[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
VA AND ACADEMIC AFFILIATES: WHO BENEFITS?
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HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, JUNE 7, 2016
__________
Serial No. 114-71
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN M. KUSTER, New Hampshire,
DAVID P. ROE, Tennessee Ranking Member
DAN BENISHEK, Michigan BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana TIMOTHY J. WALZ, Minnesota
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
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C O N T E N T S
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Tuesday, June 7, 2016
Page
VA And Academic Affiliates: Who Benefits?........................ 1
OPENING STATEMENTS
Honorable Mike Coffman, Chairman................................. 1
Honorable Ann M. Kuster, Ranking Member.......................... 2
WITNESSES
Robert L. Jesse, M.D., Ph.D., Chief Academic Affiliations
Officer, U.S. Department of Veterans Affairs................... 3
Prepared Statement........................................... 30
Accompanied by:
David Atkins, M.D., M.P.H., Acting Chief Research and
Development Officer, U.S. Department of Veterans Affairs
Ricky L. Lemmon, Acting Chief Procurement and Logistics
Officer, U.S. Department of Veterans Affairs
Mr. Randall Williamson, Director, Health Care Issues, Government
Accountability Office.......................................... 5
Prepared Statement........................................... 32
Janis Orlowski, M.D., MACP, Chief Health Care Officer,
Association of American Medical Colleges....................... 7
Prepared Statement........................................... 40
Nancy Watterson-Diorio, Board Member, National Association of
Veterans' Research and Education Foundations................... 8
Prepared Statement........................................... 52
STATEMENT FOR THE RECORD
Dr. Christian Kreipke............................................ 58
VA AND ACADEMIC AFFILIATES: WHO BENEFITS?
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Tuesday, June 7, 2016
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight
and Investigations,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 4:17 p.m., in
Room 334, Cannon House Office Building, Hon. Mike Coffman
[Chairman of the Subcommittee] presiding.
Present: Representatives Coffman, Lamborn, Roe, Huelskamp,
Kuster, O'Rourke, and Walz.
OPENING STATEMENT OF MIKE COFFMAN, CHAIRMAN
Mr. Coffman. Good afternoon. This hearing will come to
order.
I want to the welcome everyone to today's hearing, titled
``VA and Academic Affiliates: Who Benefits?'' This hearing will
examine the relationship between the VA and the academic
affiliates. The hearing will focus on issues and concerns
related to sole-source contracting, billing issues, research
funding, space, data and equipment.
VA has had a relationship with academic affiliates dating
back to World War II. This relationship was developed and
encouraged as a way to ensure that our Nation's veterans
received the best care possible following their service to our
country. We all agree our veterans deserve nothing less than
the best care.
We have already witnessed many ways in which veterans are
being denied high-quality health care, including excessive wait
times, confusing scheduling processes, and the lack of access
to non-VA care because of poor implementation of the Choice
Act.
Now we are hearing that the relationship between VA and its
affiliates may not be as beneficial as VA and veterans--I'm
sorry--not be as beneficial to VA and veterans as was initially
intended.
We are discovering that affiliates control the affiliate
relationship and make decisions related to VA and the way it
operates. Leadership positions at VA medical centers are held
by employees who also have appointments at the academic
affiliate.
This begs the question as to where the loyalties lay for
these VA leaders. Are these VA leaders making decisions in the
best interests of the veteran when they also have an allegiance
to the affiliate? How can we be sure? What oversight is in
place to ensure that veterans are benefiting from this
relationship?
According to a recent OIG report from August 2015, VA
medical centers are allowing physicians to come and go between
VA and the affiliate with no true oversight of their time.
There are no assurances that these physicians are in the VA
performing their VA responsibilities when they are supposed to
be, and the bills are being paid without questions about the
services rendered.
Similarly, we are aware that VA leadership is allowing VA
research projects to be conducted at the affiliate, VA
equipment to be removed to the affiliate, and VA research data
to be stored on university servers. These actions can greatly
impact VA's ability to assert ownership rights in inventions
made by VA employees who are using VA resources. We certainly
do not want to see VA in a similar position to what it was
regarding the hepatitis C drug.
We also know that VA nonprofit corporations are not being
utilized to their fullest potential. Congress authorized these
nonprofits in order to allow additional research dollars to be
put back into VA research for the benefit of veterans, but much
of this money is being administered by the affiliates instead,
resulting in a loss of millions of dollars to VA.
Finally, according to the GAO report just issued yesterday,
we know that VA is taking years to negotiate and enter into
sole-source affiliate contracts, which results in gaps in
patient care. This is most definitely not in the best interest
of our veterans. Hopefully we can hear what VA is doing to
improve this relationship with academic affiliates to better
benefit veterans.
With that, I now yield to Ranking Member Kuster for any
opening remarks she may have.
OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER
Ms. Kuster. Thank you, Chairman Coffman.
This afternoon, the Subcommittee on Oversight and
Investigation will delve into issues involving VA and its
academic affiliates.
The VA plays a vital role in our national health care
delivery system. In 70 years of partnership with academic
affiliates, the VA is the largest single provider of medical
training in the United States. Today, over 70 percent of health
care providers have received their training through the
Veterans Administration.
While our overall health care system reaps the benefits of
VA's education and training efforts, the VA also benefits by
being able to rely on additional providers and specialists who
are on the leading edge of medical knowledge and leaders in
their field of practice. This is especially important to the
VA, which is facing shortages in health care providers. In
fact, it's estimated that there will be a nationwide shortage
of between 46,000 to 90,000 physicians within the next decade.
The VA's relationship to its academic affiliates is
essential if the VA is to provide the level of health care that
we all expect for our veterans. This is why Congress and the VA
must work together to address areas that need improvement.
We simply must improve the contracting process between the
VA and its affiliates for medical services. How medicine is
practiced in this country is undergoing a revolution, with more
integration and more consolidation. VA's contracting process
must recognize these changes and evolve with the practice of
medicine.
It should not take 3 years for the VA to contract with its
affiliates to provide medical services to our veterans. This
cumbersome process meant that 161 academic affiliates who
wanted to provide more doctors and services during the patient
access crisis of 2014 were turned away because the contracting
process was just too hard. It's unacceptable that a
bureaucratic process stands in the way of our veterans
accessing high-quality care.
Further, according to the GAO, who is with us today, the
process for sole-source affiliate contracts is a mirror of what
we often find on this Subcommittee when we look into VA's
contracting processes in general--too little oversight, not
enough data, and too many barriers to getting the job done.
It's simply impossible to manage such a vital program if you do
not have the information to make decisions, spot problems, and
systemize and streamline the process.
I am hopeful that we have a conversation on how best to
provide needed oversight and flexibility, and how best to
recognize the changing nature of the health care industry in
America, and to make sure that we leverage these changes to the
benefit of our veterans.
I look forward to hearing from all of our witnesses invited
to appear before us today.
And I yield back the balance of my time.
Mr. Coffman. Thank you, Ranking Member Kuster.
I ask all Members--I ask that all Members waive their
opening remarks, as per this Committee's custom.
Hearing no objection, so ordered.
With that, I would like to introduce our panel. On the
panel, we have Dr. Robert Jesse, Chief Academic Affiliations
Officer for the Department of Veterans Affairs, who is
accompanied by Dr. David Atkins, Acting Chief Research and
Development Officer, and Ricky Lemmon, Acting Chief Procurement
and Logistics Officer; Mr. Randall Williamson, Director of
GAO's health care team; Dr. Janis Orlowski, Chief Health Care
Officer, Association of American Medical Colleges; and Ms.
Nancy Watterson-Diorio, Board Member of the National
Association of Veterans' Research and Education Foundations.
I now ask that all witnesses stand and raise their right
hands.
Do you solemnly swear under penalty of perjury that the
testimony you are about to provide is the truth, the whole
truth, and nothing but the truth?
Thank you. Please be seated.
And let the record reflect that all witnesses answered in
the affirmative.
Dr. Jesse, you are now recognized for 5 minutes.
STATEMENT OF ROBERT L. JESSE, M.D., PH.D.
Dr. Jesse. Good afternoon, Mr. Chairman, Ranking Member
Kuster, and Members of the Committee, and thank you for this
opportunity to discuss VA's relationship with its academic
affiliates.
As you mentioned, I'm accompanied today by Mr. Rick Lemmon,
the Acting Chief Procurement and Logistics Officer, and Dr.
David Atkins, the Chief Research and Development Officer.
January 30th of this year, marked the 70th anniversary of
Policy Memorandum 2. This established the visionary partnership
between VA and America's medical schools. Strong academic
relationships have proven to be a foundation for providing
veterans access to high-quality health care and support for VHA
to fill its statutory missions to educate for VA and for the
Nation, and to carry out a program of medical research in
connection with the provision of medical care and treatment of
veterans.
Academic affiliates facilitate the recruitment of
outstanding clinical staff to VA, and trainees working under
their supervision serve as force multipliers. The opportunity
to teach America's best and brightest attracts clinicians
motivated by professional excellence, ensuring that VA can
remain a leader in the knowledge and skills associated with the
practice, teaching, research, and the building of the learning
health care system.
The Office of Academic Affiliations manages the educational
components of these relationships through affiliation
agreements that address the health profession's educational
activities and disbursements of funds for physician trainees.
Research operations, including grant funding, as well as the
arrangements for shared space, equipment, and personnel, are
managed by the Office of Research and Development. And
contracts for professional and clinic services are managed by
the Office of Procurement and Logistics through sharing
agreements and other contractual mechanisms.
VA is profoundly important to U.S. professional education,
having affiliations with over 1,800 schools and programs.
Nearly 124,000 trainees receive supervised clinical education
in VA facilities each year, with about 70 percent of all U.S.
physicians having some VA clinical experience in the course of
their education. VA is the second-largest funder of graduate
medical education after Health and Human Services.
VA research has contributed to transformational advances
impacting virtually every aspect of health care as we know it
today. VA research benefits from its position within a national
integrated health care system, and from having a state-of-the-
art electronic health record. It also benefits from dynamic
collaborations with university partners, Federal agencies,
nonprofit organizations, and industry, which bring in
additional funding, and this was, I think, $287 million in
2015.
The Federal investment in VA research returns incredible
value to veterans and to the taxpayer. Take, for example, the
Million Veteran Program, which has already enrolled close to
half a million veterans, who have donated samples and completed
surveys to help unlock the genomic basis of health and disease,
and is poised to be a cornerstone for precision medicine in the
future.
Yesterday, GAO released its report entitled ``Improvements
Needed for Management and Oversight of Sole-Source Affiliate
Contract Development.'' This report suggested eight Executive
actions to ensure timely development of high-value, long-term
sole-source affiliate contracts and effective development and
use of short-term contracts, including the need to ensure
better effective communication between VA and its affiliates.
VA has concurred with the GAO's recommendations and has
developed an action plan to meet each of these. The goal is to
more effectively and efficiently use VA's existing sole-source
contracting authorities to meet the needs of veterans and to
ensure compliance that meets our fiscal responsibilities. VA
appreciates the input from GAO and other adviser groups to
identify root causes and develop long-term solutions.
Academic affiliations has brought great value to VA, to
veterans, and to the American public for 70 years. However,
U.S. health care has changed dramatically over this time. The
organization of health systems now often involve multiple
contracting entities. Health education is now rigidly
prescriptive, research oversight is now intense, and payment
models for health care are now rapidly evolving.
So, too, must VA change the way we do business with our
partners in order to optimize the value of these relationships
for veterans and the American taxpayer. Bold, innovative
partnership models with affiliates structured around shared
resources and accountability to optimize care for veterans are
being explored.
As VA commits to improving existing processes, we hope to
work with Congress to enhance the authorities under which
partnership can be leveraged to improve the quality, safety,
and timeliness of health care for all veterans, while also
supporting the research mission and the training of the health
care workforce for the Nation.
Mr. Chairman, this concludes my testimony. My colleagues
and I are prepared to answer any questions you and Ranking
Member Kuster may have--and the Committee. Thank you.
[The prepared statement of Robert L. Jesse appears in the
Appendix]
Mr. Coffman. Thank you, Dr. Jesse.
Mr. Williamson, you are now recognized for 5 minutes.
STATEMENT OF RANDALL WILLIAMSON
Mr. Williamson. Thank you, Chairman Coffman and Ranking
Member Kuster and Members of the Subcommittee. I am pleased to
be here to discuss GAO's report, released yesterday, on VA's
use of sole-source affiliate contracts.
VA partners with the university medical schools to provide
learning opportunities for medical residents, while also
increasing a pool of physicians available to treat our Nation's
veterans. Over 40 percent of VA's total physician workforce is
made up of residents and physicians supplied through academic
affiliations.
VA has the unique authority to establish sole-source
contracts with its university partners without competition.
Today, I will address this very important aspect of VA's
academic affiliations.
Sole-source affiliate contracts allow VA to obtain
physician services needed to treat veterans and oversee
residents working in VA medical centers. Our review covered
VA's use and oversight of these contracts and compliance with
existing VA procurement policies.
Most of these contracts are of two types: first, high-
value, long-term contracts that are over $500,000 and more than
1 year in duration; second, short-term contracts that are less
than $500,000 and less than 1 year duration. The value of the
contract is an important factor to determine the amount of
oversight it will receive. Short-term contracts under $500,000
are subject to much less oversight than high-value, long-term
contracts.
We found that at four of the five VA medical centers we
visited, they relied mainly on short-term sole-source affiliate
contracts to obtain physician services from their affiliates,
often avoiding high-level reviews and oversight that
potentially could have reduced the contract prices and better
ensured that VA was complying with procurement policy.
Contracting officials we interviewed attributed this over-
reliance on short-term sole-source affiliate contracts to a
number of factors. The most notable reason was that high-value,
long-term contracts we reviewed took 3 years to process and
finalize, on average, and this timeframe does not work for many
medical centers that must seek quick solutions to physician
shortages or add additional physicians in critical specialty
areas. In contrast, short-term contracts can be finalized in 3
months or less.
The lengthy process to develop high-value, long-term sole-
source affiliate contracts is due to incomplete and untimely
information submitted by VA medical centers to contracting
officers, rework to update paperwork to comply with revised
forms or new policies, multiple reviews, and inexperienced
contracting staff. Currently, VHA does not have performance
standards to hold contracting staff accountable for timeliness,
and does not have data to identify and resolve potential
bottlenecks in the contracting process.
Relying on short-term sole-source affiliate contracts can
have some significant downsides and risks for VA. For example,
for short-term sole-source affiliate contracts, contracting
officers aren't required to consult trained negotiators to help
them establish contract price, as occurs for high-value, long-
term contracts. Also, short-term sole-source affiliate
contracts are not monitored by VHA's central office, and place
VA at risk for overpaying the affiliate services provided
through them.
Also, at one VAMC we visited, we found that all five short-
term sole-source affiliate contracts we reviewed had serious
violations of VHA policy and VA policy, including the absence
of negotiations to address pricing issues before finalizing the
contract.
More broadly, we found that nowhere in VA does anyone
review the big-picture use of short-term sole-source affiliate
contracts among medical centers to identify patterns of
overreliance and detect potential noncompliance with VA
policies and procedures.
Exacerbating the problems that I've outlined thus far is
the relative inexperience and high turnover among medical
sharing contracting staff. We found that one-quarter of the
medical sharing staff leave each year, and two-thirds have less
than 3 years of experience working with these types of
contracts. It usually takes about 5 years to become proficient
in developing these contracts, according to senior VA
contracting staff. Moreover, VA has provided limited training
to medical sharing contract staff, further aggravating an
already difficult situation.
In short, VA needs to take bold steps now on many fronts to
rectify its poor management of these contracts. In this regard,
we made eight recommendations to improve VA's management of
sole-source affiliate contracts, and VA concurred with all of
them.
That concludes my opening remarks, Mr. Chairman.
[The prepared statement of Randall Williamson appears in
the Appendix]
Mr. Coffman. Well, thank you, Mr. Williamson.
Dr. Orlowski, you are now recognized for 5 minutes.
STATEMENT OF JANIS ORLOWSKI, M.D.
Dr. Orlowski. Mr. Chairman, Members of the Subcommittee,
thank you for the opportunity to testify on VA academic
affiliations.
The Association of American Medical Colleges is a nonprofit
institution comprised of all 145 accredited U.S. medical
schools and nearly 400 major teaching hospitals, including 51
VA medical centers. As the chief health care officer at the
association, my focus is on the interface between the health
care delivery system and academic medicine.
The VA has over 500 academic affiliation agreements with
our Nation's medical schools and teaching hospitals. As noted,
2016 is an important anniversary for the VA and academic
medicine, as we celebrate our 70th anniversary in partnership.
The relationship, as you had noted, followed World War II,
when the VA and the Nation faced very much the same situation
we face today. At that time, the VA had a severe shortage of
physicians as nearly 16 million men and women returned from
overseas. Today, there's a combination of the VA's aging
veteran population and an influx of veterans from recent
engagements. There's an increasing need for more health care,
resulting in access issues that are symptomatic of a broader
trend, which is the physician shortage.
You ask who benefits from these relationships. Simply put,
the veterans do. The AAMC projects a nationwide shortage of
between 46,000 and 90,000 physicians by 2025. Though these
shortfalls will affect all Americans, we note the most
vulnerable populations, including veterans and those in
underserved areas, will be the first to feel this impact as the
VA is now.
What the VA and academic affiliations established was
improved access and quality of care for our Nation's veterans.
What started as a simple idea in a time of great need has
developed into an unprecedented private-public partnership. The
VA's education mission trains new physicians on cultural
competency for treating veteran patients. Further, the VA has
found that a physician is twice as likely to consider
employment at the VA after training at a VA facility.
The VA's research mission creates advances in areas
important to the veterans population, such as traumatic brain
injury, PTSD, prostheses, respiratory exposure, not to mention
the system reforms that improve care delivery within the VA
systems.
Perhaps most importantly, VA academic affiliations put
veterans first in line for the best health care in the world at
the Nation's teaching hospitals. Our members take pride in
being partners with the VA and providing care to veterans. They
view this as an important part of their mission.
The AAMC believes VA's sole-source contracting, joint
ventures, and the proposed core network of the Veterans Choice
programs improve access for our Nation's veterans to the
highest quality care by preserving the academic affiliates as a
direct extension of VA care and a preferred provider.
Direct clinical care agreements, such as sole-source
contracts, allow academic affiliates to plan, staff, and
sustain infrastructure for certain complex clinical care
services that are not available elsewhere, such as trauma
centers, burn centers, comprehensive stroke centers, and
surgical transplant centers. Solely relying on fee-based
mechanisms has the potential to reduce veterans' access to care
if teaching hospitals scale back services if they are faced
with an uncertain patient load from the VA.
Both VA medical centers and their academic affiliates
recognize the value of these relationships to improving
veterans' health care access and quality. As with any
partnership, there's always room for improvement, and the AAMC
is working with the VA on contracting reform, including right-
sizing the OIG review threshold to reflect clinical services,
preapproved contract templates for selected services at
Medicare reimbursement levels, and standardized overhead rates.
These reforms will streamline agreements, reduce the
negotiation times, help prevent delays in veterans' care, and
shift reliance on short-term, temporary contracts in favor of
the high-value, long-term contracts.
The VA is at a crossroads. Strengthening the 70-year
history of the VA academic affiliation will prepare our country
for the next chapter of VA health care. The AAMC and our member
institutions will continue to work with Congress and the VA to
address the challenges and opportunities to ultimately improve
care for the veterans and all Americans.
Thank you very much for this opportunity to testify, and I
look forward to answering your questions.
[The prepared statement of Janis Orlowski appears in the
Appendix]
Mr. Coffman. Thank you.
The written statements of those who have just provided
oral--oh, I'm sorry. Ms. Watterson-Diorio, you are now
recognized for 5 minutes.
STATEMENT OF NANCY WATTERSON-DIORIO
Ms. Watterson-Diorio. Good afternoon, Chairman Coffman,
Ranking Member Kuster, and Members of the Subcommittee. Thank
you for the opportunity to discuss the topic of ``VA and
Academic Affiliates: Who Benefits?''
My name is Nancy Watterson-Diorio. I am a board member of
the National Association of Veterans' Research and Education
Foundations, also known as NAVREF, and the CEO of the Boston VA
Research Institute, known as BVARI.
As a witness, my topics include how the VA nonprofit
corporations fulfill an important role at the VA, in addition
to the academic affiliates, in administering this extramural
research.
In 1988, Congress authorized the NPCs under title 38 to
support VA research and, shortly thereafter, amended
legislation to include educational activities. NAVREF
represents the entire membership of 82 VA NPCs who are co-
located within the VA medical centers across the country.
As reported in the 2014 annual NPC report to Congress, we
raised over $260 million of annual extramural research and
educational awards specifically targeted toward the VA's health
care mission of supporting veterans' care. This represents
approximately 15 percent of the total research portfolio
supporting research at VA.
The founding legislation felt several areas of difficulty
for the VA research and education programs. It discontinued
handshake agreements with no contractual obligations, an
acknowledgement of VA's research successes. It supplemented
VA's intramural funding expertise with expert support for
extramural pre- and post-award funding and unique compliance
knowledge. It leveraged VA's ability to expand its research
portfolio to support clinical trials and Federal funding, thus
allowing more veterans to be supported with state-of-the-art
research knowledge, and the opportunity to be treated with the
newest therapies. And, finally, it fostered an innovative
spirit of public-private sponsorship that we should continue to
nurture and grow.
