, the method that works the best, especially with the young crowd now is internet communication.  People live on the internet.  It also happens to be the most cost-effective mode of communication.  This study identified things such as e-mail campaigns and e-mail banners and so forth. 

Among all the media used, the most effective in reaching the number of candidates we had to reach and the most cost effective in having the lowest cost per lead, and obviously that is a medium that we can use in any part of the country.

Mr. MICHAUD.  Do you think VA should continue using private sector strategies in recruitment and retention efforts?

Mr. BENDER.  Yeah.  It depends what those strategies are.  When you bring a marketing mindset, marketing best practices to the process, what happens is you start to improve the quality of the communication going out to the nurses.  In the pilot study, we mentioned methods such as targeted marketing, you know. 

When we are going out and we are hiring nurses or we are hiring psychiatrists, we make sure that we have the research about this particular market, about what this market's cares are, how they feel about working for not only VA but also for the government at large.  And then in the communication to these individuals, we make sure we address their specific concerns. 

So taking best practices within the marketing field and applying it to recruitment, I think, are one of the ways in which we can encourage a higher number of qualified applicants into the field.

Mr. MICHAUD.  Great.  Thank you.

In 2004, Congress passed the Physician Pay Bill, which established an improved and simplified pay structure for VA physicians that would increase salaries and make VA more competitive with the private sector.

Do you think that legislation has been effective in retaining VA physicians?

Dr. KRUGMAN.  Mr. Chairman, I think it has helped, but my understanding is that in each VISN and in each part of the country where that Pay Bill was implemented, the dollars went primarily to surgeons—and let me speak to our VISN.  It primarily went to surgeons and radiologists and did not go to some of those in internal medicine, particularly gastroenterology where there is still a huge gradient left between the private community and the VA physicians.

So it was a good start.  But, unfortunately, the community sectors in many parts of the country, particularly in ours, the ability of physicians in the private community to garner technical fees in their own imaging centers and their own ambulatory surgery centers and other ways to supplement their professional fee income have made the salary gap more than double even with the Pay Bill.

So retention is still going to be an issue.  And I think it was a good start, but it has been variable in its penetrance.

Mr. MICHAUD.  Thank you.

Any questions?  There will be additional questions that will be submitted for the record and hopefully you will be able to respond in a timely manner.

So once again, I would like to thank the four panelists.  It has been very enlightening and look forward to working with you as we move forward on this very important issue.  So once again, thank you very much.

Dr. KRUGMAN.  Thank you.

Mr. NEWMAN.  Thank you.

Mr. MICHAUD.  I would like to ask the second panel to come forward.

On the second panel we have Joseph Wilson, Assistant Director for Health Policy, Veterans Affairs and Rehabilitation Commission for the American Legion; Joy Ilem, Assistant National Legislative Director for the Disabled American Veterans (DAV); and David Cox, National Secretary-Treasurer of the American Federation of Government Employees (AFGE), AFL-CIO.

So I want to welcome the three panelists, and we will start off with you, Mr. Wilson, and work down.  Thank you.



Mr. WILSON.  Mr. Chairman and Members of the Subcommittee, thank you for this opportunity to present the American Legion's views on recruitment and retention of VA's healthcare—

Mr. MICHAUD.  Is your microphone on?

Mr. WILSON.  What about now?

Mr. MICHAUD.  Okay.  Yes.  We can hear you now.

Mr. WILSON.  Mr. Chairman and Members of the Subcommittee, thank you for this opportunity to present the American Legion's views on recruitment and retention of VA's healthcare professionals.

The Nation is facing an unprecedented healthcare shortage that could potentially have a profound impact on the care given to this Nation's veterans. 

The American Legion supports comprehensive efforts to establish and maintain the Department of Veterans Affairs as a competitive force in attracting and retaining healthcare personnel, especially nurses, essential to the mission of VA healthcare and commends the Subcommittee for holding a hearing to discuss this very important and urgent issue.

The Federal Government estimates that by 2020, nurse and physician retirements will create a shortage of about 24,000 physicians and almost one million nurses nationwide.  The American Legion strongly believes that what happens at the Department of Veterans Affairs medical centers often reflects the general state of affairs within the healthcare community as a whole.

Shortages in healthcare staff threaten the Veterans Health Administration's ability to provide quality care and treatment to veterans. 

During the American Legion's recent site visits to polytrauma centers throughout the Nation, some facilities identified uncertainty of existing staff's ability to handle an expected influx of patients as a challenge to providing care.

One major polytrauma center which serves as a front-line medical center to those returning from Iraq and Afghanistan reported recruitment and retention as part of their major budgetary challenge. 

Although the utilization of a variety of tools to include relocation, recruitment, and retention bonuses to attract new employees and retain existing employees is a step in the right direction, the locality pay is insufficient to keep pace with respective surrounding healthcare employers.

