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Restoring Trust in VA Care

STATEMENT OF

RYAN M. GALLUCCI, DEPUTY DIRECTOR

NATIONAL VETERANS SERVICE

VETERANS OF FOREIGN WARS OF THE UNITED STATES

 BEFORE THE

 COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES HOUSE OF REPRESENTATIVES

WITH RESPECT TO

 Restoring Trust: The View of the Acting Secretary and the Veterans Community

 

WASHINGTON, D.C.                                                                                        July 24, 2014

 MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE:

 On behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and our Auxiliaries, I would like to thank you for the opportunity to testify today on the current state of Department of Veterans Affairs (VA) health care and steps the VFW believes we need to take to restore trust and confidence in the VA health care system.

The recent events at the Phoenix VA Medical Center, the subsequent national audit of all VA facilities, and repeated whistleblower accusations of impropriety within VA have all shed light on major issues facing the VA health care system as it seeks to deliver timely, quality health care to our nation’s veterans. Over the past three months, we have seen a VA Secretary and numerous deputies resign. We have also seen a newly-minted Acting Secretary working diligently to understand the situation on the ground at VA health care facilities across the country, seeking to expose systemic problems and prescribe corrective action.

The allegations made against VA over the past three months are outrageous, and the 1.9 million members of the VFW and our auxiliaries are rightfully outraged. However, the VFW also worries that the loss of trust among the veterans’ community has the potential to be more harmful to our nation’s veterans than much of the impropriety about which we have recently learned.

At the center of the recent scandal is the inability of veterans to receive timely care from VA. For more than a decade, the VFW has warned both VA and Congress about the potential dangers of long wait times and improper scheduling procedures. After Phoenix, we now know that these potential dangers were all too real.

When news of the scandal broke, the VFW knew that it had to intervene directly on behalf of veterans. We had no time to wait for VA to sort out its affairs through traditional channels, which is why we readvertised our health care help line, 1-800-VFW-1899, where veterans could turn for direct intervention on the VA health care concerns, or simply share their experiences to benefit their fellow veterans. Over the first two months of the outreach campaign for the VFW help line, we received more than 1,500 comments and complaints from our members, most of whom reported negative VA care experiences. The VFW worked directly with VA leadership to help resolve more than 200 critical health care issues most often related to oncology, gastroenterology, cardiovascular health or mental health.

In addition, the VFW sorted through all 1,500 comments to evaluate the current state of VA care and make specific recommendations to ensure VA never faces these problems in the future. For our testimony today, we will focus specifically on scheduling inefficiencies, non-VA care coordination, and the culture of accountability.

According to many of the veterans who contacted the VFW over the past two months, the major issue facing the VA health care system is timely access. Even veterans who relayed positive health care experiences still shared significant concerns over appointment wait times.

While some have sought to focus solely on the issues of access, appointment scheduling and care referral processes, the VFW has recognized that access to care is clearly linked to quality health care outcomes and customer service. Veterans who contacted the VFW often pointed to delayed diagnoses, worsening health conditions and hurried screenings for potentially serious health conditions when they could not receive appointments in a timely manner.

As the strain on the VA health care system continues to grow, the VFW’s evidence also demonstrates that staff attitudes are rapidly deteriorating as veterans report doctors who shrug off serious symptoms during routine screenings and phone operators or clerks who treat veterans with contempt. It would be easy to single out these employees and blame them individually for their poor attitudes, low morale, and inadequate customer service. However, given the systemic scope of similar allegations across multiple VA health care facilities, the VFW believes that such poor staff attitudes indicate that the system is too strained to properly handle all of the veterans who require care.

After all of the recent scrutiny of the VA health care system, the VFW believes that we understand the problems now facing VA. However, we also recognize that there is no silver bullet solution to the current crisis. To the VFW, improper resourcing, archaic accountability standards, outdated technology, and inconsistent business practices have all contributed to the current crisis.

As we seek to resolve these issues, we must be careful not to dismantle the VA health care system or abdicate VA of its responsibilities to care for veterans. The VFW believes that the VA health care system is far too important, and many of its veteran-specific services cannot be easily duplicated in the civilian health care sector.

To the VFW, outdated appointment scheduling and tracking technology is central to the current crisis. Built and implemented in the 1980s, VA’s appointment-scheduling software has not changed much over the years – except for the occasional patches and work-arounds designed to gather new information. Moreover, VA’s systems that track incoming patients and specialty consults are only loosely linked to the scheduling system, meaning VA scheduling is rife with inaccuracies, allowing patients to easily slip through the cracks. VA has asked repeatedly for a new scheduling system, but IT funding shortfalls have made it nearly impossible to take the major steps of replacing a system-wide software platform.