There are many advantages to using NPCs as envisioned by
Congress. NPCs rigorously comply with Federal regulations and
are subject to VA oversight that includes recurring VA audit
requirements and inspections. Additional VA oversight includes
statutory VA board members at each NPC, and a nonprofit
oversight board at VA's central office. And NPCs operate
transparently by providing an annual report to Congress
detailing their accomplishments and successes in support of VA
research.
There are also challenges that we must find ways to
overcome. The VA NPCs are unable to pay investigators in the
same manner as the academic affiliates. We have managed to be
successful despite this inconsistency, but if we were given the
opportunity to administer payments in the same way as the
affiliates, it would further enhance our successes in
completing our mission of improved veteran health outcomes.
Local practices are inconsistent on whether an NPC or an
academic affiliate should be administering VA research
projects. I recognize that not all 82 VA nonprofits have the
current expertise to manage Federal grants. But without
allowing them an opportunity to grow into this role, they will
not be able to serve the veteran community to their potential.
And, finally, the decisionmaking process within VA
regarding the administration of Federal grants varies from site
to site. Frequently, principal investigators, who are duly
appointed at the academic affiliates, or even local leadership
make the determination on who will administer the research,
which is a potential conflict of interest.
I believe that Congress created the NPCs for all the right
reasons. However, I believe that the NPCs can contribute much
more and be of even greater benefit to our veterans if the
lingering barriers were removed.
To that end, I respectfully request that the Subcommittee
consider updated directives that would allow NPCs to pay
investigators to the same extent the academic affiliates,
provide the VA NPC right of first refusal on administering all
research awards supporting VA research, and reduce the level of
variability from site to site by creating general guidelines
and decision trees that remove or reduce conflicts of interest
among decisionmakers.
Again, thank you for this opportunity to share the good
work that is being done at the VA NPCs, and your support in
allowing us this opportunity to participate in the important
work that is being done in the VA's extramural research and
education programs. NPCs offer great services and value, and I
encourage congressional and VA leaders to look at expanding
opportunities to use these great resources.
I look forward to your questions. Thank you.
[The prepared statement of Nancy Watterson-Diorio appears
in the Appendix]
Mr. Coffman. Thank you.
The written statements of those who have just provided oral
testimony will be entered into the hearing record. We will now
proceed to questioning.
Dr. Jesse, VA has been asking for noncompetitive
contracting authority like what we see related to this hearing
topic for other purposes, such as provider agreements. Its
sole-source contracting with affiliates is such a mess, why
should we believe that sole-sourcing other contracts would be
any different?
Dr. Jesse. So I think there's two issues here. It's clear
that the administration of the existing sole-source contracts
that we have requires some work. And Mr. Lemmon can talk more
about that. It certainly is the focus of the GAO report. But
there are times when sole-source contracting provides the speed
and agility one needs in order to provide care that veterans
need in a timeframe that can be done.
And the issue here is primarily getting the proper care to
veterans when they need it, and then ensuring that it's done in
a fiscally responsible manner.
Mr. Coffman. Dr. Jesse or Mr. Lemmon, can you assure me
that this affiliate contract situation is different from the
purchase card abuse situation we have seen over the past few
years, where VA has been making payments with purchase cards
spread over many split transactions under false pretense that,
actually, contracts existed?
Mr. Lemmon. Yes. There's no relationship to those issues
with the purchase card program and what we're trying to do with
affiliates.
The purchase card program is something that we're also
working on. We didn't prepare statements for that. But we're
working on establishing a lot of national-level contracts
instead of more open-market procurements under the micro-
purchase threshold of $2,500. And so the goal is to bring that
in.
Right now, we have way too many people with purchase cards,
way too many transactions. And we want to act more as an
enterprise and buy off of nationally leveraged contracts that
provide great value to VHA, and reduce the amount of open-
market buying that's going on now that's created some of the
problems that you identified.
Mr. Coffman. Well, can you assure me there aren't any
handshake agreements here, that all this affiliate spending is
done on bona fide contracts?
Mr. Lemmon. I believe we do have contracts in place for our
affiliate agreements. It's hard to say that in no hospital at
any place in the country there's something that I wouldn't know
about, but there's been great effort to put contracts in place
with affiliates.
GAO certainly found a number of challenges that we take
ownership of and we're going to address, but I don't believe
there's handshake agreements like there were in the past.
Mr. Coffman. Dr. Jesse, in a 2015 OIG report, it was found
that the VA medical center in Pittsburgh had overpaid the
University of Pittsburgh Physicians, Incorporated, by $44,082
for call-back service hours that should have been attributed to
a VA physician as a five-eighths employee. Will this money be
refunded to the VA?
Dr. Jesse. Well, I can't answer that question. I can take
it for the record and get back to you.
But the question here is, when a five-eighths--when a part-
time physician has already committed their hours to the VA and
then are working for another agent, meaning the university,
what are the responsibilities going back and forth there.
But I don't know the exact answer to your question. I will
get back to you.
Mr. Coffman. Are you disputing the factual nature of the
OIG report in terms of the overpayment?
Dr. Jesse. No. I agree the OIG report said that they were
paid an additional $24,000. The question was, is it going to be
returned, and I said I don't know the answer to that question,
but we can find that out for you.
Mr. Coffman. It's $44,000.
Dr. Jesse. $44,000. I'm sorry.
Mr. Coffman. $44,000. And so are you going to try and get
that money back? That's the question.
Dr. Jesse. Well, we have to make sure--and I would defer to
Mr. Lemmon--do we have the authority to get that back. And
that's what I don't know. But if we have the authority to get
it back, we will try and get it back.
Mr. Coffman. Mr. Lemmon?
Mr. Lemmon. Yeah, the network contracting office involved
is working with general counsel to determine if we can recover
the funds. If they determine that legally we can do that, we
will.
Mr. Coffman. Well, since we didn't get back--since we
didn't attempt to get back any of the bonus money that was
given during the appointment-wait-time scandal, I'm not all
that surprised.
Ranking Member Kuster, you're now recognized for 5 minutes.
Ms. Kuster. Thank you.
And these go to anyone who would like to answer.
So I want to get at: Knowing that the practices of the
delivery of medicine is dramatically changing--we've got
accountable care organizations, we have group practices, we
have lots of different affiliations that are happening outside
of the VA process, but just happening with academic affiliates
across the country--how have these changes created issues with
the development of these long-term sole-source affiliate
contracts?
And if you can add to that, what is it that takes so long?
Is this contributing to the length of time? Or are they issues
within the VA that--because 3 years just sounds untenable to
me.
Dr. Jesse. So let me take, sort of, the preamble to your
question, and then I'll turn it over to Mr. Lemmon.
Actually, up in VISN 1, up in your area, there are a number
of alternative relationships being explored with the affiliates
in Burlington, Vermont, in Worcester, Mass., and in Maine,
where we are looking more at a joint-venture model, which would
share both care and accountability for care with the affiliate
in shared space, actually, where the VA could provide care to
the veteran under its authorities, the partner could provide
care to their family under their authorities, and we would
share in the other things like the social services that we know
are required to engender good health and well-being.
And that model doesn't work well in a contracting venue
that's really driven by a fee-for-service-type of model. And
that was the comment I was alluding to about really relooking
about how we can have the authorities to contract with partners
to develop these types of models. So think about joint ACOs,
for instance, as a potential, or other responsibilities, where
we would have a shared capitation for caring for a group of
patients rather than negotiating services for X number of
cardiac surgeries, X number of transplants, X number of
cholecystectomies or colonoscopies, but rather a much more
holistic approach.
And, frankly, this is where CMS is really trying to drive
with its alternative payment models, including both ACOs and
the--
Ms. Kuster. So do you think we're in a period of transition
where the VA--I mean, as the country is transitioning over to
the accountable care organizations, the VA is also following
that process, and that we could get to a place of a better
contracting and more effective and efficient and--
Dr. Jesse. So I'll speak on behalf of me and not the
agency, because this is my opinion. And I think we have to.
Because the current model--and as everybody on this panel has
alluded to, the affiliation relationships that were established
70 years ago were done for a good reason, and they're here
today, but the model of care in this country, how government
functions in this country is very different than it was in the
1940s. So we need new structures that allow us to optimize the
care for veterans consistently, where data moves back and forth
smoothly, where there is no opportunity for people to get lost
because of fractured care.
And as an example--
Ms. Kuster. Do you think you need new--do you need new
authority from Congress--
Dr. Jesse. Oh, I think we do. And I think--
Ms. Kuster [continued].--to enter into those kinds of
relationships?
Dr. Jesse [continued]. I think we do need new authorities
from Congress, and we will be exploring them. We're just not
prepared to say exactly what now.
But let me give you an example. This was just announced
last month. In Palo Alto, they have now a relationship. The
word went to CVS, to the MinuteClinics, where veterans out in
the bay area, if they have a problem, they can call the nurse
triage line. And if it's a problem that is in the purview of
what MinuteClinics provide, they will be referred to a
MinuteClinic, the closest one. They won't have to travel into
Palo Alto or go to the ER or urgent care or to their primary
care provider. They get seen on the spot. VA pays; there's no
pay for the veteran. But the information comes back over into
the VA records so we get continuity of care.
Today, any veteran can go to any Walmart in the country and
get a flu shot for free, and that information will come back
in. And so these types of more extensive partnerships, I think,
are the models we're going to be talking about in the future.
Holistically--an ACO means certain things to certain people.
I'm not sure it's exactly the right term. But more cohesive
payment models will be key.
Ms. Kuster. All right. Thank you.
My time is up. I yield back.
Mr. Coffman. Thank you, Ranking Member Kuster.
Congressman Lamborn, you're now recognized for 5 minutes.
Mr. Lamborn. Thank you, Mr. Chairman. And thank you for
having this hearing and for your leadership on investigative
and oversight issues like this.
Dr. Atkins, you might be familiar with our recent Full
Committee hearing regarding invention disclosure, which we held
in February. What is VA doing to ensure that VA employees are
disclosing inventions they develop to the VA?
Dr. Atkins. Thank you. Yes, since that February hearing,
we've instituted three steps.
With the specific example that was the subject of that
hearing, regarding the hep C drug, we have an internal--an
external review by our National Research Advisory Committee
that will be reporting to us tomorrow. There is a criminal IG
investigation of that case that has completed its interviews,
but we have not received the report of that.
And I think, to your question specifically, we're revising
our policies to ensure that we get more complete annual
disclosure of inventions, so that the VA would be aware of
intellectual property to which it may lay a legitimate claim.
Part of the problem has been the reporting process. We're
going to try to make that easier for our researchers, so they
can report it in the same way that they report it to the
universities.
Mr. Lamborn. Thank you for making some progress on that. I
would like to ask that you provide the Committee copies of
those reports as soon as you get them. You've referred to a
couple of different--
Dr. Atkins. Certainly.
Mr. Lamborn [continued].--reports or updates and status
reports. This is a big issue, and I hope there's nothing else
out there of the magnitude of this hanging problem.
On the issue of disclosures, Dr. Jesse, changing gears
slightly, we know that VA employees can have dual appointments
with the affiliates and collect salary and benefits for both
institutions. Does VA require financial disclosures from these
employees?
Dr. Jesse. Of total salaries?
Mr. Lamborn. Their dual status and--
Dr. Jesse. Oh, I don't think a dual status would be missed.
The VA--
Mr. Lamborn [continued]. And benefits.
Dr. Jesse [continued]. Yeah. So the VA maps clinicians'
time, and it apportions that to clinical care, research,
administrative, for the like. But if somebody's a part-time
physician, then the rest of their time would be known to the
university.
And, frankly, many of the clinicians are actually jointly
recruited. So the recruitment includes a department chair, say,
from the university working with a department chair, the
counterpart at the VA, to bring a person in that would spend
joint time. And this is particularly common in procedural-laden
issues.
I think one of the challenges--and I want to be really
clear about how I say this. But VA accounts for physicians'
time as essentially an 80-hour pay period. And VA time and
attendance--and I think you've heard the Secretary talk about
problems with emergency physicians and hospitalists, that they
don't fit normal hours that we ascribe physicians to work in.
But we account for hours at a 40-hour week, 80-hour pay period.
Most universities account their physicians' time closer a
70-hour work week. And this is in part because of how they have
to map and commit time on NIH grants and teaching and research.
And clinical care is not a 9-to-5 operation. And so it is
possible to have a full-time, 40-hour-a-week VA who also has a
time commitment to the university above and beyond that.
And those arrangements are disclosed, as far as I'm aware.
I don't think it could be missed. And this follows an NIH model
that actually allows physicians to be paid for, actually, an
additional 20 hours.
Mr. Lamborn. Well, thank you for that. But I'm also wanting
to make sure that we have disclosure in place that would lead
to the revealing of conflicts of interest.
Dr. Jesse. Yeah. So I would hope that would be so. And I
think you're driving at if there's shared development of
intellectual property is probably the most important thing.
And, you know, a conflict of interest that--you know, we
just talked about financial conflicts of interest, but there's
also influence conflicts of interest too. And, you know, those
have to be managed very carefully. Our lawyers, our general
counsel, always advises people that we can clear you of certain
levels of conflict of interest, but it does not absolve you, as
the individual, from a criminal conflict of interest.
So the physicians themselves, you know, myself, always need
to be aware of the rules and aware of those boundaries. But if
there are issues, we will have counsel review them to make sure
that the boundaries are clear. And this actually has happened
recently with the chief of staff, for instance.
But they're very clear. If you cross--if you, as the
individual, regardless of whatever clearance we've given you,
cross certain boundaries, then you are liable for your actions.
Mr. Lamborn. Okay.
Thank you for your answers, and thank you for being here
today, all of you.
Dr. Jesse. Thank you.
Mr. Coffman. Mr. O'Rourke, you're now recognized for 5
minutes.
Mr. O'Rourke. Thank you, Mr. Chairman.
Mr. Williamson, thank you for your work on this. The
findings are serious, and I am glad to hear that the VA agrees
with them, and has a course-correction plan in place. I'm going
to ask Dr. Jesse about that in a minute.
But I wanted to ask you, Mr. Williamson, if there's any way
to quantify the scope of these failings. There are anecdotes
about overages that extend beyond the review threshold. Do we
have an overall number? And do we know how much of this money
you would characterize as wasted, where the taxpayer and the
veteran did not receive value for the dollar spent over the
threshold?
Mr. Williamson. No, unfortunately, we don't know that. And
we certainly tried to look.
We do know that there are high risks through the use of
short-term contracts when there's been poor management. At one
VA facility where we looked at five short-term, low-value
contracts, all five had procedural errors, including basically
the affiliate getting the price they asked for with no
negotiation.
So we know it's going on. We can't quantify that.
Mr. O'Rourke. And just from human nature, we can surmise
that that leaves the VA, the veteran, the taxpayer open to
fraud potentially. We don't know that that, in fact, took
place, but--
Mr. Williamson. Absolutely.
Mr. O'Rourke. Yeah. So this is pretty serious.
I heard Dr. Jesse say that at some point in the future the
VA will come to us requesting new authorities. Is it the GAO's
position that any new restrictions or laws are necessary? Or
are you satisfied with the VA implementing the recommendations
that you made?
Mr. Williamson. Well, we're very happy that VA has
concurred with our recommendations, and is apparently taking
action. We'll see how that goes.
I think that this is a process that's going to take some
time, because, just from the standpoint of the experience of
the contracting officers who are working on medical sharing
contracts, a third of them have less than a year of experience.
Two-thirds have less than 3 years. That needs to be fixed very
quickly, on a retention plan perhaps. One of our
recommendations was that they have a retention plan.
So there are a number of things. There are duplicative
processes in the--or duplicative functions within the process.
Both, for example, the VA Office of Inspector General does a
price analysis, and the Medical Sharing Office in Nashville
also does one. You know, the question could be asked, why are
two different organizations doing that.
Mr. O'Rourke. Dr. Jesse, you said you agreed with the
findings. Do you agree that employees of the VA purposefully
avoided oversight? And if that is the case, can you outline the
accountability--
Dr. Jesse. Well, I don't know that people purposely avoided
oversight. I think people used contracts in order to get care
for veterans, and when they know that--
Mr. O'Rourke. The intentions may have been good, but, in
the process of trying to get that care for veterans, did they
know what the requirement was and exceed that requirement on
purpose?
Dr. Jesse. I don't know that that's true or not true, and I
really don't want to have to make a judgment there.
Mr. O'Rourke. Okay.
Dr. Jesse. And I think part of the issue of--
Mr. O'Rourke. How do we get VA employees to follow the
rules and regulations within the VA? And it might concern
people I represent that you don't seem to be concerned about
that being the case. And so we can implement the reforms, but
if you're not going to hold your employees accountable, I
think, you know, that would be a concern for me.
Dr. Jesse. I don't want to appear unconcerned at all. We're
very concerned about it. But I think it also speaks to Mr.
Williamson's comments about the lack of seniority amongst this
very crucial group of contracting staff. And it takes, what, 5
years to really get proficient at these contracts, so there is
a very steep learning curve.
So, you know, people are trying to get their jobs done. I
don't think they purposely lie, cheat, mislead. I think they
try and provide solutions that can get veterans what they need.
Our job is to make that job easier and to make the process
transparent so that we, all of us, can see what's going on and
have the kinds of data flows we need to be able to have
transparency into the process and know when issues arise. And
we don't have that today. And that's one of the crucial things
that needs to happen as part of the recommendations and the
reforms.
Mr. O'Rourke. I'm out of time, but I would agree with
everything you just said. And I would add that we then also
need to hold ourselves accountable. I mean, we can make
countless excuses for failure to perform, but I don't think the
people we represent, and I know you are not either, interested
in hearing those excuses for failures within the VA.
So what I really want to hear--and perhaps you can follow-
up for the record if you don't have it today--is the timeline
to implement these recommendations, and an assurance that we're
going to hold ourselves accountable for adhering to those new
standards so that we get greater value for the taxpayer, we
eliminate fraud and abuse, and we deliver care to veterans in a
timely fashion, producing better outcomes than we see today.
That's what I'm looking for.
Dr. Jesse. Okay. Absolutely. That's all laid out, and we
can get that to you.
Mr. O'Rourke. Great.
Dr. Jesse. Mr.--
Mr. O'Rourke. I'm going to have to yield back to the chair.
I'm out of time. Thank you.
Mr. Coffman. Dr. Roe, you're now recognized for 5 minutes.
Mr. Roe. Thank you, Chairman.
I'm probably going to take a little bit different vantage
point on this. First of all, we know the VA is deeply involved
in medical education. Forty percent, as Mr. Williamson, I
think, pointed out, of the VA staff now are residents or
faculty from the university. So that relationship, which has
been there 70 years, helped train our physician workforce in
the country, is absolutely paramount.
I think the Institute of Medicine back in the 1990s thought
we had 25,000 too many doctors by 2010, and that's kind of like
predicting who's going to win the next Super Bowl, but I think
we do have--whatever the number is--a physician shortage. I
don't think there's any question about that. The Committee
recognized that with the Veterans Choice Act and put 1,500
residency slots in there, which the VA's trying to implement
right now.
One of the things I think--and I may be wrong on this, but
we had hearing after hearing when we found out all these wait
times are going on. And so, if you're a contractor, you're a
medical center director, you're going to try to find the
quickest way you can to get additional manpower to see these
patients. And that may end up being why there are so many
short-term contracts.
That relationship between academia and the VA is absolutely
paramount for medical education and for care in this country.
And it's good for both parties. It's good for the veteran, it's
good for the students, the doctors, like myself, who trained
there. It's also very good for the academic institutions and
for research. The VA carries on a very big research arm, and
they have to have these collaborations with universities and
the teaching hospitals. So I think this system has to work.
One of the questions I have, Mr. Williamson or Dr. Jesse,
whoever wants to take it, how many of the contracts are short-
term contracts? What percent I guess is what I'm asking.
Mr. Williamson. There are a total of 1,200 sole-source
contracts. I'm blanking right now on how many of those are
short-term. Many of them, perhaps most of them.
Mr. Roe. Most of them.
And the other question, I think everyone's going to ask,
is, why does it take--why in the world does it take 3 years. I
mean, that's unbelievable when I heard that. If it takes that
long to have a long-term contract with an East Tennessee State
University Quillen College of Medicine, the University of
Pittsburgh, or whomever, you're going to have short-term
contracts. Because the care's got to get delivered; I mean,
there's no question. So that's got to get fixed, I think. And I
think that would be paramount, to me, to fix--so you can go
with these long-term contracts.
The other thing, the payment models, as you all have
pointed out, the fee-for-service contract ought to be pretty
simple. You're just paying somebody if it's a fee-for-service
procedure done. That's been laid out by Blue Cross, by
Medicare, by Medicaid. I mean, that's not a hard number to
find.
I will agree with you, it's a lot tougher on the new
models, with the ACO and with the capitated model. I don't know
whether VA's put their toe in that water yet or not, but that's
a little tougher one to--and you do need some very skilled
people to do that.
And I don't know whether you have or not, Dr. Jesse.
Dr. Jesse. Well, that's why I parsed it by saying that's my
opinion and not necessarily the agency's.
But we are an ACO. Fundamentally, we are a capitated system
with social responsibilities. How one brings in external
partners and pays them is actually the real challenge that we
need to figure out. And, you know, that's--if it's a tenable
model, then we'll come back to you. If it's not, we'll look at
alternatives.
Mr. Roe. Well, the way the VA's capitated model works is it
just creates waste. That's what happened in Arizona and others.
When you can't get enough providers to get in, and you run to
the end of your budget, you just put it off and--
Dr. Jesse. And that's not acceptable. There's no argument
there.
Mr. Roe. And there's a much more efficient way, I think, to
do it. I think we all agree with that.
And I think, again, I want to know--for the record, I'd
like to know what percent of those contracts are short-term
contracts versus long-term contracts.
