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Office of Public and Intergovernmental Affairs

Remarks by Secretary Robert A. McDonald

American Medical Association’s House of Delegates Interim Meeting
Dallas, Texas
November 8, 2014

Thank you, Dr. Wah. And thank you for your many years of service to Navy medicine. We at VA often tell employers that Veterans never stop serving. Dr. Wah is an example of that—23 years of service in the Navy, 17 years as a member of the House of Delegates, a year as chair of the AMA Board of Trustees, and now AMA president.

Let me also thank Dr. Gurman, Speaker the House of Delegates, for the invitation to be here today, and the rest of the AMA’s leadership, including Dr. McAneny and Dr. Madara, for your support for and help in drafting the Veterans Access, Choice, and Accountability Act of 2014. I’ll have more to say about the Act later.

Distinguished members of the House of Delegates, ladies and gentlemen:

As the principal policy-making body of the Nation’s largest medical association, you know that the Department of Veterans Affairs is in the midst of overcoming problems involving access to healthcare. We own them, and we’re fixing them.

But I know you also know that VA has a legacy of excellence, innovation, cutting-edge research, and achievements in healthcare delivery that is as broad and historically significant, as it is profound—and often unrecognized.

There’s something else. Right now, VA has before it perhaps its greatest opportunity to enhance care for Veterans in its history.

Others know that truth as well. Last July, Sloan Gibson—VA’s Deputy Secretary, my West Point classmate, and a friend for almost 40 years now—met with Harvey Fineberg, distinguished clinician and healthcare leader. When Sloan commented that VA could accomplish more in the next two-to-three years than we could have in two-to-three decades, Dr. Fineberg immediately corrected him: “No!” he said, “VA can accomplish things now it never could have accomplished!”

He’s right: We’re in an extraordinary position. We have an opportunity to not only right wrongs, but to re-frame perceptions about VA by lengthening our lead in areas where we’ve always excelled, taking the lead in service delivery areas that are lagging, and charting new ground in emerging or evolving areas of healthcare.

The problems we face are serious. The President, Congress, Veterans service organizations, taxpayers, and VA’s rank and file all understand the need for immediate reforms to achieve the three non-negotiable goals we set for ourselves more than two months ago:

  • Rebuild trust with Veterans and stakeholders,
  • Improve service delivery, focusing on Veteran outcomes,
  • And set a course for long-term excellence and reform.

Toward that end, I’ve been on the road, traveling to 41 VA facilities in 21 cities; meeting w/ hundreds if not thousands of Veterans, VA physicians and other employees, VSOs and other stakeholders; and discussing the issues with Members of Congress, VSOs, unions, and myriad other partners. Based on what we’ve heard—and the lessons I’ve learned about mission-driven corporations, strong institutional values, and good management practices during my 33-years at Procter & Gamble—we’ve wasted no time in developing a healthcare “Blueprint for Excellence.”

This blueprint is critical to achieving the third of our nonnegotiable goals—setting a course for long-term excellence and reform. The Blueprint lays out four broad themes and supporting strategies for transformation.

First, we must improve the performance of healthcare NOW. There’s a lot at stake: We deliver 240,000 episodes of care each day—more than 90 million scheduled appointments in 2013 alone. And we perform 400,000 surgical procedures annually—nearly 1,100 per day.

Second, it’s imperative that we re-set VA’s culture to put a high premium on job performance and the strong VA institutional values that support it—Integrity, Commitment, Advocacy, Respect, and Excellence. These attributes go to the heart of our mission and dictate how employees act, relate to Veterans and each other, and treat the 6.5 million unique patients we see each year. By “living” VA’s core values, we can go a long way toward overcoming the challenges before us.

Third, VA must transition from “sick care” to “health care” in the broadest sense. Many of you are already putting more stress on prevention and healthy living, consistent with the AMA’s strategic focus on “improving health outcomes,” which targets preventable diseases like heart disease and type 2 diabetes. VA needs to do more of the same, helping Veterans take charge of their own health.

Fourth, we must develop efficient, transparent, accountable, agile business and management processes to support the span of care, services, and programs we deliver.

Above all, it’s imperative that VA regain and retain a laser focus on its customer base—that means everyone from the 90-year-old Veteran who crossed Omaha Beach, to the 19-year-old who battled insurgents in Afghanistan’s “Valley of Death.”

That said, VA’s vision for change is not only Veteran-centric, but Veteran-driven—putting our customers in control of their VA experience. The healthcare industry, itself, is moving toward a more customized, consumer-centric version of primary care access.

At VA, the challenge is a more complicated because heathcare is just one of nine VA lines of business—the others being benefits like life insurance, mortgage insurance, education, pensions, disability compensation, and memorial affairs.

Our solution to the patient-experience challenge is called MyVA. We call it MyVA because that’s how Veterans should view us—as an organization that belongs to them and provides quality care in the ways they need and want to be served. MyVA means:

  • Shaping VA through a better understanding of Veterans’ needs and preferences.
  • Providing a single-entry, user-friendly access so they can effortlessly navigate VA care and services.
  • Removing cumbersome processes and procedural obstacles that frustrate users.
  • Providing the full spectrum of resources—financial, human, and otherwise—to serve them efficiently and effectively.
  • And, last, empowering employees at the lowest level possible to respond and react quickly and knowledgably to Veterans at each point of interaction.

