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Thomas Lynch M.D.

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health for Clinical Operations, Veterans Health Administration, U.S. Department of Veterans Affairs

Good morning, Chairman Miller, Ranking Member Michaud, and Members of the Committee.  Thank you for the opportunity to discuss the capacity and demand for services in VHA.  I am accompanied today by Carolyn Clancy, M.D., Assistant Deputy Under Secretary for Health for Quality, Safety and Value. 

At the outset, let me address the significant issue that has been the focus of this Committee, VA, and the American public the last many weeks.  That is the issue of wait times.  No Veteran should ever have to wait an unreasonable amount of time to receive the care they have earned through their service and sacrifice. 

America’s Veterans should know they will receive the highest quality health care in a timely manner from VA.  Last year, we scheduled 85 million outpatient visits and acted upon 25 million consults for specialized services.  While we realize that the timeliness of these services is in question, VA acknowledges and is committed to correcting unacceptable practices in patient scheduling.  These practices are not consistent with our values as a Department, and we are working to fix the problems.  

VHA has a physician workforce of more than 18,000 full time equivalents (FTEs)   representing over 30 specialties.  The largest components of the physician workforce include our Internal Medicine (largely primary care) physicians and psychiatrists.  VHA maintains a comprehensive database of the physician workforce that provides information about the staffing levels for each Medical Center and calculates the productivity of our physician workforce utilizing a standard health care measure of relative value units (RVU) per physician clinical FTE.  RVUs consider the time and the intensity of the medical services delivered and have been utilized by Medicare since the early 1990’s.  VHA is currently using this database to establish productivity standards and to assess the capacity of our provider workforce.  For our primary care physicians there are clear panel size expectations that define the number of active patients assigned to each primary care provider.   Panel sizes vary depending on a number of factors.  The current average panel size is 1,194, but panels may be adjusted up or down depending on levels of support staff, space (exam rooms) and patient complexity.  VHA is assessing the current demand for services in relation to primary care panel capacity as well as the productivity of the primary care providers and all physicians and associate providers at each of our medical centers.

During a February 2014 hearing before the Subcommittee on Health, we reported VHA’s progress in implementing an industry-accepted RVU-based approach for assessing productivity and efficiency for specialty care physicians.  More recently, on May 1, 2014, VHA briefed the physicians on the Subcommittee on the RVU-based productivity and staffing work.   Although our focus on establishing an RVU-based model to assess specialty physician productivity did not initially include Internal Medicine/Primary Care, the foundation we put in place for specialty care is now being leveraged to assess productivity, efficiency, staffing and capacity within our primary care services.  Ready access to care is our highest priority and we are mobilizing our workforce accordingly. 

VHA delivers care that encompasses nearly three dozen different specialties in a variety of settings, and access to care varies across those specialties and settings.  Our large acute care academic facilities generally employ the full complement of specialty physicians and have the capability to provide comprehensive services while our smaller or rural facilities may be challenged to recruit and retain specialty physicians.  Aligning the current demand with our ability to provide these services is part of our active work.  

Optimizing physician productivity is critical to our ability to determine clinical capacity and mobilize our clinical assets to rapidly address unacceptable delays in services to our Veterans. Supporting a productive workforce requires appropriate support staff ratios as well as the necessary capital infrastructure, e.g., exam room capacity, to ensure that the clinics run as efficiently as possible.  The key elements of capacity include:  (1) the supply of clinical providers (physicians, psychologists, optometrists, podiatrists, and associate providers such as nurse practitioners and physician assistants) within VHA; (2) the amount of services that each of these providers can safely deliver (productivity); and (3) a modern information technology infrastructure that supports and enhances clinical information for the patient and providers.  We currently know the supply of our provider workforce and, assuming a productivity expectation, we can estimate what our capacity could be. The difference between this estimated capacity and our current workload represents the amount of additional care we could potentially absorb to address Veterans waiting for care.

Productivity expectations are  critical in determining VHA’s capacity and, VHA has accelerated the adoption of productivity standards for all physicians, modeled on an industry-accepted RVU-based approach.  By the end of June 2014, VHA will have standards in place to measure productivity and efficiency for 29 different specialties, representing 91 percent of VHA’s physicians, psychologists, optometrists, podiatrists, and chiropractors.  All VHA physicians will have productivity standards in place by the end of September 2014.

The same results-oriented approach we have taken to implement physician productivity and staffing standards will be applied to address today’s challenge to measure and maximize our clinical capacity.  The work continues, and we will not be finished until VHA can assess capacity, productivity, and staffing standards for all specialties, and provide ready access to high quality, efficient care to our Nation’s Veterans.

To fulfill VHA’s primary mission of providing patient care and to assist in providing an adequate supply of health personnel to the Nation, VA is authorized by Title 38 Section 7302 to provide clinical education and training programs for developing health professionals.  VA conducts the largest education and training effort for health professionals in the U.S.  This provides VA with a unique opportunity to recruit these medical professionals, already familiar with the VA health care system.  

VA recognizes that rural communities face challenges in ensuring access to health care providers.  VA is working to develop an effective rural workforce strategy to recruit locally for a broad range of health-related professions.  These strategies include training, technology, collaboration, and academic affiliations.  Empowering Veteran patients with telehealth technology and targeted health communications have proven to be an important way to provide quality care in the daily lives of Veterans. 

In addition, VA collaborates with Federal partners such as the Department of Health and Human Services to establish pilot projects with community-based providers; the Department of Defense to improve access to care for Service members and Veterans through sharing agreements; and the Department of Housing and Urban Development (HUD) to coordinate the HUD-VA Supportive Housing program. 



Mr. Chairman, the health and well-being of the men and women who have bravely and selflessly served this Nation remains VA’s highest priority.  We must regain the trust of Veterans we serve one Veteran at a time, and VA leaders and our dedicated workforce, over a third of who are Veterans themselves, are fully engaged.  This concludes my testimony.  My colleague and I are prepared to answer any questions you or the other Members of the Committee may have.