VA also acknowledges that this antiquated, patch-work system makes it impossible to properly monitor the supply of available appointments. This means that VA cannot adhere to private industry wait time standards and also exposes the scheduling system to rampant fraud and manipulation, as evidenced by repeated VA memos to health care facilities chastising those who seek to game appointment scheduling. This also makes it nearly impossible for VA to manage the workload for its clinicians, meaning that some clinicians may be overworked, while others may be underperforming. In either case, veteran care quality suffers.

One veteran who recently contacted the VFW shared his experience trying to transfer into the Salt Lake City VA Medical System. He told the VFW that when he tried to enroll, VA said it would take at least six months to see a primary care doctor. After six months, VA contacted the veteran again to inform him that it would take another six months to get an appointment. When the veteran followed up with VA, he was informed that he was disenrolled since he had not seen his primary care physician in more than a year. This is a clear failure of VA scheduling protocols and business practices. We have to do better. This is why the VFW calls on Congress to immediately provide VA with the resources necessary to acquire a modern and sustainable appointment-scheduling system that will allow patients to easily access appointments and allow VA to finally measure its workload and adapt accordingly.

Since the scandal broke, some in Congress have presented non-VA care as the best solution to ensure veterans can receive timely care. The VFW acknowledges that VA must fully leverage its authority to provide non-VA care to veterans when VA cannot provide direct care. However, VA still must have the responsibility and the resources to properly coordinate non-VA care and ensure that such care is delivered properly. The VFW also worries that the civilian health care system lacks sufficient capacity to deliver comparable care in a timely manner.

Earlier this week at the VFW National Convention, I had the opportunity to speak with a veteran’s caregiver who recounted a recent nightmare in receiving non-VA care. The veteran who needed a seemingly-routine knee surgery was sent to a major outside health care provider for the procedure, since VA was backlogged for nearly two years to conduct the procedure in-house. While VA coordinated the care on behalf of the veteran, what followed was a bureaucratic nightmare for the both the veteran and his caregiver once the surgery was performed.

After the non-VA provider performed the operation, the veteran was quickly discharged and told that the civilian provider had no further responsibility for his convalescence. The facility discharged the veteran without providing a simple prescription for pain management associated directly with the procedure. In fact, the veteran and his caregiver had to immediately go from the non-VA facility to VA to receive proper convalescent medication and the requisite prosthetic devices that the veteran would need for recovery.

While the VFW understands that VA may have been best suited to provide both the medication and the necessary prosthetics, this was not properly communicated to the veteran prior to the procedure. Moreover, the veteran caregiver reported that the non-VA facility was inflexible in providing basic recovery services to the veteran while still in their care.

To the VFW, this is a prime example of why outsourcing VA care is not a catch-all solution to the current crisis. Must VA outsource care when they cannot deliver it in a timely manner? Absolutely. However, VA must continue to serve as the guarantor of such care, and it must be responsibly coordinated to ensure veterans have positive health outcomes.

The VFW has been fully supportive of VA’s efforts to revamp its delivery of non-VA care through the creation of Non-VA Care Coordination (NVCC) teams and the implementation of the Patient-Centric Coordinated Care (PC3) program. NVCC teams are charged with coordinating non-VA care on behalf of veterans who cannot receive adequate care from VA. While the VFW supports the concept of NVCC, Congress must ensure that NVCC teams are properly staffed with professionals capable of making responsible, timely health care decisions. PC3 is VA’s new program designed to deliver coordinated non-VA specialty care through established civilian health care networks. PC3 is a program that the VFW believes can make a difference, but we caution that Congress must have proper oversight of how PC3 works and whether referrals through PC3 can deliver timely care.

While VA must properly leverage non-VA care, the VFW also recognizes that the challenges VA faces in tracking and scheduling appointments immediately affects VA’s ability to refer veterans to non-VA providers in a timely manner.

The VFW also worries that accountability issues within VA present major, multifaceted problems. While the VFW has supported legislation to ensure the VA Secretary can easily sanction executive-level employees, we also acknowledge that accountability is a major issue at all levels in VA’s chain of command. To the VFW, allegations of underperforming and apathetic employees is likely the result of a bureaucratic culture in which VA cannot efficiently reprimand or terminate poor-performing employees; or hire quality new employees in a timely manner.

When then-VA Secretary Eric Shinseki was pressed by the Senate over how many employees he had fired under his watch, Shinseki acknowledged that very few of the 3,000 employees reprimanded had a significant adverse personnel action taken against them, such as demotion or termination. Moreover, VA has repeatedly acknowledged that the hiring process for new employees takes between six months to a year.

