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115th Congress } { Report
HOUSE OF REPRESENTATIVES
2d Session } { 115-1034
======================================================================
TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE PRODUCTIVITY OF
THE MANAGEMENT OF DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE, AND FOR
OTHER PURPOSES
_______
November 16, 2018.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Roe of Tennessee, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
together with
MINORITY VIEWS
[To accompany H.R. 6066]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 6066) to amend title 38, United States Code, to
improve the productivity of the management of Department of
Veterans Affairs health care, and for other purposes, having
considered the same, report favorably thereon with an amendment
and recommend that the bill as amended do pass.
CONTENTS
Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 3
Hearings......................................................... 5
Subcommittee Consideration....................................... 6
Committee Consideration.......................................... 6
Committee Votes.................................................. 6
Committee Oversight Findings..................................... 6
Statement of General Performance Goals and Objectives............ 7
New Budget Authority, Entitlement Authority, and Tax Expenditures 7
Earmarks and Tax and Tariff Benefits............................. 7
Committee Cost Estimate.......................................... 7
Congressional Budget Office Estimate............................. 7
Federal Mandates Statement....................................... 9
Advisory Committee Statement..................................... 9
Constitutional Authority Statement............................... 9
Applicability to Legislative Branch.............................. 10
Statement on Duplication of Federal Programs..................... 10
Disclosure of Directed Rulemaking................................ 10
Section-by-Section Analysis of the Legislation................... 10
Changes in Existing Law Made by the Bill as Reported............. 11
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PRODUCTIVITY
IMPROVEMENT.
(a) In General.--Subchapter I of chapter 17 of title 38, United
States Code, is amended by inserting after section 1705A the following
new section:
``Sec. 1705B. Management of health care: productivity
``(a) Relative Value Unit Tracking.--The Secretary shall track
relative value units for all Department providers.
``(b) Clinical Procedure Coding Training.--If the coding accuracy of
a Department provider within a clinical area of responsibility of the
provider falls below the minimum threshold set by the Secretary, the
Secretary shall require the Department provider to attend training on
clinical procedure coding.
``(c) Performance Standards.--(1) The Secretary shall establish for
each Department facility----
``(A) in accordance with paragraph (2), standardized
performance standards based on nationally recognized relative
value unit production standards applicable to each specific
profession in order to evaluate clinical productivity at the
provider and facility level;
``(B) remediation plans to address low clinical productivity
and clinical inefficiency; and
``(C) an ongoing process to systematically review the
content, implementation, and outcome of the plans developed
under subparagraph (B).
``(2) In establishing the performance standards under paragraph
(1)(A), the Secretary----
``(A) may incorporate values-based productivity models and
may incorporate other productivity measures and models
determined appropriate by the Secretary; and
``(B) shall take into account non-clinical duties, including
with respect to training and research;
``(C) shall take into account factors that impede
productivity and efficiency and, in developing remediation
plans under paragraph (1)(B), shall incorporate action plans to
address such factors.
``(d) Definitions.--In this section:
``(1) The term `Department provider' means an employee of the
Department who has been appointed to the Veterans Health
Administration as a physician, a dentist, an optometrist, a
podiatrist, a chiropractor, an advanced practice registered
nurse, or a physician's assistant acting as an independent
provider.
``(2) The term `relative value unit' means a unit for
measuring workload by determining the time, mental effort and
judgment, technical skill, physical effort, and stress involved
in delivering a service.''.
(b) Clerical Amendment.--The table of sections at the beginning of
such chapter is amended by inserting after the item relating to section
1705A the following new item:
``1705B. Management of health care: productivity.''.
(c) Report.--Not later than one year after the date of the enactment
of this Act, the Secretary of Veterans Affairs shall submit to Congress
a report on the implementation of section 1705B of title 38, United
States Code, as added by subsection (a). Such report shall include, for
each professional category of Department of Veterans Affairs providers,
the relative value unit of such category of providers at the national,
Veterans Integrated Service Network, and facility levels.