Mr. Roe. If you fix that problem, I think you've gone a
long way to fixing the other. The research arm, if you need
some other help from us on that, let us know what that is,
because that needs to be nurtured too, I think. We need to make
sure that the VA and the other folks out there trying to do
research--I think it's great. I think the VA does need to
maintain that intellectual property.
For instance, in the hepatitis C, we've all heard that. We
all know what a fiasco that was. We can't let that happen. But,
again, the good news of that whole research was hepatitis C got
cured. Whoever got the money, still, patients out there
benefited from that. It was a slipup, there's no question about
that, on the VA's part to turn that resource loose, but the
fact is patients today, right now, are getting benefit from
that research that's been done.
I yield back.
Mr. Coffman. Thank you, Dr. Roe.
Congressman Walz, you're now recognized for 5 minutes.
Mr. Walz. Thank you, Chairman.
And thank you all for being here.
Mr. Williamson, and each of us have said this, it's hard to
get people--and I'm going to focus on the contracting and the
skill set of the employees--to get them there, to be able to do
this, to get it right. But that employee skill training and
execution, that's a personnel management issue. That is a
personnel management issue.
And I don't know if I'm making--it seems to me this is a
very similar situation, with lack of training, that went into
some of the scheduling issues that we had.
So my question is this: Is there any discussion amongst VA
to standardize the training, like a training center, and have
the requirements clearly laid out, like the Foreign Service
Initiative I'm familiar with and the military? When I go to a
military school, there's a set of standards. When I come out of
there, I'm skilled, I can do A, B, C, and D, and it is measured
in there. Is there something similar in the VA for someone who
is working on contracts, just to show level of competency?
Mr. Lemmon. Yes, there is. We have a VA Acquisition Academy
in Frederick, Maryland, that provides all the training that's
required to be certified as a contracting officer. In addition,
our Medical Sharing Office has developed specific classes in
health care contracting to deliver to our workforce. So we've
got, really, two avenues that are good.
The turnover issue and the experience issue, there's a lot
of reasons for it, but one of the big ones--and maybe I'm
answering more than you asked, but we've got process issues we
have to correct. And it's been mentioned, 3 years. It's
ridiculous that it takes that much time. So if you're an 1102
with a broken process, where you can't satisfy your customer in
a reasonable amount of time, you're probably going to look for
other work that would be more satisfying.
So, in my mind, we have to fix the process. And I'm
committed to do that.
Mr. Walz. Is it a case, you have to help me understand
this, if I get all the training and I--say, I'm certified to
teach, my first year in that classroom is arguably not going to
be or shouldn't be as good as my 10th year in that classroom.
So they have the skill set, but it's still a case of you have
to execute, and there's something that comes with doing the
job, is that the case, of not having enough experience no
matter if they're trained or not?
Mr. Lemmon. Right. For warranted contracting officers,
there's requirements both for education and length of time
doing the work. So they have to have an experience requirement
to be warranted to award contracts at certain levels.
So we have that in place. And we can talk about the issues
with health care contracts, but they are much more complex than
many of the other contracts we work on. We have to keep our
workforce, and we have to have a process that makes sense so we
can get these contracts done in a reasonable time period.
Mr. Walz. And you think that's happening now? The process
changes are happening, you're making the--
Mr. Lemmon. We're working on them right now.
Mr. Walz. Okay. My next thing, we were just discussing up
here the ability on these contracts on the useable data. And
hard to--if we don't have all the useable data on them, if it's
not collected useable, how are we--what are we doing about
that? Can you fix that on your own or do we need to legislate
it?
Mr. Lemmon. Well, it depends on what you're referring to as
data. Certainly one of our plans to address the findings that
GAO provided is we're going to create enterprise visibility on
performance against new milestone plans for these contracts.
So leadership will know if there's a roadblock or
something's not moving as fast as it needs to be. I believe we
can do that without additional resources, quite frankly.
Mr. Walz. And that was not happening before?
Mr. Lemmon. No.
Mr. Walz. And it can be now?
Mr. Lemmon. It can be.
Mr. Walz. And that should--I would think that would make a
significant difference. Is that your take, that--
Mr. Lemmon. I think it will make a significant difference.
Mr. Walz. Okay. I yield back, Mr. Chairman.
Dr. Orlowski. Sir, if I can make a comment.
Mr. Walz. Oh. Absolutely. I have 40 seconds, so--
Dr. Orlowski. Thank you. About a year ago, one of the
suggestions that the academic medical centers made to the VA is
that we actually have some template agreements. They're very
complex agreements, but there are certain standards that,
rather than having each VA work on a specific language, that
we'd like to see national templates. They could have some local
changes to them as needed, but that was one of the suggestions,
because the academic affiliates actually have the same
frustration with the fact that we're dealing with short-term
contracts.
So that is one of the multiple suggestions that we've made
as we've worked with the VA.
Mr. Walz. Great.
Mr. Lemmon. I know there's just a few seconds left. But we
do have 19 standardized performance work statements for various
specialties now.
Mr. Walz. Great. Thank you.
Thank you, Mr. Chairman.
Mr. Coffman. Thank you, Congressman Walz.
Congressman Huelskamp, you are now recognized for 5
minutes.
Mr. Huelskamp. Thank you, Mr. Chairman.
First a question for Dr. Jesse. The OIG reports in three
contracts, the Pittsburgh VA entered with the University of
Pittsburgh Physicians Incorporated, there was a total of nearly
$850,000 administrative overhead expenses not supported or
documented. What is VA doing to prevent this waste of taxpayer
dollars?
Dr. Jesse. So Pittsburgh is already done. The issue is how
do we prevent that from happening again, and this is why we
have set up, for instance, the Office of Medical Sharing that
reviews these contracts and negotiates with the universities.
And, in fact, the history of that group and doing this in a
relatively short period of time of a couple of years has saved,
and Mr. Lemmon can give you the exact numbers, but it's, what,
about 113?
Mr. Lemmon. Right. Even though the current process is
horrible in terms of timeliness and we have to fix it, since
October 2013 through April 2016, the VHA Medical Sharing Office
has participated in the negotiation of 69 affiliate contracts
and has achieved price reductions of over $113 million. That
translates to well over $1 million per affiliate contract
negotiated.
Mr. Huelskamp. Follow up to the GAO on this, trying to
understand. Mr. Williamson, how widespread is it that the
contracting officers accept the affiliate's proposed prices
rather than negotiating or doing an independent price analysis?
Mr. Williamson. Why did that happen? Is that what you
asked? Why--
Mr. Huelskamp [continued]. How widespread is the practice--
Mr. Williamson. Oh.
Mr. Huelskamp [continued].--of accepting the proposed
prices?
Mr. Williamson. We don't know, but, you know, we only
looked at 12 short-term contracts, and seven of those had
problems like that. We can't project that, because, again, we
only looked at 12, but it's a high incidence, and it's happened
at more than one hospital.
Mr. Huelskamp. Okay. Second question I'd like to follow-up.
In looking at the testimony, Dr. Atkins, in the VA testimony
noted VA research has been involved in the CAT scan, the
pacemaker, organ transplants, treatments for high blood
pressure, and heart disease. You note Nobel Peace prize winners
and other such honors. How many of these inventions does the VA
own and how much money do they receive from these research
projects?
Dr. Atkins. I'll have to take that question for the record
to get back the exact number. I know some of that was discussed
at the hearing in February, and the feeling was that we could
do better, but I'll get you the exact number.
Mr. Huelskamp. Okay. So since that hearing, you didn't look
into it at all? You changed the policies or you're getting back
to us?
Dr. Atkins. So the policies on disclosure are being
changed.
Mr. Huelskamp. Okay.
Dr. Atkins. So--but we'll get back to you with the exact
number.
Mr. Huelskamp. And disclosure. And what about policies on
ownership with research affiliates and the researcher? Now
we're talking about, I think, what, up to $400 million for just
Hepatitis C. And so, yeah, I look forward to your response and
follow-up with the Subcommittee.
I do have another question, Dr. Atkins, though. We've had
reports of VA research data being stored on affiliate servers.
Is this allowed?
Dr. Atkins. That's not in compliance with policy. There are
information security audits that actually look at where VA data
is stored. It's supposed to be stored on VA servers. And so
where that's found, we seek to correct that. That's not
something we control, but the policy's pretty clear about that.
And that would be--
Mr. Huelskamp. Policy is they cannot do that?
Dr. Atkins. Correct.
Mr. Huelskamp. What are the penalties for violating that
policy?
Dr. Atkins. So we first try to go in and look and see--this
is actually under the Information Security Office, their
responsibility. And so they go and they find that, and they
issue a corrective action, and then the facility's responsible
for instituting that.
Mr. Huelskamp. And so what is the VA doing to protect
veterans' information in these and other circumstances and
their participation in VA research?
Dr. Atkins. So, that's the reason we have the policy, to
keep VA data stored on VA servers. And I think in some of those
cases, those are maybe animal studies, there may be some cases
of patient data being stored. But, again, we're seeking to make
sure that those exceptions aren't happening. I can't tell you
right now.
Mr. Huelskamp. So the policy is they can happen. You do
know it's happening, and the only way we'll protect--
Dr. Atkins. Actually, I don't know--
Mr. Huelskamp. Oh. I misunderstood.
Dr. Atkins [continued].--it's happening, but you're telling
me it is.
Mr. Huelskamp. Okay. Well, I was looking at reports. So you
don't know if it's happening or not? I thought you said earlier
you--it was--or you can't have the research data on affiliate
servers. Is that correct?
Dr. Atkins. VA data, involving VA patients, should be
stored on VA servers. There are data use agreements that can
allow sharing of data as long as other protection policies are
in place. So it's--if stored on a secure server and it's part
of an explicit data use agreement to collaborate with
investigators outside of VA, that is permitted. It's not
permitted for a university investigator to take the data from
the VA, put it on his or her university server.
Mr. Huelskamp. Thank you, Mr. Chairman. I have one more
question. If we're going to do another round, I do have an
additional question.
Mr. Coffman. There will be one more round.
Ms. Watterson-Diorio, why are some NIH grants being
administered through VA nonprofits while others are
administered through the academic affiliate, with more than 51
percent of the research--when more than 51 percent of the
research is being conducted at the VA?
Ms. Watterson-Diorio. Mr. Chairman, that's an interesting
question, and one that we have differing data on across the
country. VA nonprofits on the East Coast versus the West Coast
completely differ 100 percent, where the West Coast is actually
administering NIH grants.
Decisions are made at a local level. These are done by VA
leadership. They could even be done by a principal
investigator. So decisions are being made because, in my
opinion, there's not enough directives, regulatory directives
that would allow the investigators to be told, you know, this
is the equitable way in which we're arranging the
administration of research.
Mr. Coffman. Now aren't they supposed to be administered by
the VA?
Ms. Watterson-Diorio. Well, Title 38 proclaims that we have
the authority to administer this research. That's not, in fact,
happening all across the country.
Mr. Coffman. Who does--who again, who decides where a grant
is administered?
Ms. Watterson-Diorio. It would be on the VA leadership side
on--that would be, like, the board members of the VA
nonprofits.
Mr. Coffman. So those are not uniform? It's not--it's not
uniform?
Ms. Watterson-Diorio. It's not uniform at all.
Mr. Coffman. It's not uniform? Can you estimate how much
money VA is losing by having these grants administered through
the affiliates instead of VA nonprofits?
Ms. Watterson-Diorio. Well, again, I think that's a very
hard number for me to be able to justify, because that's--
Mr. Coffman. We're in the millions. We're in the millions.
Is that a fair assessment?
Ms. Watterson-Diorio. Yeah.
Mr. Coffman. Okay.
Ms. Watterson-Diorio. Yes. I would agree.
Mr. Coffman. Okay. Dr. Jesse, according to the GAO report,
high value--quote, ``high value long-term,'' unquote, affiliate
contracts go through three different reviews. Why is that?
Dr. Jesse. I think Mr. Lemmon is in better shape to answer
that than I am, but in--I do know that the IG does a preaudit
review, and that's one of them. So--
Mr. Lemmon. Well, certainly the contract is looked at, at
the local level. Then if it's over a half million dollars, our
current process requires our university affiliates to provide
cost data. Once we receive that cost data, there's a
requirement that the IG review that data. And it's also
reviewed at our Medical Sharing Office level, and at that
level, they get concurrence from Patient Care Services and the
Office of General Counsel. So there is a number of levels of
review.
We need to look at what pieces of this process we can
streamline. We have to do these faster, no question.
Mr. Coffman. How long have you been in your position now?
Mr. Lemmon. Since October 15th, I've been acting in this
position.
Mr. Coffman. We always have somebody--I love it when the VA
always has somebody who's brand-new and who, you know, kind of
washes their hands of the problem, but 3 years? I mean, that is
unbelievable. I--you know, it--I don't know how you have a
contracting negotiation process that lasts 3 years.
Mr. Lemmon. It's indefensible, but I would like to say that
not all of--there are multiple parties involved. With some
affiliates, getting cost data takes a long time. We do have
situations with affiliates where we can't get a reasonable
price. And I think what we have to do in those instances is
make decisions quicker whether we're going to continue the
relationship. It could involve--there are tough decisions. It
could involve pulling out a residency program.
So it's not all the contracting process itself. Certainly
there's plenty of opportunities to improve that, but some of
it, there are legitimate problems that come up when negotiating
these contracts.
Mr. Coffman. But this is supposedly done by experts who
have all the training, am I correct in that, that have gone
through--that Congressman Walz had mentioned that have gone
through the appropriate certifications of the VA in terms of
procurement?
Mr. Lemmon. They have. You have to have the requisite
warrant level to sign and negotiate these contracts.
Dr. Jesse. So if I may, and this comes back to a comment
that Ranking Member Kuster made in her opening remarks about
how health care has been changing. And 70 years ago, virtually
everything could be done on the signature of a dean of a
medical school. Today when we have contracts with academic
affiliates, as I mentioned, there are often multiple
contracting entities. So in your report, I think, two of your
agencies you were--the contracts were with the practice group
as opposed to the university.
So we now have deans of medical schools, we have CEOs of
hospitals, we have chairmen of practice groups, and they often
have a vice-president for health sciences, and even in--there
may be an office of managed care. And so it's not the--the time
is not all on the part of the VA, it's often the going back and
forth that requires multiple--multiple entities and--
Mr. Coffman. Let's just say it's a broken system.
Ranking Member Kuster, you're now recognized for 5 minutes.
Ms. Kuster. Thank you, Mr. Chair.
And let me start right where we've left off and the
changing nature of these practices and the complexity. For 25
years before I came here, I was an attorney in New Hampshire
and I represented Dartmouth Medical School, and I'm very
familiar with their relationships with the VA and White River
Junction, Vermont.
You had mentioned in our previous dialogue about
liabilities, you had used that word in passing, and sharing
responsibility, but that entails liability. I want to focus in
on the flip side of that, and which are benefits that come from
these contracts, and in particular, the benefits from
discoveries of VA researchers.
In the best of all worlds, there are times when the VA is
on the leading edge of treatment, of techniques, of protocols.
I'm working with the VA now on the reduction of use of opiates
and pain medication. I'm hoping that they'll be able to lead
the country in that.
But can you talk to me in terms of these relationships and
these contracts, how do you manage the benefits and the need to
ensure that the VA and the veterans, most importantly, but
preferably the veterans and the taxpayers, benefit from
breakthroughs in--whether it's medical technology or new
techniques?
Dr. Jesse. So I'm going to ask Dr. Atkins to answer most of
that, but as a preamble, I'd like to say that we think this is
really important. And the front end of a lot of the research we
do is an institution, and article, I'm not sure of the right
word, called a CRADA, which is an agreement of the sharing of
intellectual property, and it actually--and sometimes it's
quite frustrating to investigators, because it takes times to
work that out because it's a lawyer-to-lawyer conversation, but
that is a hard and fast thing that should be included in any
research agreement that we do with an outside entity.
So do you want to expound on that?
Dr. Atkins. Yeah. Well, thank you for your point, because I
think we all feel that this is not a zero sum game, that all
parties benefit. So the fact that our academic affiliates
benefit is a good thing, because it makes them want to partner
with us, and we benefit from that partnership.
And so, I want to comment a little bit on one of the
questions Chairman Coffman asked about the NPCs in terms of
whether all of our research should be administered through the
NPCs. We don't lose any money by administering our research
through the university. That actually builds a partnership that
provides a lot of benefit. We owe a lot to our nonprofit
corporations, they provide very good value, but they are
independent entities. They are not the VA.
And so we leave the decision of which grants should be
administered by the nonprofit corporation, which should be
administered by the university to the VA Medical Center. There
are some projects that solely recruit veterans, almost always
are administered by the nonprofit corporation; but many of our
research is relevant to veterans but may not involve patients,
may be much more aligned with the grants that are being
administered by the university, and the university certainly
benefits from having those grants.
And I think the figures that were given show that roughly
half of the non-VA research money that's brought in is
administered through the nonprofit corporations, about half
through the universities, but there's no--
Ms. Kuster. So at the risk of sounding overly lawyerly, I
want to follow the benefit, if I could, on behalf of the
veterans and the taxpayers. Walk me through, and let's just
make up an example about a breakthrough discovery in a new
medication to treat pain that's not addictive and doesn't lead
to substance use disorder.
Help me understand the value of that, and who controls it,
and who owns it. If you get into a patent, does the VA pursue
that, does it then get turned over to some other entity in the
Federal Government? Who owns the benefit of this?
Dr. Atkins. So as Dr. Jesse mentioned, that's governed by
these CRADAs, Cooperative Research and Development Agreements,
where that shared ownership is worked out upfront, and that's
the way the universities do it and the way that VA does it.
It's a shared ownership of the intellectual property and the
profits that flow from that.
Ms. Kuster. So my time is up, but if I could ask for the
record if there are examples maybe that would be beneficial for
the Committee to understand, of technologies or breakthroughs
in the past, and then how they've been adopted, and how they've
been shared around the VA, and if there is a commercial value,
how the dollars have flowed back to the taxpayers.
Dr. Atkins. Thank you.
Ms. Kuster. If that--thanks very much.
Dr. Atkins. We'll do that.
Ms. Kuster. I yield back.
Mr. Coffman. Congressman Huelskamp, you're recognized for 5
minutes.
Mr. Huelskamp. Thank you, Mr. Chairman. I appreciate the
opportunity to follow-up on a couple more questions.
First one, Ms. Watterson-Diorio, since the time it became
public that you would be testifying here today, have you
received any pushback from anyone about testifying, or
concerning what you might say?
Ms. Watterson-Diorio. Nothing official at this time, sir.
Mr. Huelskamp. Nothing official. Anything unofficial?
Ms. Watterson-Diorio. A few emails questioning where I was,
what I was doing, yes.
Mr. Huelskamp. Okay. I would be interested in sharing that
with the Committee. And I say this, obviously I know of the
certain situation, but over the last 3 or 4 years, we have run
into multiple situations where whistleblowers have received
various levels of, I would say, penalties and punishments and
displeasure from folks above them. And we rely heavily on folks
from the inside sharing with us what does occur. So I--
Ms. Watterson-Diorio. I certainly appreciate your concern,
and I will share back. Thank you very much.
Mr. Huelskamp. And, Mr. Chairman, the second question I
would have--I didn't get to last time, is in reference to
research equipment.
Dr. Atkins, we have had reports of VA research equipment
being transferred to the affiliates. Is that allowed?
Dr. Atkins. The research equipment bought by the VA belongs
to the VA. It is permissible for the research equipment to be
stored offsite where that makes sense to the research. So we
don't want to recreate a whole laboratory that exists on the
university side in the VA.
And if we buy a piece of equipment that can augment what
that laboratory can do, it makes sense for it to be over at the
university. It doesn't make sense for it to stay over there
after its use is expired. We have monitoring--tracking programs
that track all of our medical equipment at the hospitals, and
that's their responsibility.
Mr. Huelskamp. So the question wasn't about storage, it's
whether it's transferred, whether before or after the contract,
the research. Is it transferred to them? Is it given to them?
Dr. Atkins. No.
Mr. Huelskamp. Is it shared?
Dr. Atkins. No. It remains at the VA. It's just being used
over at--offsite. We don't--we don't give up ownership of that.
Mr. Huelskamp. Okay. And then if the contract ends--or
maybe they never end in this case. If they end, you collect the
equipment back, or you transfer it or give it away? I'm just
trying to follow-up what happens perhaps at the end of a
contract.
Dr. Atkins. If it's not being used at the--for research at
the university site, and we have a use for it at the VA site,
we would bring it back.
Mr. Huelskamp. Okay. Is it used by the research facility
for other types of research outside the VA? Is that permitted?
Dr. Atkins. Are you saying is it permissible for them to
use it for non-VA research--
Mr. Huelskamp. No. Yes.
Dr. Atkins [continued].--in the lab? I don't think there
would be any prohibition against that.
Mr. Huelskamp. Okay. So what oversight measures have you--
Dr. Atkins. It's a shared piece of equipment and it's
governed--
Mr. Huelskamp. Shared, but VA owns it?
Dr. Atkins. Right.
Mr. Huelskamp. So what oversight do you have to ensure that
VA ownership that's used exclusively for VA, or you don't mind?
Dr. Atkins. That's not a major concern of ours, in the
sense that usually that research is being done to benefit--it's
a partnership. And we buy the equipment where it seems to make
sense, and the fact that our partners are using it to benefit
research--
Mr. Huelskamp. That actually does bother me, Doctor. We
just discussed a $400 million invention that was done by a VA
researcher, probably using VA equipment, we don't know, and you
all are looking into that. And that should be part of the
agreement.
