VA Testimony of Elwood Headley, MD before Congress on March 22, 2004

United States Department of Veterans Affairs

STATEMENT OF
ELWOOD J. HEADLEY, M.D.
NETWORK DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK (VISN) 8
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE BAY PINES FIELD HEARING
U.S. SENATE VETERANS AFFAIRS COMMITTEE

March 22, 2004

Mr. Chairman and Members of the Committee, I appreciate the opportunity to appear before you today to discuss veteran healthcare in Florida. The areas I would like to address are:

An overview of VISN 8;
Patient access and waiting times;
Budget;
Quality of Care; and
Patient Satisfaction.

I will primarily discuss these issues from a VISN perspective and will defer to Mr. Smith Jenkins, Director of the Bay Pines VA Medical Center, for issues related to the state of healthcare at the Bay Pines facility. Mr. Jenkins, along with Mr. Bill Campbell, VA Assistant Secretary for Management, will address specific issues related to VA’s Core Financial and Logistical System, known as CoreFLS.

VISN 8 Overview

VISN 8 is presently the largest of VA’s 21 healthcare networks, treating in excess of half a million veterans annually with an enrollment of approximately 650,000. VISN 8 employs a workforce of 16,150 full time equivalent (FTE) employees with an operating budget of approximately $2 billion in fiscal year 2004, including $150 million in revenue from first and third party collections. Workload consists of 4.7 million outpatient visits, 50,000 inpatient admissions and an average daily census of 2,200. VISN 8 delivers care through seven hospitals, eight nursing homes, two domiciliaries, ten multi-specialty clinics and 35 community based outpatient clinics (CBOCs) throughout Florida, South Georgia, Puerto Rico and the U.S. Virgin Islands.

Patient Access and Waiting Times

Over the past five years, VISN 8 has experienced unprecedented growth in veteran users of our health system. This is largely due to the influx of veterans relocating to Florida in their retirement years and the establishment of the VA’s national enrollment system. In fiscal year 1999, approximately 289,000 veterans received care within the Florida/Puerto Rico Network. In fiscal year 2003, that number grew to 492,000 with VISN 8 providing healthcare to more veterans than any other network in the country. The demand for healthcare continues to grow in 2004 with workload projections that indicate over 538,000 veterans will receive care by the end of this fiscal year. CARES data also projects that workload growth in Florida will continue to escalate in the future, peaking with an increase of 18% in 2012 and slowing to an increase of 6% in 2022, over the baseline workload year of 2001. The Bay Pines VA Medical Center is an example of this phenomenal growth. Bay Pines’ workload increased from 42,000 in 1999 to 85,000 in 2003.

Due to the tremendous growth in workload, VISN 8 began to experience a growing number of new patients waiting to obtain scheduled appointments in 2001. In an effort to improve access, VISN 8 assisted VHA with the development and pilot of an electronic waiting list to track new patients and monitor progress. Improving access while maintaining quality of care continued to be the highest priority in VISN 8. While we still have room for improvement, we have made significant progress in this area. We have hired over 1,380 FTE in support of patient care, shifted resources to higher priority areas, increased physician panel sizes, and established Saturday and evening clinics where possible.

Due to these efforts, VISN 8 has reduced the number of new enrollees awaiting primary care appointments from 50,000 in June 2002, to 1,887 in February 2004. (This includes both patients awaiting a first appointment as well as those with a scheduled appointment greater than 180 days into the future). All of the original veterans on the waiting list have been seen, and service-connected veterans greater than 50% continue to receive priority care within 30 days.

Each VISN 8 facility has made great strides in improving access. For example, the Bay Pines VA Medical Center reduced new enrollee waiting lists from 16,600 in June of 2002 to 308 in February 2004. The medical center added approximately 140 FTE over the past three years to improve access. They have also implemented many of the industry-recognized principles of Advanced Clinic Access to increase efficiency.