(d) Comprehensive Staffing Models.--Not later than one year after the
date of the enactment of this Act, the Secretary of Veterans Affairs
shall develop comprehensive staffing models for all Department of
Veterans Affairs medical centers.
Purpose and Summary
H.R. 6066, as amended, a bill to amend title 38, United
States Code (U.S.C.), to improve the productivity of the
management of Department of Veterans Affairs (VA) health care,
and for other purposes, would require VA to take certain steps
to improve the productivity and efficiency of VA medical
facilities. Representative Brad Wenstrup of Ohio introduced
H.R. 6066 on June 8, 2018.
Background and Need for Legislation
The Committee believes that VA medical facilities must be
well-staffed and achieve a high level of productivity and
efficiency in order to maximize access to care for veteran
patients and ensure a prudent use of taxpayer dollars in
support of the VA healthcare system. However, the Committee is
alarmed by several analyses over a multi-year period that have
called into question how well VA tracks and monitors provider
staffing, productivity, and efficiency across the VA healthcare
system.
In 2012, the VA Inspector General (IG) issued a report on
staffing for specialty care services, which found that VA lacks
an effective staffing methodology to ensure appropriate
staffing levels for specialty care services.\1\ In this report,
the IG also found that VA lacks productivity standards for all
specialties and that VA medical center leads had failed to
develop staffing plans.\2\ This led the IG to conclude that,
``VHA's lack of productivity standards and staffing plans limit
the ability of medical facility officials to make informed
business decisions on the appropriate number of specialty
physicians to meet patient care needs, such as access and
quality of care.''\3\
---------------------------------------------------------------------------
\1\VA Office of the Inspector General 11-01827-36, December 2012,
``Audit of Physician Staffing Levels for Specialty Care Services,''
https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf.
\2\Ibid.
\3\Ibid.
---------------------------------------------------------------------------
In 2015, the VA Independent Assessment of the Health Care
Delivery Systems and Management Processes (Independent
Assessment) released a report on staffing and productivity,
which found that VA specialty providers are less productive
than their private sector counterparts on two industry
measures--encounters and relative value units (RVUs).\4\ RVUs
are a commonly used measure of a provider's productivity that
take into account the time, technical skill, mental effort, and
stress that are needed for a clinician to provide a given
clinical service.\5\ The Independent Assessment also found that
VA lacked staffing standards; that VA specialty physician
staffing levels are lower than industry ratios for most
specialties; that the number of patients assigned to VA primary
care providers is lower than the private sector benchmark for
patients of a similar acuity; and that insufficient exam room
space, poor configuration of clinical areas, and unsatisfactory
clinical and administrative support staff ratios limited
productivity and efficiency--and, therefore, access--across the
VA healthcare system.\6\
---------------------------------------------------------------------------
\4\CMS Alliance to Modernize Healthcare Federally Funded Research
and Development Center, September 1, 2015, ``Independent Assessment of
the Health Care Delivery Systems and Management Processes of the
Department of Veterans Affairs,'' https://www.va.gov/opa/choiceact/
documents/assessments/Integrated_Report.pdf.
\5\January 12, 2015, National Health Policy Forum, ``The Basics:
Relative Value Units,'' https://www.nhpf.org/library/the-basics/
Basics_RVUs_01-12-15.pdf.
\6\Ibid.
---------------------------------------------------------------------------
In 2017, the Government Accountability Office (GAO)
released a report on clinical productivity and efficiency,
which found that VA lacks complete and accurate information on
provider productivity and efficiency.\7\ GAO also found that VA
Central Office does not systematically oversee productivity and
efficiency.\8\ As a result, VA cannot ensure that low
productivity and clinical inefficiencies are addressed at
individual VA medical facilities or identify and correct
patterns that could increase productivity and efficiency across
the VA health care system.\9\ In testimony regarding this
report, GAO noted that, ``[a]s VA's funding levels increase, it
is increasingly important that the Department spend these funds
wisely and ensure that VA attains high levels of productivity
among its clinical services and operational efficiency to
maximize veterans' access to care and minimize costs.''\10\
---------------------------------------------------------------------------
\7\GAO-17-480, May 2017, ``Improvements Needed in Data and
Monitoring of Clinical Productivity and Efficiency,'' https://
www.gao.gov/assets/690/684869.pdf.