That should be part of the agreement of use of their time
and equipment in order to capitalize. I mean, we talked about
these tremendous advances through VA research. And we look
forward to the response, but I think after months of expecting
us to show, hey, this is what the VA got for all these
investments, but the private sector, these individuals have
taken that. So I just want to know what oversight measures you
have in place to ensure VA equipment is accounted for,
maintained, and used for the VA purpose, and if not, rented by
the VA--by the research facility.
Dr. Atkins. Yeah. I'm going to take that question for the
record, because I may not be entirely right about the--how much
of that is spelled upfront.
When there is an agreement to transfer the equipment for
use, and I--in terms of whether that agreement specifies that
it can only be used for certain uses and not for others, that
may exist, and I--I will get back to you.
Mr. Huelskamp. Yeah. And I'm not lawyerly. I'm a farmer.
I'd hate to be accused of that, but you mentioned storage.
Ms. Kuster. Better to be accused of a farmer than a lawyer.
Mr. Huelskamp. I agree. I agree.
So we talked about storage, we talked about sharing, and we
talked about transferring, and I think all those three terms
have been mixed up in the response, at least I haven't followed
that. So I appreciate the response and follow-up to the second
question.
Dr. Jesse. If I may, if a VA researcher is using--has
authority of a VA piece of equipment in a university lab, there
is probably a much greater chance than--not that they are
utilizing university assets in support of their VA research.
And so it's--you know, it's a shared entity, it's a shared
resource, and it's a partnership.
Mr. Huelskamp. No. I understand.
Dr. Jesse. It could go both ways, right.
Mr. Huelskamp. This question was about VA research
equipment. Now, if that's the response that, well, we share
their equipment, they share ours, then I would say there's not
enough oversight measures in effect to say whether or not it's
equal sharing, I mean, that's part of the question here, so I
appreciate us digging into that and getting a close response--a
better response to that.
I yield back, Mr. Chairman.
Mr. Coffman. Thank you, Congressman Huelskamp.
Congressman O'Rourke, you're now recognized for 5 minutes.
Mr. O'Rourke. Yeah. Mr. Chairman, I just wanted to make the
point that I think academic affiliations make a lot of sense,
and I would like to better understand the authorities that Dr.
Jesse and the VA are going to ask for, and these may be
authorities that we want to support, and certainly, I'd like to
see the process accelerated and shorten the amount of time it
takes to enter into those agreements. We know from testimony
earlier in the year from the VA that there are 43,000
authorized funded, but unfilled positions within VHA, and so
this makes a world of sense to me to do this.
I just want to, you know, make the point that thanks to the
GAO, I think there are some significant concerns that have been
raised, and I'm very grateful that the VA has agreed with the
recommendations and is going to implement them, and I'd love to
see the detail of that, that addresses the lack of performance
standards, this avoidance of oversight, intentional or not, and
some of the other issues that are raised.
But I know, Dr. Jesse, when we came through the first round
of questions, you were going to make an additional point, and I
ran out of time, where you were going to refer to one of your
colleagues. If you'd like to add anything to that, you're
certainly welcome to.
Dr. Jesse. Well, thanks. And I guess I'm going to--Janis
stole one of my lines in who benefits, being the question asked
at the title of this hearing, and she said the veterans, and
absolutely, but I would also add that it's you, me, and the
American public, because if you have a good physician, if you
have a good health care team, there is a great chance that it's
the VA academic-affiliate relationship that was intimately
involved in the training and skill building in those
individuals. So we all benefit.
Mr. O'Rourke. Yeah. You just want to make sure that there's
absolute adherence to the standards--
Dr. Jesse. Oh, yes.
Mr. O'Rourke [continued].--that you don't have fraud,
because this is a little bit of a departure in some ways if we
were to increase the level of participation with academic
affiliates to help staff and provide care for veterans like
those in El Paso, which are historically underserved. So I
don't want anything to jeopardize the program with some big
scandal, hey, we were overbilled--
Dr. Jesse. Yeah.
Mr. O'Rourke [continued].--X millions. Let's bring
everything back in house and no longer do this again.
So I think the GAO's findings give us an opportunity to get
this right so that we can expand it, accelerate it. You're
asking perhaps for new flexibilities and authorities. We may
want to do that. We just want to make sure that this thing's
being run really well, so that we can expand it.
Dr. Jesse. Absolutely.
Mr. O'Rouke. Yeah.
Dr. Jesse. Thank you.
Mr. O'Rourke. Okay.
Mr. Coffman. You know, I have one question. And out of
fairness to my colleagues, I'll let them ask another question
if they do have one, but, Mr. Atkins, I think you said that
there was really no--fundamentally no difference using the
nonprofit--VA nonprofit, versus using a university, yet it
seems to me that the issue with the Hep C drug totally
contradicts your statement, where Emory University
disproportionately benefited by whatever agreement was reached
in terms of that Hep C drug, and so I don't understand what
your rationale is.
The nonprofit, it would have flowed back into the VA versus
it flowed to Emory University. Could you comment on that?
Dr. Atkins. Well, as you know, that whole issue is under
investigation and the facts as to what the research was done. I
mean, I'm not sure that it flowing through the nonprofit would
have changed the fact, depending on where--whether that--how
that research was done and what--who had rights to the
intellectual property.
Mr. Coffman. Ms. Diorio, can you comment on that?
Ms. Watterson-Diorio. Well, I would say that, you know, as
we all know, the sole purpose of the VA nonprofits is to serve
the VA. We are under a lot of oversight to make sure that the
tech transfer is upheld, the CRADA language is just perfect. A
CRADA is a Federal document that allows the VA to enter and be
bound by language to support research.
So when we do that, there are tech transfer laws, there are
all of this documentation that is supporting the VA to own that
property, but there are also some other regulations, and I can
get that to you for the record, that allows the university an
opportunity to enter into and help with tech transfer, because
sometimes they are very expert in that field.
Mr. Coffman. Thank you.
Dr. Orlowski. If I could add.
Mr. Coffman. Thank you very much. Yeah. Go ahead.
Dr. Orlowski. Thank you, Congressman. The academic
affiliates don't take a position as to which is the better--but
I would say that there are specific reasons why the academic
institution may in certain circumstances have more experience.
There's complex regulations for human subject research, complex
regulations for animal research, and depending upon what is
being studied, DNA sequencing changes, sometimes the local VA
authorities will make a decision as to which institution has
the better oversight.
Mr. Coffman. It just seems the problem is there's not
oversight, and the problem is that some of these institutions
get the better of the VA, which is not all that hard to do,
given the lack of oversight.
Let me just conclude. Today we have had a chance to hear
about the relationship between VA and its academic affiliates.
As has been described, there are numerous issues, concerns, and
problems surrounding this relationship that takes great
advantage of VA and ultimately the veteran.
This hearing was necessary to accomplish a number of items:
To highlight the conflicts when employees in leadership
positions at VA also hold academic appointments at the
affiliate; to highlight the potential for lost intellectual
property rights when VA-approved research, VA equipment, and VA
data are utilized by the academic affiliate; to highlight the
potential lost revenue when Federal grants are administered by
the affiliate, instead of the VA nonprofit corporations, when
the majority of the research is being performed at VA; and to
highlight the problems VA has in entering into fair and timely
sole-source affiliate contracts. I hope that shedding light on
these issues will lead to changes.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks, and include extraneous
material. Without objection, so ordered.
I would like to once again thank all of the witnesses and
audience members for joining in today's conversation.
With that, this hearing is adjourned.
[Whereupon, at 5:53 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Robert L. Jesse, M.D., Ph.D.
Good afternoon, Mr. Chairman, Ranking Member Kuster, and Members of
the Committee. Thank you for the opportunity to discuss VA's
relationship with its academic affiliates, specifically, the use of
sole-source affiliate contracts, affiliate universities, billing
issues, research funding, and use of research space. I am accompanied
today by Mr. Rick Lemmon, Acting Chief Procurement and Logistics
Officer, and Dr. David Atkins, Acting Chief Research and Development
Officer.
Office of Research and Development (ORD)
For more than 90 years, VA has conducted research within its
hospitals and health care system in accord with Congressional authority
to advance scientific knowledge about critical issues facing Veterans.
In establishing VA Research, Congress recognized both the need to study
the unique problems of Veterans but also the opportunity for research
to support excellent clinical care.
Since its inception, VA Research has contributed to groundbreaking
advances such as the Computerized Axial Tomography scan, the pacemaker,
and organ transplants; it has sponsored groundbreaking studies on the
treatment of tuberculosis, high blood pressure, heart disease, and
Posttraumatic Stress Disorder (PTSD). It has partnered with industry to
demonstrate the value of vaccination to prevent shingles, and to
develop state of the art prosthetic limbs. These achievements have
resulted in three Nobel prizes, seven Lasker Awards, and numerous other
national and international honors. VA Research continues to drive
advances in Veteran care in issues as diverse as diabetes, spinal cord
injury, and mental health. Its groundbreaking Million Veterans Program
has already enrolled close to half a million Veterans who have donated
blood samples and completed surveys to help unlock the genomic basis of
medical disease.
VA Research benefits from its position within an integrated health
care system with 167 medical centers and a state-of-the-art electronic
health record. Our ability to recruit patients throughout the country,
to draw on detailed clinical data over two decades on 8 million
Veterans, and to implement research findings into clinical care makes
VA a model for bench-to-bedside research. Partnerships with national
and regional VA clinical leaders, new outreach to Veterans in the
community, and a network of research Centers with specific areas of
focus ensure that research reflects the current and future needs of
Veterans.
The VA Research program plays a unique role that cannot be filled
by external funding sources. First, VA Research prioritizes problems
that are common or important to Veterans- PTSD, traumatic brain injury,
polytrauma, military sexual trauma. Second, 60% of our researchers are
also practicing clinicians at VA medical centers (VAMC). As a result
they are familiar with the Veteran experience and are able to seek
knowledge and pursue research topics to help our patients.
Additionally, unlike other Federal agencies, VA has no laboratories
whose predominant function is research. Research studies are performed
in parallel in the same space at VAMCs where patient care is provided.
This leads to a focus on research areas benefiting Veterans. Third,
research is conducted by VA employees who are dedicated to the mission
of improving care for Veterans. Finally, a research program planned and
run within VA can adapt to the changing needs of the Veteran
population. For example, the Office of Research and Development has
dramatically increased the number of researchers and studies addressing
the needs of women Veterans over the past decade to meet the growing
population of women entering VA care.
VA's research mission is entirely supported by intramural funding.
VA does not have authority to award grants to parties outside VA, and
all VA Research funding is provided to VA-employed researchers.
VA researchers work at more than 100 VAMCs conducting research. In
addition, 124 VAMCs have formal affiliations with academic institutions
and hospitals, and many full-time and part-time VA employees also have
academic appointments or are employed at an affiliated academic
institution or hospital - they are dually appointed personnel. Many
clinicians/researchers have laboratory access at both VA and the
academic affiliate. Because of these arrangements, many VA inventions
could be jointly owned by VA and its academic affiliates.
VA Research fosters dynamic collaborations with its university
partners, other federal agencies, nonprofit organizations, and private
industry. Researchers are able to leverage $663 million in VA funding
to bring in an additional $685M in external funding from industry and
Federal agencies such as the National Institute of Health. The Federal
investment in VA Research returns incredible value to Veterans and the
taxpayers, value that is reflected in Veterans positive attitudes about
research and health care outcomes in VA.
Office of Academic Affiliation (OAA)
Strong academic relationships have been the foundation of improving
quality care and patient access in VA health care since 1946. January
30, 2016, marked the 70th anniversary of VA ``Policy memorandum #2,'' a
document crafted by General Omar Bradley and other VA leaders which
established the visionary partnership that VA has with America's
medical schools. The initial motivation for integrating academic
relationships in VA's mission is just as relevant today: academic
affiliations are invaluable to facilitate recruitment of outstanding
clinical staff to VA, and the presence of supervised trainees often
allows efficient leverage of effort for clinical staff because several
trainees working under the careful eye of one supervisor can often
treat many more patients than that senior clinician could treat if
alone. Such academic activities are also vital for assuring that VA
clinical staff remains at the leading edge of clinical knowledge and
skill, and to attract clinicians motivated by professional excellence
that is associated with practice, teaching, research, and system
improvement activities that occur in academic settings. VA's health
profession education activities have blossomed to include affiliations
with over 1,800 schools of medicine, nursing, pharmacy, and nearly all
other health professions. Through these affiliations, and VA's own
sponsorship of selected programs, nearly 124,000 trainees in health
professions receive supervised clinical education in VA facilities each
year. The Veterans Health Administration (VHA) is profoundly important
to overall health professions education in the US, with about 70% of US
physicians having VA clinical experiences at some point in their
education, VHA being the second largest funder of Graduate Medical
Education (after the Centers for Medicare and Medicaid Services (CMS)),
and VHA being a major source of both trainee and faculty funding and
clinical experiences for professions including pharmacy, psychology,
optometry, podiatry and many others.
The result is that VHA robustly fulfills statutory missions
prescribed by 38 U.S. Code Sec. 7303 ``to carry out a program of
medical research in connection with the provision of medical care and
treatment to veterans.'' It is important to note that these many
academic relationships and affiliation agreements address only
educational activities and do not address contracts for provision of
professional or clinical services for VHA's patient care services -
those are addressed by VHA through other sharing agreement and
contractual mechanisms.
Government Accountability Office (GAO) Report
GAO released its final report (GAO-16-426) titled ``Improvements
Needed for Management and Oversight of Sole-Source Affiliate Contract
Development'' on May 6, 2016 with a 30 day hold on public release. This
report recommended eight executive actions to ensure timely development
of high-value-long-term sole-source affiliate contracts (SSAC),
effective development and use of short-term SSACs, develop and maintain
medical sharing expertise within network contracting offices, and
ensure effective communication between VHA and its affiliates regarding
SSACs.
VA concurred with GAO's recommendations and developed an action
plan to implement each of the recommendations. As part of this action
plan, the Deputy Under Secretary for Health for Operations and
Management will charter a workgroup to address several of the
recommendations. The workgroup will be charged with tasks such as:
Establishing performance standards for appropriate
development time frames for high-value long-term SSACs;
Establishing the oversight process for these standards;
Developing requirements for VAMCs and network contracting
offices to effectively engage in early acquisition planning for the
replacement of expiring high-value long-term SSACs to reduce reliance
on short-term SSACs as bridge contracts; and
Developing standards for the minimum amount of time
necessary to develop and award short-term SSACs to minimize cases of
nonadherence to VA policy for these contracts.
The estimated timeframe for the workgroup to complete
deliberations, finalize performance standards, and receive approval
across all stakeholders, is one year. The estimated timeframe for
nationwide implementation of new performance standards is one year,
including pilot testing of any new technology and training of staff.
VA is strongly committed to developing long-term solutions that
mitigate risks to the timeliness, cost-effectiveness, quality and
safety of the VA health care system. VA is using the input from GAO and
others to identify root causes and to develop critical actions. As we
implement corrective measures, we will ensure our actions are meeting
the intent of the recommendations. Our actions will serve to establish
strong oversight on SSACs, improve current training offerings for VHA
staff who work on SSACs, and seek increase prioritization of funding
for training to appropriate department decision makers.
Since receiving the draft GAO report VA/VHA has initiated two short
term initiatives and one long term initiative to improve outcomes of
SSAC contracting. First, VA Directive 1663 which provides overall
guidance for sole source academic affiliate contracts is being revised
and updated to ensure more timely contract awards while still
protecting VA financial interests. The 1663 revision is expected to be
completed within the next 60 days. Second, enterprise capability to
monitor the milestone adherence of sole-source affiliate contracts will
be developed. This will enable senior management to take action when
needed to overcome barriers to timely awards, with a targeted
completion date of November 30, 2016. To meet the long-term goals of
strong oversight and address all of the GAO recommendations, VHA is
chartering an integrated workgroup.
Mr. Chairman, this concludes my testimony. My colleagues and I are
prepared to answer any questions you, Ranking Member Kuster, or other
Members of the Committee may have.
Prepared Statement of Randall B. Williamson
VA HEALTH CARE
Improvements Needed for Management and Oversight of Sole-Source
Affiliate Contract Development
Chairman Coffman, Ranking Member Kuster, and Members of the
Subcommittee:
I am pleased to be here today to discuss our May 2016 report on the
Department of Veterans Affairs' (VA) development and use of sole-source
contracts with university-affiliated hospitals, medical schools, and
practice groups. \1\ Since 1946, VA has partnered with medical schools
to provide educational opportunities for resident physicians and other
types of students and to increase the availability of specialty
physicians to treat veterans in VA medical facilities. This partnership
has grown to include 124 of the 167 VA medical centers (VAMC)
establishing affiliate relationships with at least one university
medical school and its associated university hospital. As a part of
these affiliate relationships, VA can obtain additional physician
services to supplement available VAMC physician services from a
university medical school, hospital, or affiliated physician practice
group through expanded contracting authority- referred to as sole-
source affiliate contracts (SSAC). \2\ Through SSACs, which are
available only to VAMCs and their affiliates, VAMCs can obtain
physician services directly from the affiliate without competition if
those services are necessary to support learning opportunities for
physicians during their residency training in VAMCs. \3\ SSACs serve an
important role in helping to ensure that VAMCs can provide specialty
health care services for our nation's veterans and support the
residency training of a new cadre of physicians. From fiscal year 2011
through fiscal year 2015, VA had nearly 1,200 SSACs valued at almost
$724 million throughout its health care system.
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\1\ GAO. VA Health Care: Improvements Needed for Management and
Oversight of Sole- Source Affiliate Contract Development, GAO-16-426
(Washington, D.C.: May 6, 2016).
\2\ See 38 U.S.C. Sec. 8153(a)(3)(A). For the purposes of this
testimony, we use the term physician services to describe services
provided by physicians and other highly-qualified professionals that
are necessary for the operation of clinical departments that train
resident physicians at VAMCs.
\3\ See Department of Veterans Affairs, Health Care Resources
Contracting-Buying, Title 38 U.S.C. 8153, VA Directive 1663 (Aug. 10,
2006). For the purposes of this testimony, we refer to this directive
as VA Directive 1663.
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SSACs can be used to fill short-term or long-term needs at the
VAMCs and the level of VA oversight they require varies by their value.
Specifically, high-value, long-term SSACs have a total initial value of
$500,000 or more and provide affiliate services for more than 1 year.
\4\ Among all SSACs, high-value, long-term SSACs require the most
review from the Veterans Health Administration (VHA) Central Office.
\5\ There are two types of low-value SSACs that are distinguished by
the length of time the affiliate is providing services to the VAMC, and
neither are required by VA policy to receive oversight from VHA Central
Office. Low-value, long- term SSACs have a total initial value of less
than $500,000 and provide affiliate services for more than 1 year.
Short-term SSACs have a total initial value of less than $500,000 and
provide affiliate services for less than 1 year.
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\4\ The total initial value of a SSAC refers to the combined value
of the contract's base period and any option periods included in the
contract. For example, a high-value, long- term SSAC may have a base
period of 1 year valued at $1 million and four option periods that are
1 year each with a $1 million value for each option period. This high-
value, long- term SSAC would have a total initial value of $5 million
dollars.
\5\ In this testimony, we use the term develop to describe a
multistep process used to initiate, create, and review SSACs. This
multistep process includes actions related to acquisition planning for
a SSAC, development and issuance of a solicitation used to inform the
affiliate of VA's needs, development and evaluation of the affiliate's
proposal, and preparation for and negotiation between the affiliate and
VA.
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Oversight of the VHA contracting workforce and the contracts they
create is provided by the VHA Office of Procurement and Logistics. VHA
created the Medical Sharing Office, a component of the VHA Office of
Procurement and Logistics, to provide guidance to contracting officers
and oversee the development and award of medical sharing contracts,
which include SSACs. Both VHA contracting and clinical staff are to
work together to plan, execute, and monitor medical sharing contracts.
On the contracting side, contracting officers are responsible for
developing, awarding, and administering contracts on behalf of the
federal government. Each contracting officer works within 1 of the 21
network contracting offices and is overseen by a medical sharing team
supervisor within their network contracting office. \6\ Network
contracting offices manage all the contracting activities of a single
Veterans Integrated Service Network (VISN) that oversees the day-to-day
functions of VAMCs that are within that VISN's network. On the clinical
side, the VAMC seeking the SSAC is to designate a contracting officer's
representative at the VAMC to assist in the development of the SSAC and
monitor the affiliate's performance once the contract is awarded.
Common tasks delegated to the VAMC-based contracting officer's
representative include developing the initial information required to
begin acquisition planning, referred to as the procurement package,
which includes a definition of the services the VAMC needs the
affiliate to provide and approvals from leadership officials.
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\6\ There are 21 network contracting offices within VHA that report
to the VHA Procurement and Logistics Office in VHA Central Office and
manage all the contracting activities of a single Veterans Integrated
Service Network (VISN) and all VAMCs assigned to that VISN. At the
start of fiscal year 2016, there were 21 VISNs, but VHA is in the
process of consolidating some VISNs so that by the end of fiscal year
2018, there will be 18 VISNs.
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My testimony today discusses the findings from our May 2016 report
examining VA's use of SSACs. Accordingly, this testimony addresses (1)
VHA's time frames for developing and awarding high-value, long-term
SSACs; (2) VHA's use of short-term SSACs and how it oversees their
development and use; (3) how much experience the workforce that
develops SSACs has and what specialized training VHA provides; and (4)
the challenges selected affiliates experienced with the development and
use of SSACs. In addition, I will highlight the eight actions we
recommended in our report that VA take to help ensure the timely and
effective development of SSACs, the professional growth of the VHA
contracting staff responsible for SSAC development and award, and
effective communication between VHA and its affiliates. VA concurred
with these eight recommended actions.