To do this, we’re looking at ways to restructure and reorganize, combine functions, simplify operations, make process improvements, leverage technology, and enhance efficiency and productivity. It’s a 360-degree effort designed to present Veterans with a seamless, integrated, and responsive VA—no matter whether they come to us digitally, by phone, or in person.

Our goal is simple: Provide quality medicine and first-rate healthcare delivered with the same proactive, real-time, courteous, coordinated service as the top-ranked customer service companies in the country.

The fact is, VA already has that type of service excellence in many areas. For the past decade, the American Customer Satisfaction Index, the ACSI, has ranked VA’s National Cemetery Administration as the top customer-service organization in the Nation—public or private. Better than Google, Lexus, and all the rest.

And since 2004, the ACSI has consistently shown that Veterans receiving both VA inpatient and outpatient care give VA higher satisfaction ratings than patients at most private hospitals. With the right strategies and enough support, there’s no reason why we can’t scale that performance excellence VA-wide.

Right now, one of the biggest challenges we face is the shortage of physicians and other healthcare professionals. It was an underlying reason for the problems that occurred in Phoenix and elsewhere.

And that’s why, as part of a national recruitment effort, I’ve gone to 11 of the Nation’s medical and nursing schools—Duke, UC Davis, UC San Francisco, Dartmouth, University of Vermont, Johns Hopkins, Howard, Morehouse, Massachusetts General, and a few others—to personally tell students about VA’s great mission and encourage them to join a revitalized Team VA in caring for those who defend us. Audiences everywhere have been welcoming and interest is high.

Here’s what I tell them: At VA, we have the most inspiring mission in government and the best clients in the field of healthcare—great reasons to work at VA.

Beyond our noble and respected mission, and the exceptional people we serve, VA offers practical reasons to work for Veterans.

  • The Veterans Access, Choice, and Accountability Act, or “Choice Act,” which the AMA helped write, increased VA residency positions by 1,500.
  • It also doubled the amount of our education debt reduction payment—from $60,000 to $120,000!
  • VA also offers recruitment, relocation, and retention incentives.
  • And, as part of the drive to recruit the best and brightest, we’ve eased the pay disparity with the private sector—always an issue—through salary increases for VA’s physicians and dentists.

     

The demand for VA care will not decrease any time soon. The Nation’s been at war for over a decade, and we’ll continue to be caring for many of our severely wounded and ill Veterans for decades to come, if not a lifetime.

In a still recovering economy, the number of Veterans seeking our services continues to grow steadily, and we continue to serve a population that is older, with more chronic conditions, and less able to afford care in the private sector.

The Choice Act goes a long way toward enabling VA to meet the current demand for care, and to support the large-scale reforms we’re making for long-term excellence. The law provides $5 billion to hire more physicians and other medical staff, and $10 billion to fund additional purchased care while building internal capability.

As most of you know, VA has always sponsored non-VA care in extraordinary circumstances, like geography, where rural Veterans can’t easily get to a VA facility; technology, where it makes sense to refer Veterans elsewhere for highly specialized procedures; and to cover temporary shortfalls in staffing and other resources.

We recently stepped up the use of purchased care to respond to the shortfalls that came to light last spring. From mid-May through September, VA authorized non-VA care for over one million Veterans—46 percent more than in the same period last year.

Now, with funding from the Choice Act, we are taking purchased care to a new level with our new Veterans Choice Program.

Just this week, we began phased implementation of the program: We stood up a special call center to verify eligibility and answer questions about the Veterans Choice Program. The number to call is 1-866-606-8198. We have also begun extending the option of purchased care to eligible Veterans who live more than 40 miles from a VA facility, and in the coming month, we’ll do the same for those who have been waiting too long for an appointment. By “too long,” I mean more than 30 days from the clinically appropriate date or the date preferred by the Veteran—that’s our new standard.

In a few months, every Veteran enrolled for VA healthcare will have a new Veterans Choice Card, to use for authorized non-VA care in the future, should they need it. The first Choice Cards were mailed out this week. The Veterans Choice Program can be a big part of the solution to our current access problem, but the new law is extremely complex, and we need to make sure we get things right.

Fragmentation of care could become a problem as Veterans move back and forth between VA and the private sector. We need to make sure Veterans are cared for by physicians fully knowledgeable of their medical history, that they get the screening and preventive care they need, and that VA and private-sector providers don’t duplicate services unnecessarily. So we need to configure the Choice program in a way that enables all of the doctors caring for a Veteran to work together as a team, no matter who’s paying the bill.

We’re also working to make seeking and receiving purchased care as easy as possible for both Veterans and physicians. We need you to participate in the program, and we know you won’t if it’s too much trouble. The same is true of Veterans: They need to know that their care is authorized by VA and that they’ll get the care they need. If they don’t, they may resist going outside VA and put off being seen.