\8\Ibid.
\9\Ibid.
\10\United States Cong. House Committee on Veterans' Affairs.
``Maximizing Access and Resources: An Examination of VA Productivity
and Efficiency.'' July 13, 2017. 115th Cong. 1st sess. Washington: GPO,
2017 (testimony of Randall B. Williamson, Director, Health Care,
Government Accountability Office.).
---------------------------------------------------------------------------
In 2018, the IG released a report on staffing shortages,
which found that physicians and nurses were the top two most
commonly cited shortage occupations across the VA healthcare
system.\11\ The Veterans Access, Choice, and Accountability Act
of 2014 (Public Law 113-146; 128 STAT. 1754) first established
the requirement for an annual IG report on VA staffing
shortages. The report was then modified by the VA Choice and
Quality Employment Act of 2017 (Public Law 115-46; 131 STAT.
958). Since the first such report was released in 2014, the
findings have remained largely consistent, with the largest
clinical staffing shortages being physicians, nurses,
psychologists, physician assistants, medical technologists, and
physical therapists.\12\ To address these findings, the IG has
recommended since 2015 that VA develop staffing models for
critical occupations.\13\ The 2018 report notes that, ``the
[IG] has made recommendations related to the development and
implementation of a staffing model in each of its previous
staffing determination reports,'' and, ``re-emphasizes the need
for VHA to develop and implement a robust and targeted staffing
model.''\14\
---------------------------------------------------------------------------
\11\VA Office of the Inspector General 18-01693-196, June 2018,
``OIG Determination of Veterans Health Administration's Occupational
Staffing Shortages,'' https://www.va.gov/oig/pubs/VAOIG-18-01693-
196.pdf.
\12\Ibid.
\13\Ibid.
\14\Ibid.
---------------------------------------------------------------------------
The Committee is concerned that, despite the significant
amount of study and analysis and repeated recommendations for
action, VA continues to struggle with medical facility
staffing, productivity, and efficiency and continues to lack
relevant models, tracking mechanisms, and plans to improve.
Accordingly, section 1 of the bill would require VA to develop
comprehensive staffing models for all VA medical centers, track
RVUs for all providers, establish performance standards to
evaluate clinical productivity and efficiency, develop
remediation plans to address low clinical productivity and
inefficiency, and ensure that providers who fall below minimum
thresholds attend training on clinical procedure coding. The
Committee recognizes that factors outside of an individual
provider's control--like insufficient exam room space or
support staff--may negatively impact productivity and
efficiency. The Committee also recognizes that some VA
providers perform important and necessary functions--like
training and research--that may also impede productivity and
efficiency. As such, section 1 of the bill would require VA to
take non-clinical duties and productivity-limiting factors into
account when developing performance standards and remediation
plans. The Committee further recognizes that there may be non-
RVU based measures and models that may be useful for VA to
consider when implementing the requirements of this bill. In
light of that, section 1 of the bill would also authorize VA to
incorporate values-based productivity models. Feedback from
stakeholder groups, including multiple veteran service
organizations, was taken into account in the drafting of this
bill and the Committee is grateful for their input. The
Committee is also grateful for a letter provided by the Nurses
Organization of Veterans Affairs (NOVA), which expressed
support for an RVU-based system to capture and compare provider
productivity and efficiency across the VA healthcare system,
noted that VA already uses RVUs to track provider productivity
in certain specialty services, and stated that that, ``[b]y
tracking these metrics, leadership would have a clearer picture
of how resources are being used in each facility with the goal
of providing effective and efficiency high-quality care.''\15\
The Committee agrees with that assessment. NOVA also requested
that, ``consideration of any new requirement to address
performance measures of providers take into account VA's `whole
health' approach to care and the complex injuries of the
veteran patients they serve.''\16\ The Committee certainly
expects that, in developing the performance standards and
remediation plans that would be required by this bill, VA would
account for the Department's unique mission, needs, and
initiatives.