To conduct our work, among other things, we selected five VAMCs-
located in Indianapolis, Indiana; Miami, Florida; Minneapolis,
Minnesota; Palo Alto, California; and San Antonio, Texas-to visit along
with the five network contracting offices responsible for developing
and awarding SSACs for these VAMCs. We selected these VAMCs based on
VHA reports on the number and value of SSACs. These five VAMCs are each
located within different VISNs. At each of these VAMCs, we selected
four to six SSACs and reviewed the terms of these contracts and
supporting documents to determine the total elapsed time spent by VHA
staff in developing and awarding each contract. We reviewed a total of
25 SSACs from these five VAMCs for services provided from fiscal year
2011 through fiscal year 2015. \7\ In addition, we administered a data
collection instrument to supervisors responsible for overseeing the
development and award of SSACs in all 21 network contracting offices
throughout VHA to capture information about various aspects of network
contracting offices' experiences developing SSACs, including oversight
by the Medical Sharing Office and contracting officer turnover. We also
reviewed VA policy documents and interviewed officials from the VHA
Medical Sharing Office and the VHA Procurement and Logistics Office, as
well as officials from our selected VAMCs and their associated network
contracting offices. \8\ Further, we interviewed representatives of the
five university affiliates that provided services to VAMCs under the 25
SSACS we selected for review and discussed their experiences with the
development of SSACs. For each of our objectives, we reviewed relevant
standards for internal control in the federal government. \9\ Further
details on our scope and methodology are included in our May 2016
report. The work this statement is based on was performed in accordance
with generally accepted government auditing standards.
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\7\ These 25 SSACs included 11 high-value, long-term SSACs from
three VAMCs; 2 low- value, long-term SSACs from one VAMC; and 12 short-
term SSACs from four VAMCs
\8\ VA Directive 1663 outlines VA's policies and procedures for the
establishment of medical sharing contracts, including SSACs.
\9\ See GAO, Internal Control: Standards for Internal Control in
the Federal Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November
1999). Internal control is a process effected by an entity's oversight
body, management, and other personnel that provides reasonable
assurance that the objectives of an entity will be achieved.
Selected VAMC's Time Frames for Developing High- Value SSACs Can Be
Significant, But VHA Has Not Established Standards for Timeliness
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and Does Not Collect Data
We found that the 11 high-value, long-term SSACs we selected for
review from three of the five VAMCs we visited took nearly 3 years
(33.8 months) on average to develop and award. \10\ (See fig. 1.) The
total time required for the development and award of these 11 high-
value, long-term SSACs ranged from 18 to 46 months and the longest
contracting phases were the solicitation and negotiation phases.
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\10\ One of our selected VAMCs acquired affiliate services
exclusively through short-term SSACs and another of our selected VAMCs
acquired affiliate services through low-value, long-term SSACs and
short-term SSACs.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Note: Time frames for the development and award of 11 selected
high-value, long-term SSACs from three VA medical centers (VAMC) are
calculated using dates from available documentation in each contract's
file; however, not all development actions are documented within
contract files. As a result, this figure does not include calculations
for actions that are not documented. The total time spent developing
and awarding a high-value, long-term SSAC is calculated from the date
the Veterans Integrated Service Network (VISN) approved the VAMC to
acquire the service through a SSAC to the date the contract was awarded
to the affiliate. VISNs are required to approve all SSACs before the
formal solicitation process can officially begin. The duration of each
contracting phase was calculated based on our analysis of selected
contract files. Minimum and maximum values in this figure represent the
shortest and longest time spent developing and awarding a single
contract, as well as the shortest and longest time each phase took for
a single contract. Average values in this figure represent the average
time spent developing and awarding a high-value, long-term SSAC across
all 11 of our selected contracts, as well as the average time each
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phase took across all 11 selected contracts.
According to leadership officials and contracting officers from all
five of the network contracting offices we visited, establishing high-
value, long- term SSACs in a timely manner has been challenging for
several reasons, including (1) not always receiving a complete,
actionable, and timely initial information package from the VAMC that
contains information the contracting officer needs to begin acquisition
planning; (2) lengthy review processes for high-value, long-term SSACs;
(3) negotiation challenges with the affiliates on the price of high-
value, long- term SSACs; and (4) VAMC resistance to developing and
pursuing high- value, long-term SSACs. VAMC-based contracting officer's
representatives and medical directors from all five of the VAMCs we
visited also explained that establishing high-value, long-term SSACs
has presented challenges for them. Specifically, 9 of the 14
contracting officer's representatives we spoke with noted that they are
often asked to resubmit initial information packages to the contracting
officer throughout the development of a SSAC due to form updates or
policy changes that occurred since the time they created these
documents. Moreover, VAMC officials from all five VAMCs we visited
indicated that the length of time it takes to develop and award high-
value, long-term SSACs presents many challenges for their VAMCs,
including the potential for gaps in patient care and the need to
repeatedly establish short-term solutions.
We also found that VHA has not developed standards that can be used
to measure the timeliness of developing high-value, long-term SSACs.
However, during fiscal year 2016, VHA developed estimates for the
maximum duration of each contracting phase, referred to as procurement
action lead times (PALT). Currently, the PALT goal for the development
and award of a high-value, long-term SSAC is between 20 and 21 months;
however, we found that 10 of the 11 high-value, long-term SSACs we
reviewed exceeded these PALT goals by as little as 1.4 months and as
many as 25.8 months. According to VHA officials we interviewed, PALT
goals are not used as performance standards for VAMC, network
contracting office, and Medical Sharing Office staff responsible for
the development of high-value, long-term SSACs. These officials told us
that VHA is currently developing and conducting validity tests of
revised PALT goals for several types of contracts, including SSACs, but
there is no planned end date for these tests and they do not expect to
implement revised PALT goals across VHA until at least fiscal year
2017. These officials explained that the revised PALT goals will be
used for setting expectations with VAMC officials for the length of
time it should take to develop and award several types of contracts,
including SSACs. Federal internal control standards recommend
establishing and reviewing performance standards at all levels of an
agency. \11\ Absent such standards, VHA cannot ensure that its high-
value, long-term SSACs are being developed in a timely manner.
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\11\ See GAO/AIMD-00-21.3.1.
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Additionally, we found that VHA does not collect data on the length
of time each contracting phase took to complete for any SSACs,
including the 11 high-value, long-term and 12 short-term SSACs we
selected for review. Federal internal control standards state that
information should be recorded and communicated to management and
others within the agency that need it in a format and time frame that
enables them to carry out their responsibilities. \12\ However, in
contrast with these standards, VA is unable to analyze the time spent
in each phase of SSAC development, and this inability has disadvantages
in terms of management decisions and accountability for SSAC
development. The absence of real-time data on the amount of time being
spent within each contracting phase limits VA's ability to make
informed management decisions, including changes to the assignment of
staff that are either overburdened by their workloads or in need of
additional training to build their competency with a particular type of
contract or contracting phase. This lack of information prevents VHA
from effectively setting clear and consistent objectives for
organizational performance and making improvements as needed.
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\12\ See GAO/AIMD-00-21.3.1.
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Our report concluded that a lack of attention to the time spent to
develop and award high-value, long-term SSACs has resulted in VHA's
inability to ensure that contracts are being developed in a timely
manner. To ensure the timely development of high-value, long-term
SSACs, we recommended that VA (1) establish performance standards for
appropriate development time frames for high-value, long-term SSACs and
use these performance standards to routinely monitor VAMC, network
contracting office, and Medical Sharing Office efforts to develop these
contracts; and (2) collect performance data on the time spent in each
phase of the development of high-value, long-term SSACs and
periodically analyze these data to assess performance. VA concurred
with these recommendations and said that it will take steps to address
these weaknesses, including the creation of a workgroup that will
establish performance standards for development time frames for high-
value, long-term SSACs and the designation of an office within VHA to
routinely monitor these performance standards. VA also said that it
will assess its current data systems to determine whether a new or
different system would be needed to capture all relevant data and that
the Medical Sharing Office will collaborate with other stakeholders to
determine the need for and the mechanism to collect additional data.
Short-Term SSACs Have Been Used to Overcome Lengthy High-Value, Long-
Term SSAC Development Time Frames, but VHA Lacks Effective
Oversight for Their Development and Use
We found that short-term SSACs are used to provide coverage to
bridge the gap between an expired or expiring high-value, long-term
SSAC and its replacement. Specifically, 6 of our 12 selected short-term
SSACs were awarded as bridge contracts, which creates duplicative work
for VAMC and contracting staff because they must simultaneously develop
both the short-term SSAC bridge contract and the replacement high-
value, long- term or low-value, long-term SSAC. \13\ Of the remaining 6
short-term SSACs we reviewed, 5 were awarded to allow affiliate
services to begin while new high-value, long-term SSACs were being
developed for the same services and 1 was awarded to fill a short-term
staffing need at a VAMC. In addition, we found that the use of these 12
short-term SSACs was consistent with reasons reported by from the
majority of the medical sharing team supervisors from the 21 network
contracting offices. Specifically, 12 medical sharing team supervisors
from the 21 network contracting offices (57 percent) reported that the
most prevalent reason that they opt to award short-term SSACs is to
avoid any gaps in services due to the length of time it takes to
develop and award high-value, long- term SSACs.
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\13\ See GAO, Sole-Source Contracting: Defining and Tracking Bridge
Contracts Would Help Agencies Manage Their Use, GAO-16-15 (Washington,
D.C.: Oct. 14, 2015).
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Federal internal control standards state an agency should provide
for an assessment of the agency's risk associated with achieving its
objectives, including identifying risks through forecasting and
strategic planning. \14\ However, in contrast with these standards, VHA
does not have a policy that requires VAMCs and network contracting
offices to engage in timely acquisition planning to ensure that
expiring high-value, long-term SSACs are replaced without the need to
use a short-term SSAC as a bridge contract. Moreover, VA's governing
directive for the development of SSACs does not specify when VAMC and
network contracting office staff should begin acquisition planning
activities to replace an existing high- value, long-term SSAC. \15\ As
a result, VHA lacks assurance that its staff are performing and
accountable for their roles in ensuring that replacement high-value,
long-term SSACs are developed in time and that the agency is minimizing
duplicative work when short-term SSACs are used as bridge contracts.
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\14\ See GAO/AIMD-00-21.3.1.
\15\ VA Directive 1663.
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We also found that VHA was further exposed to potential risks
associated with using short-term SSACs because the Medical Sharing
Office, the VHA Central Office entity with oversight authority of
SSACs, does not consistently review available data on all SSACs awarded
throughout VHA; in particular, it does not review the level of reliance
on short-term SSACs. While this office creates monthly reports for all
VISNs and network contracting offices that provide information on the
status of their medical sharing contracts, including all SSACs, they
rely on network contracting offices to determine if they are selecting
the appropriate term for their contracts. This can potentially be
problematic because 7 of the medical sharing supervisors from the 21
network contracting offices we contacted and leadership teams and
contracting officers from 3 of the 5 network contracting offices we
visited told us that at times they have purposefully developed short-
term SSACs in lieu of high-value, long-term SSACs because the Medical
Sharing Office does not review any short- term SSACs. In fact, we found
6 of the 12 short-term SSACs we selected for review were extended
beyond their initial performance periods for up to 11 months resulting
in total values for these 6 contracts that ranged from almost $686,000
to $1.4 million-well beyond the $500,000 Medical Sharing Office review
threshold. Standards for internal control in the federal government
state that control activities should occur at all levels of an agency
to help ensure that management's directive are carried out by staff and
that top-level reviews of actual performance by agency management are
needed to track major agency achievements and compare these to plans,
goals, and objectives that were previously established. \16\
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\16\ See GAO/AIMD-00-21.3.1
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In addition, we found that 7 of the 12 short-term SSACs we selected
for review from two network contracting offices did not follow VA and
VHA policy for the development of SSACs. Specifically, we found 5
short-term SSACs we reviewed from one network contracting office where
(1) a solicitation was not issued to the affiliate, (2) the affiliate
did not provide VHA a formal proposal outlining its services and
instead submitted a price quote, and (3) negotiations were not
conducted to address potential pricing issues before awarding the final
contract. \17\ The contracting officer responsible for these 5 short-
term SSACs explained that he was often given as little as 10 business
days to develop and award a short-term SSAC before the prior short-term
SSAC expired and that he did not have the skills needed to conduct
negotiations with the affiliate. We found that this contracting
officer's supervisor had reviewed all 5 of these contracts prior to
their award; however, the review process did not identify the areas
that did not adhere to VA and VHA policy requirements for the
development of SSACs. Federal internal control standards recommend that
agencies establish processes to ensure the proper execution of
transactions, including the provision of the proper amount of
supervision. \18\ However, without ensuring that contracting officers
are adhering to VA and VHA policies and network contracting offices are
effectively reviewing the development of short-term SSACs as required
by VA and VHA policies, VHA may be at risk for overpaying for affiliate
services provided through these contracts.
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\17\ The other two short-term SSACs that did not follow VA and VHA
policy for the development of SSACs had similar policy adherence
problems.
\18\ See GAO/AIMD-00-21.3.1.
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Our report concluded that the lack of attention to this
overreliance on short-term SSACs as bridge contracts exposes VHA to
risks. To ensure the effective development and use of short-term SSACs,
we recommended VA (1) develop requirements for VAMCs and network
contracting offices to effectively engage in early acquisition planning
for the replacement of expiring high-value, long-term SSACs, (2)
prioritize the review of SSAC contract data to identify patterns of
overreliance on short-term SSACs that avoid appropriate Medical Sharing
Office oversight, and (3) develop standards for the minimum amount of
time necessary to develop and award short-term SSACs to minimize cases
of nonadherence to VA policy for these contracts. VA concurred with
these recommendations, and laid out plans to develop new requirements
and standards while also charging the Medical Sharing Office with
conducting data reviews of short-term SSACs.
High Turnover and Limited Training Opportunities Result in
Inexperienced VHA Medical Sharing Contracting Officers and Impede
the Development of SSACs
We found a high level of turnover among medical sharing contracting
officers in all 21 network contracting offices that was exacerbated by
a high level of inexperience among contracting officers responsible for
developing SSACs. Network contracting office medical sharing teams
experienced significant turnover in recent years, with 23 percent (49
of 217) of medical sharing contracting officer full-time employee
equivalents (FTEE) in fiscal year 2014 and 27 percent (65 of 239) of
FTEEs in fiscal year 2015 either resigning or transferring to another
VHA contracting team.
Medical sharing supervisors offered several potential explanations
for turnover on medical shar17ing teams, including job burnout, the
complexity of medical sharing contracts, the workload associated with
medical sharing teams, and frustration with the layers of review
required for these contracts. Medical Sharing Office officials told us
that this turnover hinders the SSAC development process because newer
contracting officers have greater difficulty developing high-value,
long-term SSACs due to a lack of experience and knowledge. They also
told us that they believe it takes approximately 5 years for a
contracting officer to become experienced in developing medical sharing
contracts, including SSACs. We found, however, that more than half of
medical sharing contracting officers had 2 years or less medical
sharing contract experience and less than one-quarter had more than 4
years of experience developing medical sharing contracts. Federal
internal control standards state that effective management of an
organization's workforce, such as having the right personnel on board,
is essential to achieving results. \19\ However, in contrast to these
standards, VHA does not have a plan to address medical sharing
contracting officer turnover. As a result, VHA lacks assurance that
network contracting offices can maintain and develop the contracting
officers' skillsets that are necessary for developing complex medical
sharing contracts, such as SSACs.
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\19\ See GAO/AIMD-00-21.3.1.
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Moreover, we found that limited training opportunities for medical
sharing contracting officers further erodes VA's knowledge base for
developing high-quality and cost-effective SSACs. The Medical Sharing
Office has developed and offered three in-person training courses
designed to progressively build a contracting officer's competence in
developing medical sharing contracts, including SSACs. Medical Sharing
Office officials reported in February 2016 that over 90 percent of all
participants for each of the training classes reported that the
trainings increased their medical sharing competency and that the
information presented would contribute to their job performance. Since
fiscal year 2015, however, VHA has not consistently provided training
for medical sharing teams in network contracting officers throughout
VHA. VHA has canceled some of their course offerings due to budget
constraints. In addition, VHA Central Office requested that the Medical
Sharing Office cut the class size of each course offering by 25
percent. Federal internal control standards state that agencies should
establish good human capital policies and practices, such as
appropriate practices for training. \20\ In contrast to these
standards, VHA has not determined how to either provide the existing
training courses or develop alternatives that do not require travel in
response to a changing budgetary environment. As a result, VHA cannot
build the skills of its medical sharing contracting officers and
overcome the challenges associated with their inexperience.
---------------------------------------------------------------------------
\20\ See GAO/AIMD-00-21.3.1.
---------------------------------------------------------------------------
Our report concluded that instability in the medical sharing
workforce, due to high levels of turnover among medical sharing
contracting officers, has limited VHA's ability to develop high-quality
SSACs throughout VHA. To develop and maintain medical sharing expertise
within the network contracting offices, we recommended that VA (1)
create a plan to increase retention of contracting officers that work
in medical sharing teams, and (2) develop mechanisms to either provide
existing training courses or create training courses that do not
require travel for contracting officers working within network
contracting offices. VA concurred with both of these recommendations
and summarized planned steps to address these recommendations,
including the development of a retention plan and soliciting agency
leadership for assistance in resource prioritization to fund VHA health
care contracting training courses.
Selected Affiliates Reported Communication and Coordination Challenges
with VHA Regarding SSACs
We found that representatives from the five affiliates that provide
services through SSACs to our selected VAMCs noted challenges related
to receiving information on changes to VA and VHA requirements for
SSACs. These included communication from VHA about what services the
VAMC needed from the affiliate, the documentation requirements
affiliates needed to submit to support their physician salary pricing,
and changes to VHA's approach to negotiations. The affiliate
representatives also noted coordination challenges related to
responding to SSAC solicitations. For example, representatives reported
that it was challenging for them to provide services to VAMCs under
short-term SSACs because the length of these contracts does not provide
a commitment from VHA for the physicians hired by the affiliate to
fulfill the contract. These affiliate representatives explained that it
can take a year or longer to recruit a well-qualified academic
physician and short-term SSACs do not provide the funding commitment
needed by the affiliate to recruit these physicians. Federal internal
control standards state that information should be communicated both
internally and externally to enable the agency to carry out its
responsibilities; for external communications, these standards state
that management should ensure that there are adequate means of
communicating with, and obtaining information from, external
stakeholders that may have a significant impact on the agency achieving
its goals. \21\ In contrast to these standards, VHA's efforts to
cultivate better communication and coordination with affiliates at the
national level have been limited, consisting of three regional forums
with all its affiliates in fiscal year 2012. Since 2012, VA has relied
primarily on local coordination with affiliates in lieu of regional
forums, due to travel restrictions associated with VA's recent budget
shortfalls. As a result, VHA cannot ensure that it is effectively
responding to the concerns of its affiliates.
---------------------------------------------------------------------------
\21\ See GAO/AIMD-00-21.3.1.
---------------------------------------------------------------------------
Our report concluded that concerns about VA's communication and
coordination with its affiliates, as voiced by representatives from the
five affiliates we spoke with, demonstrate potentially ineffective
communication streams with these critical partners. To ensure VHA
effectively communicates with its affiliates regarding SSACs, we
recommended that VA reach out to all its affiliates, identify any
concerns, and determine the most effective method of communicating with
affiliates regarding SSAC development. VA concurred with this
recommendation and said that the VHA's Office of Academic Affiliations
and Medical Sharing Office will re-engage with the American Association
of Medical Colleges to determine the best ways to gather input from
affiliates on their concerns and determine the most effective method of
communication with them regarding SSAC development. Furthermore, VA
added that these offices will evaluate VA's current partnerships with
affiliates to identify both highly functional relationships that could
be highlighted as best practices and partnerships that could benefit
from targeted intervention.
Chairman Coffman, Ranking Member Kuster, and Members of the
Subcommittee, this concludes my prepared statement. I would be pleased
to answer any questions that you may have at this time.
GAO Contact and Staff Acknowledgments
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Affairs may be found on the last page of this statement. Other
individuals who made key contributions to this testimony include Marcia
A. Mann, Assistant Director; Cathleen Hamann; Katherine Nicole
Laubacher; Dharani Ranganathan; and Said Sariolghalam.
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Prepared Statement of Janis Orlowski, M.D.
Fostering Department of Veterans Affairs Relationships with Academic
Affiliates to Improve Health Care Access and Quality for Veterans
Executive Summary
As you finalize legislation to reform and improve health care for
our nation's veterans, the AAMC respectfully asks that you recognize
the importance of Department of Veterans Affairs (VA) academic
affiliations and urges you not to undermine these important public-
private partnerships. For 70 years, VA's shared research, education,
and patient care missions with academic medicine have improved access
and quality of care for veterans, both inside and outside the VA
system.
The AAMC is a not-for-profit association comprised of all 145
accredited U.S. medical schools; nearly 400 major teaching hospitals
and health systems, including 51 VA medical centers; and more than 80
academic societies. The AAMC serves the leaders of America's medical
schools and teaching hospitals and their 148,000 faculty members,
83,000 medical students, and 115,000 resident physicians.
To better align the VA and the nation's medical schools and
teaching hospitals, the AAMC supports the DOCs for Veterans Act (S.
1676, H.R. 3755, H.R. 4011); the Enhanced Veterans Health Care Act
(H.R. 3879); and the Improving Veterans Access to Care in the Community
Act (S.2633).