For those reasons, we have signed contracts with two healthcare companies with experience running similar programs—TriWest and HealthNet—and we’ll be working with them to administer the Choice program in the best way possible.

Purchased care is not a replacement for a strong and vital Veterans’ healthcare system. Veterans need VA, and Americans everywhere—indeed the global community—benefit from VA.

  • From VA research leading to major breakthroughs and advances in medical science and care—like the licensing of the shingles vaccine as a result of a VA Cooperative Study;
  • From VA training 70 percent of America’s physicians—62,000 medical students and residents, 23,000 nurses, and 33,000 other health professionals—each year.
  • And from VA’s highly specialized knowledge and know-how to deliver clinical and rehabilitative care to those who have “borne the battle.”

But VA cannot accomplish its healthcare mission as a stand-alone system. It is naturally and appropriately part of the larger healthcare community, facing the same challenges many of you face, and benefiting as you do from exchanges of expertise and from the movement of patients and providers within the community.

The growth in purchased care sets the stage for re-envisioning new relationships and reenergizing existing partnerships between VA and the private sector—as well as other parts of the public sector—for better care, better health, and better value.

Purchased care addresses some of VA’s current problems, but, as important, it opens the doors to other transformative aspects of patient care. In care coordination and interoperability, for example—challenges common to both public- and private-sector healthcare providers.

If VA and private providers are caring for the same Veteran-patient, we’re in a position to collaborate, to share information and knowledge. There’s a potential to leverage improvements in electronic health records by developing a public-private platform and infrastructure to generate new ways of using patient information and data, new ideas, new approaches, and new solutions for better patient care.

Increased purchased care also has the potential for increasing high-value care—particularly in reducing medical waste and redundancies. Here again, because we’re working in tandem, there’s practical, real-time opportunity to ask ourselves, “How do we prevent costly redundancies in x-rays, MRIs, blood tests, and countless other tests?”

More than that, asking, “How do we reduce unnecessary testing, period?” It gives us the opportunity to tackle these types of issues and develop answers and solutions that have import across the medical community.

It all comes down to what Dr. Fineberg said—we have an unique opportunity before us at VA to “accomplish things now [we] never could have accomplished.”

Employees across the Department have rolled up their sleeves, and work is underway to make the changes to VA systems, procedures, and culture that the law requires. We’ve done a lot, but there’s a lot left to do if we’re to right the wrongs, institute reforms and employee accountability, modernize, and recruit the numbers of healthcare professionals we need. We are committed to doing the right thing—delivering the right programs, in the right way, at the right time, for those special Americans we serve.

As we go forward, one thing’s clear. VA cannot do what needs to be done, and accomplish its goals, without a full complement of partners—public, private, and volunteer. We don’t have all the answers. We can’t operate in a vacuum—no 21st century organization can. That’s why we’re aggressively leveraging our existing relationships and affiliations, and forging new ones. Here are a few examples:

  • VA’s partnering with the Institute of Medicine in a study of access standards and wait-time metrics.
  • We’ve entered into a first-of-its-kind partnership with Walgreens to provide vaccinations to Veterans—Walgreens will share its immunization records with VA to ensure we have complete patient medical records.
  • We’re collaborating on a new nursing academic partnership focused on psychiatric and mental healthcare—a key area of care for VA and for DoD.
  • We’re partnering with DoD to improve recruitment of recently or soon-to-be discharged military healthcare professionals.
  • We’re expanding a pilot program to bring combat medics and corpsmen into VA facilities as clinicians.
  • We’re partnering with the Northern Virginia Technology Council to establish a pro-bono technology task force to review VA’s scheduling system and make recommendations for improvement.
  • We’re setting up a consulting Board of Physicians—comprising the foremost medical minds in the Nation—to advise me on industry best practices.

In my three months at VA, one thing stands out as I’ve traveled around the country—the goodwill and support shown by the medical community to VA, its mission, and its achievements. Harvey Fineberg, Jonathan Perlin, Ken Kizer, Navy Surgeon General Matt Nathan, Morehouse President Valerie Montgomery Rice, your own Executive Vice President Jim Madara, and so many others from both the public and private sectors, have all expressed their willingness to publicly speak out and “right the record” in telling the VA story.

We’re taking advantage of their offer. Right now, VA’s in the process of creating a VA Alumni Group—a “Friends of VA” committee of sorts. Our thought is to gather interested leaders in medicine and the healthcare industry, brief them regularly on VA operations, initiatives, and performance, and solicit their input and assistance.

One of our objectives is to insert a degree of balance and truth to the one-sided conversation about VA care and services. You can help with that. You can share with colleagues and laypersons your positive experiences working with VA and your professional perspective on the challenges VA and other healthcare providers face.

So I’d like to invite you to consider becoming a part of this initiative. We want and need your professional advice. We seek your input as we move forward in implementing the Choice Act. We welcome your participation and collaboration across the spectrum of care.

Once again, thanks for this important opportunity to speak this afternoon, and for your support for the Nation’s Veterans. I look forward to working with you to improve healthcare for Veterans and all Americans.

Thank you.