Although we recognize our tremendous accomplishments in getting new patients seen and triaged by providers, these actions have increased demand and subsequent waiting times for specialty care in VISN 8. This is most acutely felt in those specialties that are difficult to recruit and retain due to VA’s present physician salary limitations. VHA currently measures the waiting times of five outpatient specialty clinics. These are audiology, cardiology, eye care (ophthalmology and optometry combined), orthopedics and urology. VISN 8 has a total of 3,881 patients waiting over 180 days for appointments in these five specialties, with the majority being in audiology and eye care. This has decreased from 16,965 in January of 2003. It should be noted that all veterans with urgent needs, either in primary or specialty care, are immediately scheduled an appointment and provided care.

VISN 8 is aggressively working to improve access to all specialty care through improved efficiency, patient throughput, recruitment of additional physicians as possible within VA salary limitations, new technology and equipment, telehealth and alternative delivery systems, VISN and medical center contracts with our affiliates, community and fee basis providers.

Budget

We would like to thank this Committee and the Members of Congress for recognizing the workload demands placed on our system by enhancing VA’s budget in 2004. VISN 8 continues to benefit from these budgetary increases. As the veterans have migrated to the south and southwest, the funding has also shifted. In 2004, VISN 8 will receive nearly $2 billion in general purpose funding for its full workload distribution. The Bay Pines medical center experienced an increase of 43% in general purpose funding from 1999 to 2003.

With anticipated collections of $156 million in fiscal year 2004, VISN 8 has placed great importance on generating external revenue to supplement the appropriated budget and provide care to more veterans. Bay Pines is one of the best performers in terms of generating external revenue, collecting approximately $28 million in 2003.

Systematic Review of Quality of Care

Through our governance structure and senior leadership at each medical center, VISN 8 systematically reviews quality of clinical care and ensures communication and deployment of clinical policies, plans and strategies. We strive to standardize clinical practice and reduce variability in care wherever possible, as well as stay abreast of emerging technology and changing patient requirements.

We currently have ongoing review and improvement efforts in the following key areas of clinical care: primary care, cardiac care, mental health, acute and specialty services, women’s health, care coordination including telemedicine and telehealth, extended care, patient safety and pharmacy.

The quality of care throughout the network is consistently monitored using national benchmarks through organizations such as the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), Commission on the Accreditation of Rehabilitation Facilities (CARF), National Committee for Quality Assurance (NCQA), VA’s National Surgical Quality Improvement Program (NSQIP), and VA Continuous Improvement in Cardiac Surgery Program (CICSP).

Current VHA performance measures include numerous measures of clinical performance in our most significant areas of disease management and preventive health related to veteran healthcare. These include cancer screening, diabetes, cardiovascular care, mental health, infectious disease care, and tobacco cessation. VHA currently sets the benchmark when compared with the private sector on 18 of 18 measures available for comparison. Likewise, VISN 8 also consistently outperforms the private sector and is above the VHA national average on many indicators.

Patient Satisfaction

Even though workload in VISN 8 has increased significantly over the past several years, patient satisfaction has continued to remain high. VA measures both outpatient and inpatient satisfaction on a quarterly basis. The most recent results from the third quarter of fiscal year 2003 are as follows.

Outpatient Satisfaction: Outpatient satisfaction results indicate veterans rate their overall satisfaction with VISN 8 facilities at 77%, three points higher than the national average of 74%. Bay Pines results are among the best in the VISN at 80%, ranking second behind Tampa at 82%.

Inpatient Satisfaction: VISN 8’s overall inpatient satisfaction is 77%, which is also greater than the national average of 73%. Bay Pines ranks the second highest in the Network on inpatient satisfaction at 78%, slightly lower than Tampa’s score of 82%.

All VISN 8 facilities continue to strive to improve patient satisfaction and customer service.

Summary

In summary, VISN 8 has experienced tremendous workload growth over the past five years. While we acknowledge access issues have developed due to the influx of veterans into Florida, we are diligently working to keep pace with the demand placed on our system in both primary and specialty care. Our progress has been facilitated by recent budget increases as well as enhancements to our internal revenue generation processes. VHA’s established measures of quality indicate VISN 8 is providing quality care with above average customer satisfaction. Access, quality and customer satisfaction remain our highest priorities in VISN 8.

Thank you, Mr. Chairman. That concludes my formal remarks. At this time I would like to entertain any questions the Committee Members may have.