The AAMC believes VA graduate medical education, research, joint
ventures, sole-source contracting, and the proposed Core Network of the
Veterans Choice Program help ensure access for our nation's veterans to
the highest quality care by preserving academic affiliates as a direct
extension of VA care and a preferred provider. This relationship serves
multiple purposes:
Access to Complex Clinical Care - Direct clinical care contracts
allow academic affiliates to plan, staff, and sustain infrastructure
for certain complex clinical care services that are scarcely available
elsewhere, including trauma centers, burn care units, comprehensive
stroke centers, and surgical transplant services. Solely relying on
fee-basis mechanisms has the potential to reduce veterans' access to
care if teaching hospitals scale back services when faced with an
uncertain patient load from the VA.
Workforce Development - There is a pressing need for physicians to
care for our nation's veterans now and in the future. VA physician
shortages are symptomatic of a broader trend, the proverbial ``canary
in the coal mine.'' The AAMC projects a nationwide shortage of between
46,000-90,000 physicians by 2025. Though these shortfalls will affect
all Americans, the most vulnerable populations, including veterans, in
underserved areas will be the first to feel the impact.
Physician Recruitment - The VA is an irreplaceable component of the
U.S. medical education system, training more than 40,000 medical
residents annually, but academic partnerships also facilitate the joint
recruitment of faculty to provide care at both institutions. VA GME
programs also educate new physicians on cultural competencies for
treating veteran patients (inside and outside the VA), and help recruit
residents to the VA after they complete their training.
Innovation and Quality - The combination of education, research,
and patient care at VA and academic medical centers cultivates a
culture of curiosity and innovation. Under this tripartite mission, it
is critical to expand VA research on chronic conditions of aging
veterans, emerging conditions prevalent among younger veterans, and the
Million Veteran Program. Medical faculty must be skilled in the latest
clinical innovations to train the next generation physicians that will
care for veterans. State-of-the-art technology and groundbreaking
treatments jump quickly from the research bench to the bedside,
enhancing the quality of care provided to veterans.
Good evening and thank you for this opportunity to testify on
behalf of the Association of American Medical Colleges (AAMC). As you
consider reforms to improve health care for our nation's veterans, the
AAMC respectfully asks that you recognize the importance of the
Department of Veterans Affairs (VA) academic affiliations and urges you
not to undermine these important partnerships. VA's shared patient
care, research, and education missions with academic medicine improve
access and quality of care for veterans, both inside and outside the VA
system.
The AAMC is a not-for-profit association dedicated to transforming
health care through innovative medical education, cutting-edge patient
care, and groundbreaking medical research. Its members comprise all 145
accredited U.S. and 17 accredited Canadian medical schools; nearly 400
major teaching hospitals and health systems, including 51 VA centers;
and more than 80 academic societies. Through these institutions and
organizations, the AAMC serves the leaders of America's medical schools
and teaching hospitals and their nearly 160,000 faculty members, 83,000
medical students, and 115,000 resident physicians.
This year, the VA and academic medicine will celebrate their 70th
anniversary. This relationship dates back to the end of World War II
when the VA faced a severe shortage of physicians as nearly 16 million
men and women returned from overseas, many with injuries and illnesses
that would require health care for the rest of their lives. At the same
time, many physicians were returning from the war without having
completed residency training.
The solution was VA-academic affiliations established under VA
Policy Memorandum No. 2, making the VA an integral part of residency
training for the nation's physicians. In return, the VA improved access
and quality of care for our nation's veterans. What started as a simple
idea in a time of great need has developed into an unprecedented
private-public partnership. Today, the VA has over 500 academic
affiliations, and 127 VA facilities have affiliation agreements for
physician training with 135 of the 145 U.S. medical schools.
THE ROLE OF ACADEMIC AFFILIATES IN CARING FOR VETERANS
The AAMC believes VA sole-source contracting, joint ventures, and
the proposed Core Network of the Veterans Choice Program help ensure
access for our nation's veterans to the highest quality care by
preserving academic affiliates as a direct extension of VA care and a
preferred provider. This relationship serves multiple purposes:
Access to Complex Clinical Care
VA sole-source contracting allows academic affiliates to plan,
staff, and sustain infrastructure for complex clinical care services
that are scarcely available elsewhere. U.S. teaching hospitals provide
around-the-clock, onsite, and fully-staffed standby services for
critically-ill or injured patients, including trauma centers, burn care
units, comprehensive stroke centers, and surgical transplant services.
Solely relying on fee-basis mechanisms like the Veterans Choice Program
has the potential to reduce veterans' access to care if teaching
hospitals scale back services when faced with the inability to plan for
a consistent patient load from the VA.
Medical Education
The VA is an irreplaceable component of the U.S. medical education
system. The VA trains more than 40,000 medical residents within its
walls annually. VA medical centers are the largest training sites for
physicians, and fund approximately 10 percent of graduate medical
education (GME). VA residency programs are sponsored by an affiliate
medical school or teaching hospital. Without these affiliations, many
VA programs would be unable to meet the requirements set by the
Accreditation Council for Graduate Medical Education (ACGME). A
provider referral preference for academic affiliates under clinical
services contracts helps ensure an adequate and diverse patient load
necessary for GME program accreditation.
Physician Recruitment
Academic partnerships between VA institutions and academic medical
centers facilitate the joint recruitment of faculty to provide care at
both sites. VA GME programs also educate new physicians on cultural
competencies for treating veteran patients (inside and outside the VA),
and help recruit residents to the VA after they complete their
training. According to results from the VA's Learners Perception
Survey, residents that rotate through the VA are nearly twice as likely
to consider employment at the VA. The Veterans Choice Act recognizes
the importance of this recruitment to addressing Veterans Health
Administration (VHA) health professional shortages by creating up to
1,500 new VA GME positions.
Innovation
The combination of education, research, and patient care that
occurs because of the close relationships between VA institutions and
academic medical centers cultivates a culture of curiosity and
innovation. Medical faculty must be skilled in the latest clinical
innovations to train the next generation physicians that will care for
veterans. State-of-the-art technology and groundbreaking treatments
jump quickly from the research bench to the bedside, enhancing the
quality of care provided to patients, including access to a majority of
National Institutes of Health (NIH)-funded clinical trials. Without
strong ties to academic affiliates, VA's tripartite mission is put in
jeopardy.
AAMC SUPPORTS VA PLAN TO CONSOLIDATE COMMUNITY CARE PROGRAMS
The Veterans Health Care Choice Improvement Act of 2015 (P.L. 114-
41) required the VA to ``develop a plan to consolidate all non-
Department provider programs by establishing a new, single program to
be known as the `Veterans Choice Program' to furnish hospital care and
medical services to veterans enrolled in the system of patient
enrollment established under section 1705(a) of title 38, United States
Code, at non-Department facilities.''
The AAMC applauds the VA for including academic providers in its
proposed VA Core Network of preferred providers under its Plan to
Consolidate Community Care Programs delivered to Congress last year.
The plan, which outlines how the VA will purchase veteran health care
at non-VA facilities, proposes a tiered network of providers and allows
academic affiliates to continue contracting directly with local VA
medical centers.
Current and Previous Challenges Hinder Clinical Relationships
The AAMC supports VA's goal of streamline and improve the
efficiency of VA contracting with the nation's medical schools and
teaching hospitals. Unwieldy and drawn-out clinical contracting has
hinder these relationships, despite their potential to greatly expand
the reach of the VHA. Several of these issues have been raised
previously by the AAMC and academic affiliates but there has been no
subsequent VA reforms to their contracting process. For example, as the
VHA faced patient-access issues across the country, 161 of our member
medical schools and teaching hospitals have told us they had the
capacity to help, yet were often stymied due to contracting hurdles -
delaying, and in some cases preventing, veterans' access to health
care.
Fee-basis care through a predecessor to the Veterans Choice
Program, the ``Patient-Centered Community Care (PC3)'' program,
inserted a middleman between longtime partners, resulting in delayed
and misdirected referrals due to skewed third party incentives,
additional costs for the VA and affiliates directed to the third party,
and unnecessary administrative burden for all. The AAMC appreciates
that the VA has now recognized the inefficient processes for onboarding
physicians/institutions through third party administrators, which
further delayed veteran access to care.
The VA Plan to Consolidate Community Care Improves the Current System
There are many aspects of the proposed VA plan that will improve
VA-academic affiliations and veterans' access to quality health care.
The VA plan proposes a tiered network of providers. The Core Network
would include federal and academic partners, and would be treated as a
direct extension of VA care. The External Network would include a
Standard Tier as well as a Preferred Tier for providers that
demonstrate quality and value.
Under the plan, academic affiliates would be able to continue
contracting directly with the local VA Medical Center to provide
clinical services. This contracting would be streamlined with national
templates, but allow for local flexibility.
Importantly, medical schools and teaching hospitals would also be
eligible for fee-basis care under the new External Network that is
reimbursed at Medicare rates with customized fee schedules for selected
areas and scarce specialty services.
The VA would be responsible for case management and referrals
instead of third party administrators. Additionally, VA would accept
academic affiliates' credentialing, with a new VA oversight committee
to audit compliance with credentialing standards. The VA also plans to
streamline referrals and health information sharing by automating these
processes.
The plan also calls for greater monitoring of outcomes and quality
metrics for non-VA providers. VA is expected to utilize existing
metrics, such as those under the Centers for Medicare and Medicaid
(CMS) Hospital Value-Based Purchasing (VBP) program.
Recommendations
The AAMC recommends that the Veterans Choice Program continue a
provider referral preference for academic affiliates. We support
passage of the Improving Veterans Access to Care in the Community Act
(S.2633) implement the VA plan to consolidate community care. This bill
would allow VA to create a tiered network that facilitates provider
participation, but importantly does not dictate how veterans will use
the network. For academic affiliates who do not yet participate in the
VA Choice Program, the Core Network will enable VA to sustain and
strengthen relationships with affiliates and allow veterans access to
the high quality, timely care these affiliates deliver.
The Veterans Choice Program should also continue full Medicare
reimbursement rates, including medical education costs. Additionally,
we respectfully ask that the agency and Congress consult with
representatives from the academic affiliate community as you implement
the updated Veterans Choice Program. One important venue is the VA's
National Academic Affiliations Council (NAAC) federal advisory
committee, established by VA for the very purpose of advising the
Secretary on these issues.
IMPROVING VA SOLE-SOURCE CONTRACTING WITH AFFILIATES
While it is important to have performance standards and data, they
will only confirm what we already know: the process for long-term, high
value sole-source affiliate contracts (SSACs) is too arduous, resulting
in short-term SSACs as a fallback. In other words, the problem is the
process itself, not the oversight of the process. The most frequently
identified barrier is the additional review of contracts greater than
$500,000 by the VA Office of Inspector General (OIG). To apply similar
review to short-term contracts under $500,000 would only create the
same problems we've seen with long-term, high-value SSACs.
Short-term agreements are made as services are about to expire and
leave veterans in a lurch. AAMC members frequently report that short-
term contracts are used as placeholders for long- term, high-value
contracts. Both VA medical centers and their affiliates would prefer
long-term, high-value SSACs, but the process and OIG oversight prevents
or significantly delays agreements. As such, the focus should be on
improving the process of long-term, high-value SSACs, rather than
imposing similar arduous oversight on short-term SSACs.
In addition to improving turnaround for SSAC development and
approval, the contracting rules for the VA are not designed with
clinical services in mind. The size of clinical services contracts
varies greatly, but AAMC members report that virtually all 5-year
contracts with the VA are between $2 million and $10 million, far
exceeding the current $500,000 threshold for additional review. As an
example, the AAMC estimates that contracts for the following clinical
services would surpass $500,000 and trigger additional review:
10 uncomplicated cardiac surgeries
4 burn cases
5 intensive care unit cases
10 outpatient radiation cases
10 esophageal cancer surgery cases
The AAMC understands the need for federal oversight, but often the
administrative bodies designed to review and enforce this oversight
have a less than full understanding of the value in contracts with
academic affiliates. This value is why VA Directive 1663 states,
``Sole-source awards with affiliates must be considered the preferred
option whenever education and supervision of graduate medical trainees
is required (in the area of the service contracted). The contract cost
cannot be the sole consideration in the decision on whether to sole
source or to compete.''
However, by VA's own estimation, once the decision to contract out
care has been made, VA sole-source contracting with trusted academic
affiliates takes longer than the formal competitive solicitation
process - officially between 17-28 weeks compared to 14-18 weeks,
respectively, according to VA Directive 1663. The contracting decision
tree from VA Directive 1663 (attached as an Appendix) outlines the
complexity and administrative burden embedded in the process. Sole-
source contracts over $500,000 go through an additional 10-11 weeks of
review (23-25 weeks total) compared to contracts under $500,000.
Contracts over $5 million require an additional 3 weeks (26-28 weeks
total). AAMC members report additional delays of up to 18 months as a
result of the VA OIG pre-award audit for sole-source contracts that
exceed $500,000.
Further delaying action, the VA can require academic affiliates to
submit documentation of all costs associated with physician employment.
As an example, this might include faculty contracts, continuing
education policies, time and effort reports, benefits costs, vacation
policies, time and attendance policies, the distance and time it takes
to walk from the hospital to the VA hospital, and even the monthly cost
of parking. The VA reviews these items, in some cases for months. There
are often a variety of questions about the data submitted, some
substantive but many that seem to be of dubious value.
As a result of approval delays, it is necessary to execute a series
of extensions or short-term contracts to continue to be paid for
services. This requires a great deal of time and effort on the part of
both the VA and the academic affiliate. In some cases, payment is
delayed as a result of this process. In the long term, it makes it
difficult for departments to recruit faculty for the VA because there
is no commitment for future funding.
Recommendations
Local VA medical centers and their academic affiliates see the
benefits of these relationships, but are stymied by a process mired in
misplaced oversight. Sole-source contracting with trusted academic
affiliates should not take longer than the competitive bid process. The
AAMC recommends exempting sole-source contracting with academic
affiliates from additional OIG review triggered by the $500,000
threshold, or raising the trigger to at least $2.5 million for 5- year
contracts.
As referenced in the VA's consolidation plan, the AAMC appreciates
VA's willingness to develop pre-approved template contracts that
reimburse certain services with at least Medicare rates. Additionally,
we have discussed the development of standardized overhead rates to
eliminate unnecessary negotiations and contract administration.
Involving individuals with academic appointments in the contracting
process should not be considered a conflict of interest, but rather
recognized for the value they add to VA leaderships' ability to
contract for clinical services. The AAMC recommends allowing VA
officials with academic appointments to participate in contract
negotiations with the academic affiliate.
VA must recognize the unique costs and circumstances associated
with clinical contracting compared to other goods and services. The
AAMC recommends increased training for VA contracting officers
regarding clinical services contracting.
Academic affiliates also have a role to play in improving these
negotiations. We have committed to working with our institutions to
develop single points of contact instead of renegotiating the same
contract with each program head.
ESTABLISHING JOINT VENTURES WITH ACADEMIC AFFILIATES
To better align the VA and the nation's medical schools and
teaching hospitals, the AAMC supports the Enhanced Veterans Health Care
Act (H.R. 3879). The VA and academic medicine have enjoyed a 70-year
history of affiliations to help care for those who have served this
nation. This shared mission can be strengthened through joint ventures
in research, education, and patient care. Already our institutions and
medical faculty collaborate in these areas, but often VA lacks the
administrative mechanisms to cooperatively increase medical personnel,
services, equipment, infrastructure, and research capacity.
Current authority for VA to coordinate health care resources with
affiliates has been narrowly interpreted by VA Office of General
Counsel and the OIG. VA can occupy and use non-VA space for limited
purposes, but only under 6-month sharing agreements, 6-month revocable
licenses, or 5-year leasing agreements - all of which have failed in
practice.
The Enhanced Veterans Healthcare Act of 2015 would direct the VA to
enter into sole-source agreements for health care resources (including
space) with schools of medicine and dentistry, university health
science centers, and teaching hospitals to deliver care to our veterans
to meet the growing demand for veteran health care services.
INVESTING IN VA-CENTRIC RESEARCH FOR CLINICIAN RECRUITMENT
The VA Medical and Prosthetic Research and Development program is
widely acknowledged as a success on many levels, all directly leading
to improved care for veterans and an elevated standard of care for all
Americans:
Advancing Patient Care - VA research has made critical
contributions to advancing standards of care for veterans in areas
ranging from tuberculosis in the 1940s to immunoassay in the 1950s to
today's ongoing projects dealing with Alzheimer's disease, developing
and perfecting the DEKA advanced prosthetic arm and other inventions to
help the recovery of veterans grievously injured in war, studies in
genomics and in chronic pain, cardiology, diabetes, and improved
treatments for PTSD and other mental health challenges in veterans.
These studies and their findings ultimately aid the health of all
Americans.
Recruitment and Retention - VA research is a completely
intramural program that recruits clinicians to care for veterans while
conducting biomedical research. More than 70 percent of these
clinicians are VA-funded researchers. VA also awards more than 500
career development grants each year designed to help retain its best
and brightest researchers for long and productive careers in VA health
care.
High-Quality Research - VA researchers are well published
(between 8,000 and 10,000 refereed articles annually) and boast three
Nobel laureates and seven awardees of the Lasker Award (the ``American
Nobel Prize''); this level of success translates effectively from the
bench to the veteran's bedside.
Investing Taxpayers' Dollars Wisely - Through a
nationwide array of synergistic relationships with other federal
agencies, academic affiliates, nonprofit organizations, and for-profit
industries, the program leverages a current annual appropriation of
$631 million into a $1.9 billion research enterprise.
Sustaining Research Investment and Addressing Emerging Veteran Research
Needs
The AAMC strongly believes funding for VA research must be steady
and sustainable to meet current commitments while allowing for
innovative scientific growth to address critical emerging needs.
Despite documented success, since FY 2010 appropriated funding for
VA research and development has lagged far behind biomedical research
inflation, resulting in a net loss of nearly 5 percent of VA purchasing
power. As estimated by the Department of Commerce Bureau of Economic
Analysis and the National Institutes of Health (NIH), to maintain VA
research at current service levels, the VA Medical and Prosthetic
Research appropriation would require $17 million in FY 2017 (a 2.7
percent increase over the 2016 pending appropriation). Should the
availability of research awards decline as a function of budgetary
policy, VA risks terminating ongoing research projects and losing these
clinician researchers who are integral to providing direct care for our
nation's veterans. Numerous meritorious proposals for new VA research
cannot be awarded without a significant infusion of additional funding
for this vital program.
The AAMC believes an additional $17 million in FY 2017, beyond
uncontrollable inflation, is necessary for expanding research on
conditions prevalent among newer veterans as well as continuing
inquiries into chronic conditions of aging veterans from previous
wartime periods. For example, VA research is uniquely positioned to
advance genomic medicine through the Million Veteran Program (MVP), an
effort that seeks to collect genetic samples and general health
information from one million veterans over the next five years.
Additional funding will also help VA support emerging areas that remain
critically underfunded, including:
Post-deployment mental health concerns such as PTSD,
depression, anxiety, and suicide;
The gender-specific health care needs of the growing
population of women veterans;
Engineering and technology to improve the lives of
veterans with prosthetic systems that replace lost limbs or activate
paralyzed nerves, muscles, and limbs;
Studies dedicated to understanding chronic multi-symptom
illnesses among Gulf War veterans and the long-term health effects of
potentially hazardous substances to which they may have been exposed;
and
Innovative health services strategies, such as telehealth
and self-directed care, relatively new concepts that can lead to
accessible, high-quality, cost-effective care for all veterans, as VA
works to address chronic patient backlogs and reduce wait times.
The Million Veteran Program
The VA research program is uniquely positioned to advance genomic
medicine through the MVP, an effort that seeks to collect genetic
samples and general health information from 1 million veterans over the
next five years. When completed, the MVP will constitute one of the
largest genetic repositories in existence, offering tremendous
potential to study the health of veterans. To date, more than 450,000
veterans have enrolled in the MVP.
To support the President's Precision Medicine Initiative, AAMC
recommends an additional $75 million to process the first 100,000
samples without reducing funding for other designated research areas.
VA Research Infrastructure
State-of-the-art research also requires state-of-the-art
technology, equipment, and facilities. For decades, VA construction and
maintenance appropriations have failed to provide the resources VA
needs to replace, maintain, or upgrade its aging research facilities.
The impact of this funding shortage was observed in a congressionally-
mandated report that found a clear need for research infrastructure
improvements systemwide. Nearly 40 percent of the deficiencies found
were designated ``Priority 1: Immediate needs, including corrective
action to return components to normal service or operation; stop
accelerated deterioration; replace items that are at or beyond their
useful life; and/or correct life safety hazards.''
The AAMC believes designating funds to specific VA research
facilities is the only way to break this stalemate. In 2010, VA
estimated that approximately $774 million would be needed to correct
all of the deficiencies found throughout the system; only a fraction of
that funding has been appropriated since. A follow-up report is already
underway and will guide VA and Congress in further investment in VA
research infrastructure to recruit the next generation of clinicians to
care for the nation's next generation of veterans. However, Congress
needs to begin now to correct the most urgent of these known
infrastructure deficiencies, especially those that concern life safety
hazards for VA scientists and staff, and veterans who volunteer as
research subjects.
Recommendations
The Administration and Congress should provide at least $740
million for the VA Medical and Prosthetic Research program for FY 2017
to support current research on the chronic conditions of aging
veterans, emerging research on conditions prevalent among younger
veterans, and the Million Veteran Program.