VA nurses are one of the most important resources in delivering high-quality, compassionate care to veterans.  Currently, there are challenges in attracting nursing personnel to VA due to both the shortage of people entering the career field and VA's inability to remain competitive in salary and benefits.

The American Legion urges the VA and Congress to provide adequate resources to implement the Commission's recommendations and urges VA to continue to strive to develop an effective strategy to recruit, train, and retain advanced practice nurses, registered nurses, licensed practical nurses, and medicine assistants to meet the inpatient and outpatient healthcare needs of its growing patient population.

VA recently established a Nursing Academy to address the nationwide nursing shortage issue.  The Nursing Academy has embarked on a five-year pilot program that will establish partnerships with a total of 12 nursing schools.  This pilot program will train nurses to understand the healthcare needs of veterans and increase the availability of nurses, thereby allowing VA to continue to provide veterans with the quality of care they deserve.

The American Legion affirms its strong commitment and support for the mutually beneficial affiliations between VHA and the medical and nursing schools of this Nation.

The American Legion is also appreciative of the many contributions of VHA nursing personnel and recognizes their dedication to veterans who rely on VHA healthcare.  Every effort must be made to recognize, reward, and maximize their contributions to the VHA healthcare system because veterans deserve nothing less.

VHA currently conducts the largest coordinated education and training program for healthcare professions in the Nation.  Their recent and newest recognitions as a leader providing safe, high-quality healthcare to the Nation's veterans can be directly attributed to the relationship that has been fostered through medical school affiliations which allows VA to train new healthcare professionals to meet the healthcare needs of veterans and the Nation.

Mr. Chairman and Members of the Subcommittee, the American Legion sincerely appreciates the opportunity to present testimony and looks forward to working with you, your colleagues, and staff to resolve this critical issue.

Thank you for your continued leadership on behalf of America's veterans.

[The statement of Mr. Wilson appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Wilson.

Ms. Ilem?


Ms. ILEM.  Mr. Chairman and Members of the Subcommittee, thank you for inviting the DAV to testify today.

Without question, recruitment and retention of high-caliber healthcare professionals is critical to VHA's mission and essential to providing safe, high-quality healthcare services to sick and disabled veterans.

Since 2000, VA has been working to address the ever-increasing demand for medical services while coping with the impact of a rising national nursing shortage. 

In 2004, VA's Office of Nursing released its strategic plan to guide national efforts to advance nursing practice within VHA and to improve VA's abilities to recruit and retain sufficient nursing staff.

One of VA's greatest challenges today is effective succession planning.  VA faces significant anticipated workforce supply and demand gaps in the near future along with an aging workforce and an increasing percentage of VHA employees who become eligible for retirement each year.

In a recent succession planning and workforce development conference, VHA identified registered nurses as its top occupational challenge.  Over the past several years, VHA has been trying to attract younger nurses and create incentives to keep them in the VA healthcare system.

To address this problem, VA created a Nursing Academy Pilot Program in which it plans to partner with four universities.  Academy students will be offered VA funded scholarships in exchange for defined periods of VA employment following graduation.

VA notes that in order for this program to move forward, legislation will be required to reactivate VA's Health Professions Education Assistance Program authority.

Although the Nursing Academy offers an innovative solution to recruitment and retention challenges, we would like to bring to your attention a number of reports dealing with VA nursing workplace issues.

We continue to hear complaints about marginal nursing staff levels, overuse of mandatory overtime, unofficial hiring freezes and delays in hiring for critical positions, reduced flexibility in tours of duty, limiting of nurse locality pay, and shortages of ward secretaries and other key support personnel.

Many of these difficult working conditions continue to exist today for nursing staff despite VA's efforts to make positive changes.  We hope that VA will place greater emphasis on improving the work environment for nurses, to increase staff satisfaction, ensure the provision of safe, high-quality patient care.

Likewise, DAV is concerned about the stressful working environment also confronting VA physician workforce.  Recently DAV received a copy of a letter written by a group of VA physicians.  I will mention only a few of the concerns it expresses.

Complaints focused on the negative impact of provider shortages including understaffing of both nurses and doctors, increased panel size for doctors, increased turnover rates, difficulty in recruiting for key positions, and a lack of an adequate number of support staff.

The following statement sums up the heavy burden these providers are shouldering, and I quote, "We state we must not compromise quality of care, access, and patient and provider satisfaction in the quest for increasing panel size.  Providers who are already struggling will not be able to provide high-quality care and ultimately you will have fewer providers to provide that care.  We have not been able to recruit new providers in the current climate.  Our ability to recruit will be further hampered by the unbearable workload that would be created by an increased panel size.  Preventing panel size increases is critical to the future quality of primary care within VA."

If the general situation in clinical care across the VA is anything like this report suggests, VA has a serious and rising morale problem that eventually may interfere with recruitment and retention as well as healthcare quality, safety, efficiency, and effectiveness.

For these reasons, we ask that the Subcommittee con