---------------------------------------------------------------------------
\15\July 11, 2018, Letter from Thelma Roach-Sherry BSN, RN, NE-BC.,
President, Nurses Organization of Veterans Affairs, to the Honorable
David P. Roe, Chairman, Committee on Veterans' Affairs, U.S. House of
Representatives regarding H.R. 6066, as amended.
\16\July 11, 2018. Letter from Thelma Roach-Sherry BSN, RN, NE-BC.,
President, Nurses Organization of Veterans Affairs, to the Honorable
David P. Roe, Chairman, Committee on Veterans' Affairs, U.S. House of
Representatives regarding H.R. 6066, as amended.
---------------------------------------------------------------------------
Hearings
On June 13, 2018, the Subcommittee on Health conducted a
legislative hearing on a number of bills including H.R. 6066.
The following witnesses testified:
The Honorable Vicky Hartzler, U.S. House of
Representatives, 4th District, Missouri; The Honorable
Marcy Kaptur, U.S. House of Representatives, 9th
District, Ohio; The Honorable Matt Cartwright, U.S.
House of Representatives,17th District, Pennsylvania;
The Honorable Clay Higgins, U.S. House of
Representatives, 3rd District, Louisiana; The Honorable
Mike Bost, U.S. House of Representatives, 12th
District, Illinois; The Honorable Jeff Denham, U.S.
House of Representatives, 10th District, California;
The Honorable Jenniffer Gonzalez-Colon, U.S. House of
Representatives, Puerto Rico; The Honorable Brad
Wenstrup, U.S. House of Representatives, 2nd District,
Ohio; Roscoe Butler, Deputy Director for Health Care,
Veterans Affairs and Rehabilitation, The American
Legion; Jeremy Villanueva, Associate National
Legislative Director, Disabled American Veterans; Kayda
Keleher, Associate Director, National Legislative
Service, Veterans of Foreign Wars of the United States;
and Jessica Bonjorni MBA, PMP, SPHR, Acting Assistant
Deputy Under Secretary for Health for Workforce
Services, Veterans Health Administration, U.S.
Department of Veterans Affairs, who was accompanied by
Dayna Cooper MSN, RN, Director, Home and Community-
Based Programs, Veterans Health Administration, U.S.
Department of Veterans Affairs.
Statements for the record were submitted by:
American Orthotic and Prosthetic Association,
Paralyzed Veterans of America, and Military Officers
Association of America.
Subcommittee Consideration
On June 27, 2018, the Subcommittee on Health met in open
markup session, a quorum being present and favorably forwarded
H.R. 6066, as amended, to the Full Committee. During
consideration of the bills, the following amendment was
considered and agreed to by voice vote:
An amendment in the nature of a substitute offered by
Representative Neal Dunn of Florida, which would modify
the performance standards and remediation plans as well
as require VA to develop comprehensive staffing models
for all VA medical centers.
Committee Consideration
On July 12, 2018, the full Committee met in open markup
session, a quorum being present, and ordered H.R. 6066, as
amended, to be reported favorably to the House of
Representatives by voice vote. During consideration of the
bill, the following amendment was considered:
An amendment in the nature of a substitute offered by
Representative Ann Kuster of New Hampshire, which
would--with the exception of the requirement for VA to
develop comprehensive staffing models for VA medical
centers--convert the bill to a three-year pilot program
and impose numerous reporting requirements on VA and
GAO. The amendment was not agreed to by voice vote.