The Administration and Congress should provide funding for up to
five major construction projects in VA research facilities in the
amount of at least $50 million and appropriate $175 million in
nonrecurring maintenance and for minor construction projects to address
deficiencies identified in the independent VA research facilities
review provided to Congress in 2012.
TRAINING THE NEXT GENERATION OF PHYSICIANS TO CARE FOR VETERANS
To help VA address patient access and recruitment issues, the AAMC
supports the Delivering Opportunities for Care and Services (DOCs) for
Veterans Act (S. 1676, H.R. 4011) and H.R. 3755. VA physician shortages
are symptomatic of a broader trend, the proverbial ``canary in the coal
mine'' for the nation's health system. The AAMC projects a nationwide
shortage of physicians between 61,700 and 94,700 physicians by 2025.
Though these shortfalls will affect all Americans, the most vulnerable
populations in underserved areas will be the first to feel the impact
(e.g., the VA, Medicare and Medicaid patients, rural and urban
community health centers, and the Indian Health Service).
The study, conducted by the Life Science division of the global
information company IHS Inc., and prepared on behalf of the AAMC, and
estimates a shortfall of between 14,900 and 35,600 primary care
physicians and between 37,400 and 60,300 non-primary care specialties.
Similarly, an AAMC review of physician vacancies advertised by the VHA
found that approximately two thirds were for non-primary care
specialists, and about one-third were for primary care providers.
To address this shortage, the nation's medical schools have done
their part by expanding enrollment by 30 percent. However, there has
not been a commensurate increase in the number of GME residency
training positions. The primary barrier to increasing residency
training at teaching hospitals - and the U.S. physician workforce in
turn - is the cap on Medicare GME financial support, which was
established in 1997. Thankfully, the DOCs for Veterans Act helps
address this hurdle.
Just as Medicare GME supports Medicare's share of training costs at
institutions that care for Medicare beneficiaries, VA GME supports
residency training programs based at VA medical centers. According to
results from the VA's Learners Perception Survey, residents that rotate
through the VA are nearly twice as likely to consider employment at the
VA. The Veterans Access, Choice, and Accountability Act of 2014 (VACAA,
P.L. 113-146) instructs VA to add 1,500 GME residency slots over five
years at VA facilities that are experiencing shortages. However,
without an increase in Medicare GME support, there may not be enough
affiliate residency positions to accommodate this VA expansion.
Most VA residency programs do not operate independently. They rely
upon the existing administrative and training infrastructure maintained
by the nation's medical schools and teaching hospitals. Nearly all VA
residency programs are sponsored by an affiliate medical school or
teaching hospital.
To assure that VA-based residents receive the highest quality
training possible, they need diverse and supervised experiences in a
variety of clinical settings. This includes training experiences at the
nation's teaching hospitals and the multispecialty practices run by the
nation's medical schools. While there is considerable variability among
VA medical centers, programs, and specialties, on average medical
residents rotating through the VA spend approximately three months of a
residency year at the VA (i.e., a quarter of their training).
As such, simply increasing VA GME funding alone will not address
the VA crisis. Without a corresponding increase in Medicare GME
support, VA medical centers will be unable to capitalize fully on
increases in VA GME funding. The DOCs for Veterans Act will allow
affiliate teaching hospitals that are already at or above their 1997
Medicare GME cap to receive Medicare support for VACAA residents while
they are training at a non-VA facility.
CONCLUSION
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify on these important issues. To improve the
relationships between the VA and the nation's medical schools and
teaching hospitals, the AAMC reiterates its support the following
bills:
The Delivering Opportunities for Care and Services (DOCs)
for Veterans Act (S. 1676, H.R. 4011) and H.R. 3755;
The Enhanced Veterans Health Care Act (H.R. 3879); and
The Improving Veterans Access to Care in the Community
Act (S.2633).
The VA is at a crossroads. VA GME, joint ventures, sole-source
contracting, and the proposed Core Network of the Veterans Choice
Program can strengthen the 70-year history of VA- academic affiliations
and prepare our country for the next chapter of VA health care. The
AAMC and our member institutions will continue to work with the
Congress and the VA to address the challenges and opportunities to
ultimately improve care for veterans and all Americans.
APPENDICES
VA Directive 1663 Contracting Decision Tree
Biography of Janis Orlowski, M.D., MACP
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Nancy Watterson-Diorio
EXECUTIVE SUMMARY
Testimony by Nancy Watterson-Diorio, board member of the National
Association of Veterans' Research and Education Foundations (NAVREF)
and CEO of the Boston VA Research Institute, Inc. (BVARI).
The VA Nonprofit Corporations (VA NPCs or NPCs) fulfill an
important role at the VA, in addition to the academic affiliates (AAs),
in administering extramural research. I believe the NPCs can contribute
much more and be of greater benefit to our veterans if the lingering
barriers surrounding consistent national practices were removed. To
that end, I respectfully request consideration of the following
recommendations: 1) Allow NPCs to pay investigators to the same extent
as AAs. 2) Provide NPCs right-of-first-refusal on administering all
awards supporting VA research. 3) Reduce the level of variability from
site-to-site by creating general guidelines and decision trees that
remove or reduce conflicts of interests among decision-makers.
The NAVREF network consists of 82 VA NPCs that are co-located
within the VA medical centers (VAMCs or VAs) across the country. As
reported in the 2014 Annual Report to Congress, the NPCs raised over
$260M of annual extramural research and educational awards specifically
targeted toward the VA's mission of supporting veterans' care. This
represents approximately 15% of the total portfolio supporting research
at the VA.
The NPCs' congressional founding legislation solved several areas
of difficulty for VA research and education programs: 1) It
discontinued handshake agreements with no contractual obligations and
acknowledgement of the VA's research successes. 2) It supplemented VA's
intramural funding expertise with expert support for extramural pre-
and post-award funding and unique compliance knowledge. 3) It leveraged
VA's ability to expand its research portfolio to support clinical
trials and federal funding; thus, allowing more veterans to be
supported with state-of-the-art research knowledge and the opportunity
to be treated with the newest therapies. 4) It fostered an innovative
spirit of public-private sponsorship.
There are many advantages to using NPCs as envisioned by Congress.
First, NPCs rigorously comply with federal regulations and are subject
to VA oversight that includes recurring VA audit inspections.
Additional VA oversight includes statutory VA board members at each NPC
and a Nonprofit Oversight Board at VA Central Office. In addition, NPCs
operate transparently by providing an annual report to Congress
detailing their accomplishments and successes in support of VA
research.
There are also challenges that we must find ways to overcome in
order to successfully carry out the mission and purpose of the
congressional vision for NPCs: 1) The NPCs are unable to compete on a
level playing field with the AAs because we are unable to pay
investigators in the same manner. 2) The decision-making process within
VA, regarding the administration of federal grants, varies from site-
to-site. Frequently, Principal Investigators (PIs) who are dually-
appointed at the AA, or local leadership, make the determination on who
will administer the research, which is a potential conflict of
interest.
By congressional design, the NPCs exist to advance veterans' health
through innovative research and education programs, and I request that
we remove all barriers and employ all available tools to accomplish
that powerful mission.
Witness Disclosure Statement
Begins on following page.
Disclosure of Foreign Payments to Witnesses
I, Nancy Watterson-Diorio, attest that I am a nongovernmental
witness and that I am not receiving foreign payments or contracts as a
witness or a representative of the National Association of Veterans
Research and Education Foundation or the Boston VA Research Institute,
Inc. and have never received foreign payments.
Nancy Watterson-Diorio
Curriculum Vitae: Nancy Watterson-Diorio
Begins on following page.
TESTIMONY
Chairman Coffman, Ranking Member Kuster, esteemed Subcommittee
Members, I am Nancy Watterson-Diorio, and I am honored to be with you
here today to share with you my experiences and insights regarding the
Department of Veterans Affairs' medical research program and the role
of the Congressionally authorized VA-affiliated nonprofit research and
education corporations. As a board member of the National Association
of Veterans' Research and Education Foundations (NAVREF) and CEO of the
Boston VA Research Institute, Inc. (BVARI), I have over twenty years of
experience in administering VA research through VA nonprofit
corporations.
My career path has been exclusively spent engaged in medical
research administration, first at the academic affiliate (15 years) and
then at the Boston VA Research Institute, Inc. (BVARI), the VA
nonprofit located at the VA Boston Healthcare System (20 years). I was
told when I started at BVARI (and just 3 years from its inception) that
``if you build it, they will come.'' BVARI's revenues were $100,000 in
1996 and only a few active investigators were interested. After 20
years, BVARI has increased its annual revenue to $14M, much of which is
supported by the Department of Defense (DoD). Key areas of interest
include posttraumatic stress disorder/syndrome (PTSD), traumatic brain
injury (TBI), the Precision Medicine Initiative, and a newly developed
clinical trials network supporting the northeast medical centers. I am
proud of the work we have done at BVARI to support research that has
positively impacted so many veterans and their families.
Veterans' Affairs Nonprofit Corporations (VA NPCs or NPCs) are
congressionally authorized entities under US Public Law 111-163 Title
38 - Subchapter IV - Research and Education Corporations (``Title 38")
sponsored by a great advocate for our nation's veterans, the late
Congressman Sonny Montgomery. The mission and purpose of the VA NPCs is
``to provide a flexible funding mechanism for the conduct of approved
research and education'' at an affiliated VA Medical Center (VAMC or
VA) 1. Under Title 38, NPCs are allowed to ``accept, administer,
retain, and spend funds derived from gifts, contributions, grants,
fees, reimbursements, and bequests from individuals and public and
private entities.[and] enter into contracts and agreements with
individuals and public and private entities''1. Recognizing that VA-
appropriated funds are not the only source of revenue available to
support US veterans' research and educational programs, Congress
established VA NPCs to enable more avenues to support and add capacity
to these programs. The mission of the NPCs is to advance veterans'
health through innovative research and education programs by providing
the technical support and the management expertise necessary to best
enable their success. Over the past 28 years, since the establishment
of the NPCs, the original concept has yielded great success; for the
10-year period from 2005-2014, NPCs expended over $2 billion in support
of VA research activities, expending over $260M in 2014 alone in direct
support of improving veterans' health. This represents over 4,000
research and education activities. Funds are predominantly federal
(excluding VA appropriated dollars), at 72% of total, with the rest
made up of private industry trials, foundation grants, donations, and
other sources2.
The NPCs are accountable under congressional oversight, which
requires a detailed annual report to the Committees on Veterans'
Affairs of the Senate and House of Representatives, triennial Nonprofit
Program Office (NPPO) audit and direct oversight under the federal
Nonprofit Oversight Board (NPOB), as well as other regulatory
requirements including federal, state, and local regulations governing
their 501(c)(3) benefit status1. Those NPCs who are recipients of
federal awards and meet certain financial threshold criteria are also
subject to government's Single Audit requirements under the Uniform
Guidance policy.
In addition to the NPCs, most VAs are affiliated with university
academic affiliates (AAs). The affiliation supports healthcare,
research, and medical education and training. The academic affiliation
constitutes direct advantages to veterans' health research, most
notably, it allows the VAs to recruit and retain the most highly
qualified research Principal Investigators (PIs), who traditionally
have an academic faculty appointment at the non-governmental academic
medical centers (AMCs). At the VA, this faculty appointment exists in
addition to their VA appointment, and thus they are dually appointed.
Under this dual appointment, PIs may conduct research at the AA under
their academic appointment, but in keeping with the intent of Title 38,
their AA research must be clearly severable from their VA-approved
research. With this option available to dual appointments, there are,
however, notable inconsistencies around the nation about how this
distinction is overseen and enforced. With the objective of achieving
the maximum effectiveness of the affiliation in reference to the
research aim, I am not aware of any specific definitions, metrics, or
governance requirements guiding this partnership, which as noted may
function differently at every local site.
Problem Statement and Recommended Action
Due to the inconsistencies of national practice on whether the NPCs
or the AAs administer extramural research programs for the VA, the
potential growth of NPCs and their ability to support veterans'
research programs have yet to achieve their full potential that I
believe was originally envisioned by Mr. Montgomery. A recommendation
in the VA's 2009 Blue Ribbon Panel Final Report, conducted in
partnership with the American Association of Medical Colleges (AAMC)
stated (emphasis added):
``Transformative medical research requires investigators with
disparate expertise. Moreover, many research questions are best
addressed collaboratively. To enhance the translation of biomedical
science into improved health care, the Panel recommends that VA and its
academic partners redouble their efforts to develop new knowledge
through collaborative research. The Panel endorses the need for a
strong VA intramural research program, but cautions that policies
limiting more dynamic collaboration with affiliated institutions
[including the NPCs] may ultimately undermine the quality of the
Nation's overall research enterprise.''3
In this context, there are many areas to pursue in recognition of
this recommendation. One such area I believe to be important is that
the VA establish clear guidelines through its Office of Academic
Affiliations governing policy for the administration of non-VA funded
research activities that maximizes the benefits of the NPC and
generally offers the NPC ``right of first refusal'' for all research
efforts where the majority of effort occurs physically within the VA.
Background and NPC Qualifications
As statutorily established and governed entities, and due to their
close relationship and direct knowledge of the VA system, NPCs are
uniquely qualified to acquire funding and administer research awards
supporting veterans' health priorities.
Additionally, NPC personnel and their volunteers are not paid
federal employees and are therefore not restricted from fundraising
activities like their federal colleagues, allowing them to directly
solicit funds in support of their mission-an avenue that has improved
veterans' health outcomes, as all funds raised are reinvested in the
NPC's veteran research and educational programming in accordance with
its statement of purpose.
The NPCs also provide a specialized role significant in securing
research grant and contract funding opportunities. As specialists in
veterans' health programs, the NPCs are highly qualified and have
direct access to the resources and expertise necessary for successful
programming. Some of the benefits of an NPC's internal expertise
include access to government and non-government space; knowledge of and
direct access to VA infrastructure, including the complexities of
government information technology (IT); professional connections and
recruitment channels to specialized research program staff; familiarity
of the federal Without Compensation (WOC) process and direct
relationships with VA HR personnel for processing WOCs; the direct
ability to reimburse VA personnel for their work on a funded project;
and direct understanding and knowledge of the unique effort-reporting
and payment practices for VA PIs, including the ``60-hour workweek''
and effort disclosure Memorandum of Understanding (MoU), which are
discussed in more detail below.
The NPCs are also recognized by the Department of Defense (DoD) as
the direct conduit to the VA patient population, an important criterion
on grant review and funding allocation due to the DoD's programmatic
priorities. As of the 2014 NPC annual report to Congress, federal
funding represented 87% of the top five NPCs' research portfolios2. The
NPCs' role as specialized program experts can be compared to a disease-
focused hospital that is seen as a national leader in that disease.
There are, for example, numerous hospitals, AAs, and corporate entities
pioneering advances in cancer research outcomes, but a few major
dedicated cancer treatment and research institutes across the nation
remain the most highly-renowned and receive very large annual funding
allocations from research awards and donors. When comparing the NPCs'
expertise and dedicated efforts, they serve in a comparable capacity
for veterans' health advances.
NPCs also have significant expertise in negotiating and
administering industry-funded clinical trial research agreements, by
using the federally approved VA Cooperative Research and Development
Agreement (CRADA) mechanism. Veterans represent a large patient
population that encompasses some of the nation's most serious health
concerns, which are priority areas for many pharmaceutical and device
companies' research and development initiatives. More importantly,
veteran patients deserve access to the most cutting-edge therapies and
treatments, which frequently can only be found through industry-funded
clinical trials. NPCs provide the VA with a mechanism to accept and
administer these much-needed trials. The VA also maintains a robust
inventory of patient data and bio-specimen samples, which offers
researchers rich insight into many diseases and their treatments. They
have been leaders in major discoveries and treatment advances in over
thirty disease areas, most significantly including PTSD and TBI, and in
many cases, the NPCs enabled the research funding for these advances4.
A final area in which NPCs support veteran medical research is
through the direct financial support of Veterans' Equitable Resource
Allocation (VERA) under the Research Support weighting program. VERA
Research funds are managed by the VA to ``acknowledge the additional
expense and provide an allocation of dollars for a facility to support
and sustain a research mission''5. Revenue supporting VA-administered
research programs, including NPC revenue, is weighted toward research
support at 100%, whereas non-VA administered programs, including AA
revenue, is weighted at 25%-75%5. According to the 2015 VERA Book, ``by
weighting VA-administered research at 100% and discounting non-VA
administered research, there is an incentive to encourage VA
administered research''5. NPC revenue, therefore, more directly
supports veterans' research initiatives.
Significant Challenges Affecting NPCs and Impacting Research to Improve
Veteran Health Outcomes
Among the most significant and pervasive issues for many NPCs are:
1) the inconsistent management of National Institutes of Health (NIH)-
funded research award administration, and 2) PI salary payments on NIH
(and other) awards.
The current practices surrounding NIH award administration varies
greatly across the US. In some regions, AAs are administering the
entire VA NIH-funded research portfolio; in others, NPCs maintain a
productive relationship with the AAs and collaborate on NIH award
administration; at still others, NIH award administration is considered
by local VA officials on a case-by-case basis. Due to a lack of
consistent policy interpretation, at this time, several VAs prohibit
their NPCs from administering NIH awards, even though there is no
formal regulation against doing so. As the NIH is the ``largest public
funder of biomedical research in the world''6, this represents a
significant impairment to NPC growth and development. When AAs
administer VA-approved research programs in lieu of the NPCs, there is
often a significant increase in the amount of federal funding allocated
to the program due to the often substantially higher F&A rates at the
AAs in contrast to the NPCs. The biggest discrepancy in F&A rates
between NPCs and AAs is seen in the small- to medium-sized NPCs, who
typically do not have access to the NIH portfolio (data available upon
request to NAVREF). These NPCs' growth trend has plateaued after their
initial establishment, potentially due to the tendency at many VAMCs to
allow all NIH awards to flow to the AA regardless of where the majority
of effort is being exerted. Whether or not intentional, imposing
barriers to NPCs' access to the largest source of US medical research
funding is akin to cutting off the lifeblood of the NPCs, which in turn
contributes to a reduction in veterans' research programs' ability to
thrive.
Additionally, there are very specialized policies in the NIH Grants
Policy Statement (NIHGPS or GPS) pertaining to jointly-affiliated VA-AA
PIs, which are a major contributor to the inconsistencies in national
understanding and practice surrounding federal award administration. In
my conversations with numerous representatives on this issue, I have
observed that many parties hold to historical interpretations and
unilateral application of the NIH GPS language, which currently
restricts the ability of entities to pay VA-AA joint-appointed PIs on
NIH awards such that only a university AA may make those payments7. An
NPC may be the recipient of NIH awards, but may not pay the PI's salary
directly unless it is in the form of a reimbursement to the VA for the
PI's official VA tour of duty7. Hence, if the PI is working on the
project above-and-beyond his or her VA tour of duty (an allowable and
recognized activity as long as total professional effort [TPE] remains
within 60 hours per week across all employers [``the 60-hour
workweek'']), the only functional mechanism for payment of that time is
via a Joint Personnel Agreement (JPA), a convention that allows an AA
to employ and issue salary payments when an NPC is the award recipient.
The salary for PI effort is awarded to the NPC, but through a JPA
agreement, the NPC agrees to send those awarded salary funds to the AA,
who issues the PI's paycheck using those funds. After comprehensive
research of the history and applicability of these practices, I have
discovered that other agencies (federal and non-federal) accept the 60-
hour workweek concept and have no objections to NPCs issuing PI salary
payments directly, without using a JPA. However, local practices and a
lack of understanding of the applicable policies have prevented many
NPCs from making direct payments, which has resulted in direct
financial loss to the NPCs due either to: 1) the need to forego the
drawdown of budgeted award revenue covering PI project salary because
there is no agreed-upon mechanism for issuing payment by the NPC, 2)
the decision by the PI to forego acceptance of the award because they
are unable to be paid under the original contractual expectations and
terms of the award, or 3) the direct loss of the entire award by the
NPC under local directives to relinquish it to the AA in order to
enable PI salary payments. These foregone payments have had a
devastating impact on the ability of the NPCs to support veteran
research programs.
In my research and discussions with national leaders on this issue,
I have not found a significant regulatory basis behind the NIH policy
language that restricts the flexibility of NPCs, and if left unaltered,
the language will continue to raise concerns as it gives direct
preferential treatment to the university AAs. NAVREF, with the approval
of VA's Office of Research and Development (ORD), is discussing with
NIH the possibility of modifying language in the GPS to allow NPCs to
pay PIs directly for their NIH-funded project effort.
NIH has current policy language restricting VA PI ``60-hour
workweek'' payments to the use of JPAs, but it is our finding that no
other agency publishes such restrictions. Due to local policies and
practices, many NPCs are utilizing ``optional JPAs'' (a JPA that is
being practiced locally, but that is not officially sanctioned or
governed by the funding agency). While optional JPAs are in some cases
useful mechanisms for NPCs, there are several ways in which their local
application can affect the NPCs financially: first, some AAs charge an
administrative fee-on top of their federally negotiated fringe benefit
(FB) rate and rolled into the award's FB budget-for processing these
payments. The fee is treated as a Direct Cost (DC) expense on the
award, and often costs the award more than the NPC FB rates would, thus
taking funds away from the veterans' healthcare research project. In
addition, several AAs do not currently allow JPAs due mostly to the
inherent risk posed to the AA in taking accountability for the PI's
effort without direct knowledge of the project. In many cases, the
decision is being made locally to request that the AA directly
administer the entire research award, simply as a means of enabling PI
payment. This approach is in direct competition with the NPCs' mission
and purpose, as defined in Title 38, to further veterans' health
outcomes by administering VA-approved research and educational programs
(when they are funded by non-VA-appropriated dollars).