This prompted the VFW to ask whether or not VA managers make trade-offs in evaluating employee performance. The VFW believes that if VA has a poor-performing employee, the current system incentivizes retaining that poor-performing employee in lieu of initiating the laborious process of terminating the employee, then finding a quality replacement.

The hiring process makes it even more difficult for VA to properly staff its facilities. Veterans have consistently reported to the VFW that staffing shortages and high turnover, even among clinicians, has contributed to current access issues. To make this situation worse, VA simply cannot compete with the private health care sector when it seeks to hire new clinicians. Private health systems can hire new clinicians in a matter of days and weeks. So even if a doctor wants to work for VA, the VFW recognizes that many doctors cannot wait six months to a year for VA to follow through. If VA cannot quickly fill its vacancies with top talent, we cannot expect VA to properly reprimand poor performers. If VA cannot reprimand poor performers, we cannot reasonably expect VA to deliver timely, quality care to the veterans who need it. This will take significant changes to federal employee protections and federal hiring practices, but the VFW believes that this can be done equitably to provide reasonable protections for employees, but decisive accountability for underperformers.

The VFW is also concerned that for far too long VA has focused on its internal business models rather than the needs of its end-users, the veterans. In other words, in accomplishing its mission, VA does what is best for VA, instead of what is best for the customer. The VFW believes that this culture must change.

To the VFW, the culture of secrecy and low morale among VA employees are symptoms of a VA culture that does not focus on the well-being of patients. The VFW has heard concerns from veterans that resources are stretched too thin, but employees are afraid to speak up. In this environment, if doctors are forced to rush treatment, they will naturally misdiagnose their patients or botch a critical procedure. Doctors will also burn out and leave VA – especially when hospital administrators downplay or neglect the legitimacy of their concerns.

To make this situation worse, inspectors have found clear examples where whistleblowers who exposed inadequate care standards or disingenuous business practices were quickly penalized for speaking up. Instead of incentivizing proper care or patient safety, the business mindset of VA seemed to encourage employees to cut corners in order to make the system work.

VA has to change this business mindset. Administrators and clinicians must recognize that their primary mission is serving veterans – not VA. Congress must also ensure that VA employees at all levels feel comfortable asking for help or voicing their concerns to leadership when the situation demands it.

Finally, the VFW has repeatedly heard from veterans that VA Patient Advocates are incapable of directly intervening on behalf of veterans at many VA health care facilities. Some veterans even quipped that Patient Advocates do not advocate for the patients; they advocate for VA. The Patient Advocate is designed as the primary method of recourse for a veteran to resolve health care issues locally. They are supposed to be able to intervene directly with either hospital directors or care providers. However, veterans have told the VFW that Patient Advocates often lack the authority to perform their most basic functions. VA Patient Advocates must be appropriately staffed with professionals capable of intervening on behalf of veterans. They must also have the institutional support of VA leadership to intervene in difficult circumstances.

 As you can see, the current problems in VA are multifaceted and demand decisive reforms. Thankfully, not everything the VFW hears about VA health care has been bad. Nearly 40 percent of the veterans who contacted us to share their health care experiences praised the care they received at VA. At the recent VFW National Convention, several veterans sought out our national staff to share their stories on how VA doctors had saved their lives. Others offered their perspective on how much the VA health care system has improved over the last three decades. We believe the system can work, but it cannot work unless Congress takes action.

 This week at the VFW National Convention, the membership of our organization passed a stern resolution calling on Congress to quickly pass the VA Access and Accountability Act that currently sits in conference. Though this bill will not solve all of VA’s current woes, both the House and Senate have already agreed that these necessary reforms will help veterans receive the care that they need. Congress absolutely cannot go into the August recess without passing this bill. When the current VA scandal broke, every legislator agreed that this was a national imperative. However, in recent weeks, some legislators have backed off, caring more about the cost of the legislation than the veterans who are waiting for care. This week, the members of the VFW said this is unacceptable. If Congress fails to pass this legislation before the recess, our members will hold their representatives accountable during the August recess.

We have an opportunity here. We have an opportunity to show our veterans and the men and women still serving in harm’s way that our nation will live up to its promise to care for those who defend our way of life. We have to get this right. We have to restore trust and confidence in the VA system, and the VFW will do whatever it takes to make that happen.

Mr. Chairman, this concludes my testimony and I am prepared to take any questions you or the committee members may have.

  

 

 

 

 

Information Required by Rule XI2(g)(4) of the House of Representatives

 

Pursuant to Rule XI2(g)(4) of the House of Representatives, VFW has not received any federal grants in Fiscal Year 2013, nor has it received any federal grants in the two previous Fiscal Years.

 

 

 

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