Committee Votes
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, there were no recorded votes
taken on amendments or in connection with ordering H.R. 6066,
as amended, reported to the House. A motion by Representative
Gus Bilirakis of Florida to report H.R. 6066, as amended,
favorably to the House of Representatives was adopted by voice
vote.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
(2)(b)(1) of rule X of the Rules of the House of
Representatives, the Committee's oversight findings and
recommendations are reflected in the descriptive portions of
this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives are to increase the productivity and
efficiency of VA medical facilities in order to improve the
accessibility and quality of care that VA provides to veteran
patients.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee adopts as its
own the estimate of new budget authority, entitlement
authority, or tax expenditures or revenues contained in the
cost estimate prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Earmarks and Tax and Tariff Benefits
H.R. 6066, as amended, does not contain any Congressional
earmarks, limited tax benefits, or limited tariff benefits as
defined in clause 9 of rule XXI of the Rules of the House of
Representatives.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
6066, as amended, prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
for H.R. 6066, as amended, provided by the Director of the
Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, August 1, 2018.
Hon. Phil Roe, M.D.,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 6066, a bill to
amend title 38, United States Code, to improve the productivity
of the management of Department of Veterans Affairs health
care, and for other purposes.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Keith Hall,
Director.
Enclosure.
H.R. 6066--A bill to amend title 38, United States Code, to improve the
productivity of the management of Department of Veterans
Affairs health care, and for other purposes
Summary: H.R. 6066 would require the Department of Veterans
Affairs (VA) to train certain medical staff to identify the
level of resources used to provide medical services. CBO
estimates that implementing the bill would cost $320 million
over the 2019-2023 period, assuming appropriation of the
necessary amounts.
Enacting the bill would not affect direct spending or
revenues; therefore, pay-as-you-go procedures do not apply.
CBO estimates that enacting H.R. 6066 would not increase
net direct spending or on-budget deficits in any of the four
consecutive 10-year periods beginning in 2029.
H.R. 6066 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated Cost to the Federal Government: The estimated
budgetary effect of H.R. 6066 is shown in the following table.
The costs of the legislation fall within budget function 700
(veterans benefits and services).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
----------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2019-2023
----------------------------------------------------------------------------------------------------------------
INCREASES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level.................. 0 90 70 60 60 50 330
Estimated Outlays.............................. 0 80 70 60 60 50 320
----------------------------------------------------------------------------------------------------------------
Basis of estimate: For this estimate, CBO assumes that H.R.
6066 will be enacted near the beginning of fiscal year 2019 and
that the estimated amounts will be appropriated each year.
Estimated outlays are based on historical spending patterns for
the affected programs.
The bill would require VA to train licensed independent
providers (also known as LIPs, which include physicians,
dentists, and nurses) who fail to meet certain standards for
using relative-value units (RVUs) to evaluate medical services.
RVUs are tools used by physicians participating in Medicare to
rank on a common scale the resources (such as time, technical
skill, and physical effort) used to provide various health care
services.
VA currently tracks RVUs for health care provided by the
agency. Furthermore, the department is in the process of
developing an internal website to offer voluntary training to
its medical providers on using RVUs. However, according to VA,
only 5 percent of the 63,000 LIPs accurately document their
medical services using RVUs.
Using information from VA, CBO estimates that under the
bill the department would train roughly 60,000 medical staff to
use RVUs in 2019. We expect that training would be repeated
annually until LIPs demonstrated sustained proficiency. On
average, each LIP would require about three hours of training,
which equates to a loss of about 540,000 clinical visits at an
average cost of $145 per visit, CBO estimates. In order to
continue the provision of health care, CBO expects VA would
utilize community care to cover appointments while the LIPs are
in training. Over time, CBO expects LIPs at VA would become
increasingly proficient in using RVUs, and would therefore
require less training. On that basis, CBO estimates that
providing training on using RVUs would cost $70 million in 2019
and $260 million over the 2019-2023 period.
In addition, CBO expects VA would need to hire the
equivalent of 140 full-time staff at an annual compensation
rate of $80,000 each to provide ongoing training and support at
each medical facility. VA also would hire an additional staff
member at VA's central office at an annual compensation of
$135,000 in 2019 for oversight. After factoring in inflation,
CBO estimates that the increase in support staff would cost $10
million in 2019 and $60 million over the 2019-2023. CBO
estimates minimal costs to prepare a one-time report and
comprehensive staffing models within one year of enactment.