I am concerned about the inherent conflict of interest posed by the
PI and/or any organization's (e.g., VA, AA, NPC) direct leadership if
they are given the option to choose the entity under which to submit
grants, rather than following a vetted policy or directive. Whether or
not intentional, a reasonable independent party could conclude that the
person making the choice as to where the award is administered stands
to personally gain from that decision, as they will either receive
direct salary (and, potentially, benefits) from that entity (in the
case of PIs) or financially benefit as an organization (in the case of
organizational leadership being the decision-maker). The lack of
consistent national practice has led to significant variation in which
party administers the research project and/or pays the PI for project
effort, and has resulted in consequential significant loss of potential
revenue for veterans' medical research programs. Although the VHA
Handbook 1200.17 allows NPCs to hire and pay VA employees (PIs)-and 18
U.S. Code Sec. 209 provides NPCs with an exemption from salary
supplementation concerns, as the employees serve in a ``without
compensation'' (WOC) government capacity when working for an NPC on a
portion of their 60-hour workweek-a lack of clear national guidance on
conflict of interest vetting has resulted in paralysis of the ability
of many NPCs to make payments8,9. I recommend a single national
practice on NPC/VA conflict of interest vetting and a national
directive explicitly allowing NPCs to make payments to PIs.
Summary, Impact, and Request for Action
The NPCs were created under Title 38 to serve as flexible funding
mechanisms to enable advancements to veteran health outcomes. Because
of inconsistent national practices, local decision-making, and a lack
of clear and consistent policy language, the intent of the original
legislation in Title 38 pertaining to the NPCs' missions has been
diluted and redistributed across multiple parties (NPCs and AAs).
Without any clear VA or congressional guidelines, each local medical
center is afforded the ability to pick and choose the source of
research award administration.
I recommend a comprehensive review of national practices and
updated policies and directives to clarify the roles and
responsibilities of the AAs and NPCs, and to give the NPCs the enhanced
opportunity to participate in the important work that is being done in
the VA's extramural research and education programs. I believe this is
in keeping with the original intent of the NPCs and their statutory
authorization, which was designed to directly benefit-without
interpretation, dilution, or bias-the veterans.
Thank you for inviting me to discuss these important issues and
thank you for your support of veterans. The VA's medical research
program is a hidden jewel with an enduring legacy of improving the care
of veterans and citizens throughout the nation. The close collaboration
and cooperation of VA medical centers, their academic affiliates, and
the nonprofit corporations is absolutely essential to the continued
success of this impactful research program.
TESTIMONY: NANCY WATTERSON-DIORIO
PROFESSIONAL BACKGROUND: My career has been focused on research
administration for over 35 years. Of that, 15 years has been spent as
an employee of the academic affiliate, Harvard Medical School, in
several capacities. During that time I was directly employed by the
affiliated teaching hospitals, Brigham and Women's Hospital and Beth
Israel Hospital. My role involved many administrative aspects of
research administration, which would often overlap with issues
pertaining to the Department of Veterans Affairs (VA). In 1996 I became
the Executive Director of two VA nonprofit organizations, the New
England Medical Research Institute, Inc. (NEMRI) and the Boston VA
Research Institute, Inc. (BVARI). Both organizations were in their very
early stages of business development (less than five years). Annual
revenue of both organizations was approximately $100,000. As the
medical center underwent a merger, it was decided by VA leadership to
merge both VA nonprofits into one. BVARI has just recently celebrated
its 25th year of operations and its annual revenue for FY2015 totaled
over $13M. BVARI directly supports 125 employees who play a key role in
the organization from administration (12 employees) to research
positions (113 employees). BVARI serves the faculty in both research
and educational projects and programs from foundation grants to
administering federal awards.
PERSONAL BACKGROUND: I am the granddaughter of a WWI veteran, the
daughter of a WWII veteran, the niece of a vast array of service
veterans, and the aunt of two nephews who most recently served. I've
only known my family to be devoted Americans who felt it was their duty
to serve in the military. I will mention that my Grandmother was a Gold
Star Mother and my family most recently lost my nephew to suicide upon
his successful completion of a tour as a submarine operator in the US
Navy. And finally, my granddaughter graduated high school this week and
her active military status in the U.S. Navy begins in July of 2016.
Although not a veteran myself, I've had close family ties throughout my
life. My service to the VA now makes me feel a part of this inclusive
family bond.
References
1. US Public Law 111-163 Title 38 - Subchapter IV - Research and
Education Corporations: www.navref.org/assets/1/7/1-----NPC--Auth--
Statute-----38--USC--7361-7366-Word.doc
2. VA NPC Annual Reports to Congress: http://www.navref.org/about-
our-members/va-annual-reports-to-congress/
3. The Report of the Blue Ribbon Panel on the VA-Medical School
Affiliations (quotation: pg. 3): http://www.va.gov/oaa/archive/BRP-
final-report.pdf
4. VA Research Advances: http://www.research.va.gov/pubs/docs/
VAResearchAdvances2015-16.pdf and VA Research Topics: http://
www.research.va.gov/topics/
5. 2015 VERA Book: https://commissiononcare.sites.usa.gov/files/
2016/01/20151116-13-Veterans--Equitable--Resource--Allocation--VERA--
1025--Briefing--Book.pdf
6. NIH Grants & Funding: https://www.nih.gov/grants-funding
7. NIH Grants Policy Statement: http://grants.nih.gov/policy/
nihgps/index.htm
a. 17.3 VA-University Affiliations: http://grants.nih.gov/grants/
policy/nihgps/HTML5/section--17/17.3--va-university--affiliations.htm
b. 17.6 Allowable and Unallowable Costs: http://grants.nih.gov/
grants/policy/nihgps/HTML5/section--17/17.6--allowable--and--
unallowable--costs.htm
8. VHA Handbook 1200.17: http://www.navref.org/about-our-members/
npc-statute-and-vha-handbook/
9. 18 U.S. Code Sec. 209: https://www.gpo.gov/fdsys/pkg/USCODE-
2012-title18/html/USCODE-2012-title18-partI-chap11-sec209.htm
Statement For The Record
Dr. Christian Kreipke
To the Subcommittee on Oversight and Investigations of The House
Committee on Veterans Affairs:
Nearly five years ago I was traveling the world sharing the results
of my research which were touted in Neurology Today as the first real
hope for a cure for head trauma. I was generously funded by both the
National Institutes of Health (NIH) and the Veterans Administration
(VA) to develop this research into a viable treatment for our Veterans
and the public, at large, suffering the effects of brain injury. I was
an assistant professor on tenure track, a VA investigator, a world-
renowned expert in the field of traumatic brain injury (TBI), had a
well-staffed laboratory, mentored students, the Chairman of the Board
of Southfield Oncology Institute (IRB), and had a very successful and
happy personal life-all the signs of success that can be achieved in
America. However, this was all stripped away from me when I started to
detect and brought to light chronic and systemic misappropriation of
government monies. Now, I am an entry level line worker at an
automotive plant without a home, swimming in debt, and involved in
multiple litigations against the very entities I am trying to protect.
In short, my payment for blowing the whistle on hundreds of millions of
dollars of grant fraud is not protection but, rather, currently total
destruction.
To explain how my life was ruined, in 2010 I was heavily immersed
in my research which sought to develop a drug therapy to alleviate the
signs and symptoms of head trauma. Additionally, I was selected by
multiple government agencies (e.g., Department of Defense, VA, NIH) to
review grants pertaining to TBI. Around the same time, large amounts of
tax payers' dollars were being requested and reallocated to develop
treatments for TBI which appears to be a national crisis affecting both
our military personnel and the general public. At this same time I
received funding from both NIH and VA to explore a novel therapy for
TBI. The mechanism to allow me to explore further research to combat
TBI was facilitated by a three way contract entered into between
myself, VA and the affiliated educational institute for VA in Detroit,
Wayne State University (``WSU'') (Exhibit A).
While engaged in research at WSU, I began to detect irregularities
in the grant procurement process-from how grants were being funded, who
reaped the benefits of the money, to even how my salary was being
determined. Specifically, I was asked by VA's educational affiliate,
WSU, to sign off on an effort report which declares to government
agencies how much time I was willing to allocate to a particular funded
project in order for the University to be reimbursed from federal funds
for my salary. I noted that I was being asked to sign off on a document
that contained erroneous information. The University was claiming that
I was allocating more time on my NIH grant than I was and,
consequently, was asking the government to reimburse more of my salary
than should be. I protested this and refused to sign off as it was not
a true reflection of my effort and represented potential grant fraud.
Two months after this I noted that grant funds from my grant were being
syphoned off to pay for another faculty member's project. This, too,
seemed blatantly wrong and I further protested this to the chair of my
department. In December 2010, after discussing some of these issues
with colleagues that sat on the policy committee at WSU I was
recommended to serve on an internal committee designed to report to the
Provost, Ronald T. Brown, any irregular policies that may be occurring
at the University. I specifically was tasked to probe the research
division. What I found was astonishing.
In the process of my review of Wayne State University's granting
practices, I discovered that a chronic issue was manipulation of effort
reports in order to obtain more money from the government to offset
salary costs of faculty. I also discovered that often money allocated
to particular projects was being used to fund different projects
without reporting this to the funding agency. I detailed this in a
report to the Provost and to the Vice President of Research, Hilary
Ratner. It was at this time that I was severely retaliated against. I
was charged with allegations of committing scientific misconduct in my
own research. Ironically, my ultimate judges in this matter were both
the Provost and the Vice President of Research who both promptly
terminated my employment at WSU and reported to NIH that I was not a
trustworthy individual.
In March of 2012, after being terminated from Wayne State on
spurious charges of scientific misconduct after I blew the whistle
regarding grant fraud, I moved my entire research project to John D.
Dingell VAMC (JDDVAMC), again, Wayne State University's academic and
financial partner. Unfortunately, the same type of retaliation
continued, leading to my termination at VA, as well. After being
exonerated twice of the same misconduct charges at VA, a third inquiry
was undertaken that ultimately led to an Administrative Investigative
Board (AIB) and pronouncement of my guilt at VA, too. It should be
noted that WSU inserted its influence in that inquiry and AIB members
wore two hats, being faculty or even Deans at WSU in addition to VA
employees. Furthermore, the new Chief of Staff at the time, Scott
Gruber, was also a Dean at WSU's medical school.
To now focus on, specifically, the VA involvement in this
situation, through my own investigation of my grants and those that I
had access to through grant review, I detected the following grant
disparities which occur through partnering of VA medical centers with
affiliated Universities:
1). Inappropriate sharing of funds between VA and the affiliate
without proper oversight. Upon comparing my VA grant expenditures to my
NIH grant expenditures I noticed that the vast majority of my VA grant
was going directly to Wayne State University (Exhibit B), supposedly to
pay for faculty and personnel at Wayne State that would contribute to
my VA grant project. There were two fundamental problems, here. First,
those same personnel were being paid by my NIH grant and/or University
start-up funds and, second, many of these people never contributed to
my VA project. In one case, there was a ``ghost employee'', or someone
who I was not even sure who it was. Obviously, Wayne State should not
have been receiving VA funds for these people as they were,
essentially, ``double-dipping''.
2). Allegedly falsified effort reporting. I also noted that effort
was being manipulated by several individuals in order to allow those
individuals to compete for other grants without exceeding 100% effort
or in some cases disregarding time and effort standards altogether. As
recently as my pending trial in front of the Merit Systems Protection
Board (MSPB), it was revealed through the course of testimony that the
administration at JDDVAMC arbitrarily manipulated my effort on a
currently funded grant in order to make the math work on me having two
projects at once. In fact, through my grant reviewing efforts, I
discovered that this is, in fact, common practice. As an example I have
included a biosketch of a VA-funded researcher at University of
Pittsburg, Edward Dixon, who is Principle Investigator on numerous
grants which, conceivably, it is impossible that he could devote
physical effort to all of these projects, yet he is receiving salary
support for each (Exhibit C).
3). Inappropriate sharing of equipment and payments for this
equipment between VA and the affiliate. Furthermore, Wayne State
University in many cases charged VA for use of its space and equipment
even when, in some cases, the very equipment being purchased is being
purchased by VA funds. Thus, Wayne State not only benefits from
receiving VA-funded equipment, but also receives direct funds from VA
to utilize this equipment and/or the space that houses the equipment.
It should also be noted that in many of the same cases this space and/
or equipment, is also being charged to NIH and, thus, the government is
paying twice for the same item while the University is reaping in the
government funds.
4). ``Improper influence'' \1\ of the Affiliate over VA. Also
astonishing was what I discovered about oversight of VA grants. I
discovered that Wayne State University provides research and monetary
oversight over JDDVAMC using Wayne State personnel, many of which are
both Wayne State and VA employees. Thus, the VA had little control over
how research is conducted or how research money is being processed as
the oversight is conducted by and through Wayne State University, the
affiliated University, which receives a significant portion of the VA
funds. It is through this affiliate oversight and influence over the VA
that another chronic problem emerges. Contracts with individual faculty
that share University and VA appointments are negotiated chiefly by
University personnel or by those VA personnel that also have
appointments with the University. In fact, as pointed to above, the
Chief of Staff at JDDVAMC, Scott Gruber, is a Dean at WSU's medical
school. This allows for a broad range of salaries to be paid via VA
funds to supplement University salary (e.g., in excess of $155,000 per
year for just the VA portion of an individual's salary), none of which
conform to any VA policy, let alone to any general schedule (GS)
standards. These potentially fraudulent practices are not limited to
Wayne State University/JDDVAMC, but, rather, are ubiquitous throughout
the nation.
---------------------------------------------------------------------------
\1\ See Mithen v. Department of Veteran's Affairs. Of note, this
case involves similar "improper influence" of Universities over VA.
---------------------------------------------------------------------------
What steps were taken to try to rectify these troubling grant
practices? After discovering these allegedly illicit practices which
not only waste tax payers' resources but also divert funds that are
supposed to be used to help discover cures for disease and infirmity, I
first reported to my superiors. At Wayne State I reported to first my
chair and then to the Provost. At VA I reported many of these
irregularities through a series of administrative Grievances filed
against the Medical Center Director, Pamela Reeves, and other VA
personnel. What was the outcome? My report to the Provost at Wayne
State was, in the words of the Provost's assistant, ``deep-sixed.'' My
Grievances were either ignored or summarily dismissed by Pam Reeves,
the very person being grieved. I also brought my allegations to both
administrators at HHS and the VA IG. They were largely ignored or
referred back to the very people that ignored them initially. Even at
the highest levels, my Grievances were ignored. Robert Petzel, former
Undersecretary of Health, chose not to address the problems that I
raised in the Grievances. Further, Douglas Bannerman, former Research
Misconduct Officer for the VA, admitted, under oath, that he was aware
of my Grievances yet did nothing. As what happened to me in WSU, I was
likewise retaliated against and terminated by VA by a panel stacked
with members that have clear conflicts as further discussed above.
To address my wrongful termination at WSU, I had no choice but to
file lawsuit. Currently, my False Claims lawsuit against Wayne State is
pending cert. from the Supreme Court of the United States of America.
(By way of background, the current laws governing the False Claims
action are interpreted differently across circuits as to whether or not
Wayne State can be sued based on its status as a ``State-
Institution''.). To address my wrongful termination by VA, I filed an
appeal, which is currently being tried through the MSPB. I continue to
be retaliated against even pending the outcome of this trial.
Despite heroic efforts by Congress to protect whistleblowers, does
the VA still engage in retaliation for blowing the whistle? Yes. I feel
it is important to also illustrate to you the level at which the VA
continues to retaliate against those that blow the whistle, which is
the subject of my MSPB claim. While at the VA, and after making my
disclosures of grant fraud at Wayne State University, JDDVAMC's
affiliate, I was charged and found guilty of scientific misconduct
despite there being little to no evidence which suggests that I
committed any misconduct. In fact, previous to VA being aware of my
disclosures, I was found not guilty of misconduct. It was only after
they were made aware of my disclosures of grant fraud that a third
investigation against me was conducted which, again, was run by VA
employees who had Wayne State appointments as stated above.
During the course of this investigation VA personnel took my
computers (even though they admitted that no evidence was located on
these computers) and accidentally erased all of my data which
completely eradicated my ground-breaking research. I was subjected to
being warehoused in a small office with two other individuals that
often exceeded 90 degrees Fahrenheit. My phones were routinely
monitored. My emails were routinely hacked. My due process rights were
trampled on. My salary was reduced. I never received salary from a
grant that I was on despite JDDVAMC receiving the funds to cover
salary. I was stripped of my union representation. I was harassed by
multiple VA personnel. I was taken out of the building by police escort
in front of my colleagues and forced to go on paid leave (which further
crippled my research mission). Further, my personnel, who supported me
in testimony, were terminated despite my grant continuing to be funded.
To meet their retaliatory end, VA personnel ultimately fired me and
banned me from VA service for 10 years (which is outrageous even if I
had committed misconduct, especially in light of the lack of punishment
for so many VA administrators who did manipulate data with regards to
wait times). Even the current MSPB trial has been met with great
challenge at the hand of VA personnel. For example, VA agreed to
mediation in settling this matter only to go on to show a lack of good
faith by not proffering any reasonable offer. This added unnecessary
time to the MSPB proceedings. Dennis McGuire, Chief Counsel to VA,
taunted me after one of their witnesses stated that VA routinely
changes effort in order to facilitate other grants, stating that he
welcomes me to file a lawsuit against the VA for grant fraud.
Furthermore even Robert McDonald, Secretary of the VA, attempted to
strip me of my due process rights by, through his lawyers, submitting a
motion to essentially attempt to block my ability to exercise my rights
through the MSPB. So currently, instead of putting my talents to
finding a cure for TBI I am sorting and balancing tires for pickup
trucks twelve hours a day. To add insult to injury, during the course
of my current trial, this matter was raised and Counsel for VA, Amy
Slameka, objected stating that I should not complain since a line job
is not a bad job. While I will not comment on the degree of
satisfaction of my current job, certainly we can agree that I did not
go through nearly twelve years of University coursework and training to
work in an entry level position at a fraction of my previous salary.
To further illustrate the extent to which retaliation is the modus
operandi of VA administrators, the retaliation against me is not
limited to just me. My colleague and former student, Justin Graves,
refused to condemn me when he was called to be a witness in the
investigation into scientific misconduct. Further, he called into
question the Administrative Investigation Board's conduct (which
included stripping him of his union rights) and within weeks he was
fired. Now Mr. Graves is involved in a separate MSPB lawsuit which has
languished on for over two years now. He too has been humiliated and
stripped of his career trajectory. Thus, despite the efforts of
Congress to establish laws that protect whistleblowers, regrettably
these laws do not dissuade VA personnel from engaging in what appears a
chronic culture of retaliation.
How does one fix this systemic problem?
Now that I have illustrated not only how University/hospital
affiliates exert undue influence on the VA which often leads to waste
and gross mismanagement in hundreds of millions of dollars of VA funds
and after articulating my personal case of how the VA continues to
engage in Kafkaesque retaliation to those that are compelled to blow
the whistle on such schemes, I would be remiss in not acknowledging
that this otherwise dismal situation can be fixed. First, the lines
that University affiliates have so blurred need to made clear again.
Proper policies that make clear the dissemination of resources need to
be put into place to protect the VA mission and resources from being
squandered. Second, oversight needs to be placed back into the central
authority of the VA and not entrusted to Universities which often have
self-interests that may conflict with the ethics and standards of VA.
Third, proper oversight of all government granting agencies needs to be
centralized such that redundancy and overlap in resources and effort
are mitigated. With these and other measures, the ever-encroaching
cancer that infects the otherwise beneficial mission of the VA can be
excised. As for the whistleblower, VA administration must shed the
current culture of treating whistleblowers as the enemy that needs to
be crushed and try to understand that the vast majority of us are
trying to help a broken system. Regrettably, currently even the
Secretary of VA seems to want to live in a fantasy world where making
excuses for what the nation sees as systemic problems is the way to fix
the VA, while many of us are begging for the eyes to be open and to be
transparent to systemic problems that CAN be fixed before the entire VA
is reduced to mere ruins.
In closing, I discovered hundreds of millions of dollars of grant
fraud (billions if one includes institutions in addition to Wayne State
University and JDDVAMC) which deplete government funds, including those
earmarked for the VA. Much of this fraud is related to the lack of
oversight of grant funds to the VA and, more broadly, to the affiliated
Universities. When I reported this I was met with extreme retaliation
leading to my current dismal situation.
However, as I still have complete faith in my country, my
government, and my government institutions, I do believe this tragedy
is still capable of being fixed. I also believe that many of the
aspects that make this Great Nation were accomplished through great
personal sacrifice. Though I have made this sacrifice and have been
annihilated by the VA, I am still committed to helping in any way that
I can to fix this problem. With appropriate oversight, clear separation
of duties between the VA and its affiliated University/Hospital, and
proper provisions to assure accountability of those receiving
government funds, VA's commitment to finding cures for diseases and
injuries can be achieved. As our country faces ever increasing health
problems, whether it be cancer or head trauma or new issues such as
Zika virus, I still firmly believe that government-funded research
holds the answer to cures to overcome the adversity associated with
these medical issues.
I thank you for your due diligence in investigating this matter, I
thank you for allowing me the opportunity to bear witness to my
situation as being a representative of a more chronic dilemma, and I
thank you for serving our country in its efforts to protect the
American People. Once again, please feel free to call on me to assist
in any way that I can in fixing this problem so that the VA and other
government institutions can more efficiently and more effectively treat
medical complications.
Respectfully Submitted,
Dr. Christian Kreipke
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