In total, CBO estimates implementing H.R. 6066 would cost
$320 million over the 2019-2023 period.
Pay-As-You-Go considerations: None.
Increase in long-term direct spending and deficits: CBO
estimates that enacting H.R. 6066 would not increase net direct
spending or on-budget deficits in any of the four consecutive
10-year periods beginning in 2029.
Mandates: H.R. 6066 contains no intergovernmental or
private-sector mandates as defined in UMRA.
Previous CBO Estimate: On February 15, 2018, CBO
transmitted a cost estimate for H.R. 4242, the VA Care in the
Community Act, as ordered reported by the House Committee on
Veterans' Affairs on December 19, 2017. H.R. 6066 is similar to
section 205 of H.R. 4242. CBO estimated that implementing
section 205 of H.R. 4242 would cost $9 million over 5 years for
the direct costs of training and support. The estimated costs
for implementing the similar requirements in this bill are
higher, however, because new information from VA indicates that
the department believes it would be required to spend more time
and funding to train and support VA personnel on using RVUs. In
addition, the department would outsource appointments while the
VA personnel undergo training.
Estimate prepared by: Federal costs: Ann E. Futrell;
Mandates: Andrew Laughlin.
Estimate reviewed by: Sarah Jennings, Chief, Defense,
International Affairs, and Veterans' Affairs Cost Estimates
Unit; Leo Lex, Deputy Assistant Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 6066, as amended, prepared by the
Director of the Congressional Budget Office pursuant to section
423 of the Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
6066, as amended.
Statement of Constitutional Authority
Pursuant to Article I, section 8 of the United States
Constitution, H.R. 6066, as amended, is authorized by Congress'
power to ``provide for the common Defense and general Welfare
of the United States.''
Applicability to Legislative Branch
The Committee finds that H.R. 6066, as amended, does not
relate to the terms and conditions of employment or access to
public services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Statement on Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII of the Rules of the
House of Representatives, the Committee finds that no provision
of H.R. 6066, as amended, establishes or reauthorizes a program
of the Federal Government known to be duplicative of another
Federal program, a program that was included in any report from
the Government Accountability Office to Congress pursuant to
section 21 of Public Law 111-139, or a program related to a
program identified in the most recent Catalog of Federal
Domestic Assistance.
Disclosure of Directed Rulemaking
Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017),
the Committee estimates that H.R. 6066, as amended, contains no
directed rulemaking that would require the Secretary to
prescribe regulations.
Section-by-Section Analysis of the Legislation
Section 1. Department of Veterans Affairs health care productivity
improvement
Section 1(a) of the bill would amend subchapter I of
chapter 17 of title 38 U.S.C. by inserting after section 1705A
a new section ``Sec. 1705B. Management of health care;
productivity''.
The new section 1705B(a) would require VA to track RVUs for
all VA providers.
The new section 1705B(b) would require VA to require VA
providers to attend training on clinical procedure coding if
the coding accuracy of the VA provider within their clinical
area of responsibility falls below the minimum threshold set by
VA.
The new section 1705B(c) would require VA to establish, for
each VA facility: standardized performance standards based on
nationally recognized RVU production standards applicable to
each specific professional in order to evaluate clinical
productivity at the provider and facility level; remediation
plans to address low clinical productivity and clinical
inefficiency; and an ongoing process to systematically review
the content, implementation, and outcome of such plans. In
fulfilling these requirements, the new section 1705B would
authorize VA to incorporate values-based productivity models
and other productivity measures and models as determined
appropriate by VA as well as require VA to take into account
non-clinical duties, (including with respect to training and
research), factors that impede productivity and efficiency, and
actions plans to address such factors.
The new section 1705B(d) would define ``Department
provider'' to mean an employee of VA who has been appointed to
the Veterans Health Administration as a physician, dentist,
optometrist, podiatrist, chiropractor, advanced practice
registered nurse, or physician's assistant acting as an
independent provider and ``relative value unit'' to mean a unit
for measuring workload by determining the time, mental effort
and judgement, technical skill, physical effort, and stress
involved in delivering a service.
Section (b) of the bill would amend the table of contents
at the beginning of chapter 17 of title 38 U.S.C. by inserting
after the item relating to section 1705A the following new
item: ``Sec. 1705B. Management of health care; productivity.''.
Section (c) of the bill would require VA, not later than
one year after the date of enactment of this Act, to submit to
Congress a report on the implementation of the new section
1705B of title 38 U.S.C. and require such report to include,
for each professional category of VA providers, the RVU of each
category at the national, regional, and facility levels.
Section (d) of the bill would require VA, not later than
one year after the date of enactment of this Act, to develop
comprehensive staffing models for all VA medical centers.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (new matter is
printed in italic and existing law in which no change is
proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
PART II--GENERAL BENEFITS
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I--GENERAL
Sec.
1701. Definitions.
* * * * * * *
1705A. Management of health care: information regarding health-plan
contracts.
1705B. Management of health care: productivity.
* * * * * * *
SUBCHAPTER I--GENERAL
* * * * * * *
Sec. 1705B. Management of health care: productivity
(a) Relative Value Unit Tracking.--The Secretary shall track
relative value units for all Department providers.
(b) Clinical Procedure Coding Training.--If the coding
accuracy of a Department provider within a clinical area of
responsibility of the provider falls below the minimum
threshold set by the Secretary, the Secretary shall require the
Department provider to attend training on clinical procedure
coding.
(c) Performance Standards.--(1) The Secretary shall establish
for each Department facility--
(A) in accordance with paragraph (2), standardized
performance standards based on nationally recognized
relative value unit production standards applicable to
each specific profession in order to evaluate clinical
productivity at the provider and facility level;
(B) remediation plans to address low clinical
productivity and clinical inefficiency; and
(C) an ongoing process to systematically review the
content, implementation, and outcome of the plans
developed under subparagraph (B).
(2) In establishing the performance standards under paragraph
(1)(A), the Secretary--
(A) may incorporate values-based productivity models
and may incorporate other productivity measures and
models determined appropriate by the Secretary; and
(B) shall take into account non-clinical duties,
including with respect to training and research;
(C) shall take into account factors that impede
productivity and efficiency and, in developing
remediation plans under paragraph (1)(B), shall
incorporate action plans to address such factors.
(d) Definitions.--In this section:
(1) The term ``Department provider'' means an
employee of the Department who has been appointed to
the Veterans Health Administration as a physician, a
dentist, an optometrist, a podiatrist, a chiropractor,
an advanced practice registered nurse, or a physician's
assistant acting as an independent provider.
(2) The term ``relative value unit'' means a unit for
measuring workload by determining the time, mental
effort and judgment, technical skill, physical effort,
and stress involved in delivering a service.
* * * * * * *
MINORITY VIEWS
As written, the Minority has serious concerns with H.R.
6066. In particular, we are concerned the implementation of
this measure on a permanent basis will erode the unique the
patient-provider relationship within the Department of
Veterans' Affairs (VA). In addition, this measure could also
lead Congress to misinterpret VA's budgetary needs and workload
as it considers appropriations measures in the coming years.
Not only is the measure superfluous in its call for
collection of RVUs, but redundant as VHA has collected and
reported back to facilities on clinical productivity metrics
since 2013. By utilizing the Specialty Productivity-Access
Report and Quadrant (SPARQ) tool, VHA ``measures specialty
physician value in the form of ``compensation per RVU'' so as
to demonstrate [its] ability to be good stewards of public
healthcare resources.''\1\
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\1\United States Cong. House Committee on Veterans' Affairs,
Subcommittee on Health Oversight Hearing--``Clinical Productivity and
Efficiency in the Department of Veterans'' Affairs Healthcare System.''
July 13, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement
from Carolyn Clancy, M.D., Deputy Under Secretary for Organizational
Excellence at the Veterans Health Administration of the Department of
Veterans' Affairs).
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While we agree with the Majority that increasing provider
productivity at VA should be addressed in order to ensure VHA
remains a leader in the delivery of veterans' health care, we
are alarmed this provision could have unintended consequences
as we move forward. For this reason, we must align ourselves
with the concerns expressed by a variety of witnesses in regard
to the measure including VA and Veterans Service Organizations
(VSOs).
On July 13, 2017, the Members of the Subcommittee on Health
heard from several witnesses, including representatives from
the Government Accountability Office (GAO) and VA, that each
indicated the capture of traditional RVUs at VA would not
provide the most accurate reflection of provider productivity
for several reasons. Chief among these is attempting to compare
RVUs at VA with the private sector.
As witnesses stated, this is problematic because the
comparison is not apples-to-apples. Instead it is more akin to
apples-to-oranges. Witnesses pointed out (1) VA providers have
limited space with a provider-to-office ratio of 1:1 whereas
private industry is 1:3 or 4 even; and (2) veteran care is more
time consuming as veterans tend to list a litany of ailments
during a Primary Care Provider visit due to their likelihood of
having multiple comorbidities; whereas civilians tend to
experience one health issue at a time.
While the measure at hand does not call for an explicit
comparison of VA to private sector RVUs, the capture and public
reporting to Congress on this data would provide opponents of
VA with fodder to further misrepresent VA's capacity to deliver
quality healthcare. By taking the data produced as a result of
this measure and comparing it to various private sector
facilities, opponents of VA could argue that taxpayer's money
would be better spent in the community. However, the services
provided by VA when compared to the private sector are more
comprehensive, time consuming, and of a higher quality.\2\ The
Minority is not confident this data would be published in a
responsible manner that would lead to an increase in VA
productivity.
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\2\Comparing Quality of Care in Veterans Affairs and Non-Veterans
Affairs Settings, https://www.rand.org/pubs/external_publications/
EP67588.html.
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In addition, the implementation of this measure system-wide
would threaten the integrity of VHA's currently data
architecture, the Veterans Information Systems and Technology
Architecture (VistA). In July 2017, VA testified that VistA
``was never designed to capture data related to billing type,
so a variety of complex workarounds are needed to assemble an
approximation of RVUs. These workarounds introduce a risk of
reporting inaccurate numbers; and we magnify that risk by
expanding the scope of measurement.''\3\
---------------------------------------------------------------------------
\3\United States Cong. House Committee on Veterans' Affairs,
Subcommittee on Health Oversight Hearing--``Clinical Productivity and
Efficiency in the Department of Veterans'' Affairs Healthcare System.''
July 13, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement
from Carolyn Clancy, M.D., Deputy Under Secretary for Organizational
Excellence at the Veterans Health Administration of the Department of
Veterans' Affairs).
---------------------------------------------------------------------------
However, in May 2018, VA officially signed a contract to
modernize VHA's electronic health record system by adopting a
system similar to that of the Department of Defense's. Among
other advancements, the new electronic health records system is
expected to be ``better configured for workload capture and
billing using private-sector standards, and could help embed
workflow indicators that transparently capture data regarding
productivity and minimize inaccuracies due to our current
workarounds.''\4\
---------------------------------------------------------------------------
\4\Id.
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Given all of these concerns, the Minority offered an
alternative at markup which would have created a three-year
pilot program to be carried out at 15 medical facilities in
which VHA tracks the relative value units of health care
providers. Much like H.R. 6066, the Secretary would be required
to provide additional training to providers falling below an
average level of productivity and would be required to
establish performance standards for each medical facility.
Additionally, it called on VA to submit a well-rounded
implementation plan, quarterly reports and a final report on
whether it was feasible and advisable to extend the program.
GAO would be required to assess both the implementation plan
and final report within 60 days of its submission.
Unfortunately, it was not adopted.
The Committee is in agreement that the productivity of
healthcare providers employed by the Department of Veterans'
Affairs should increase in accord with budgetary increases, the
minority is not convinced that the tracking of RVUs will
produce reliable information upon which veteran-patients and
Congressional appropriators should base their decisions.
Mark Takano,
Vice Ranking Member.
[all]
