May 15, 2015
As far back as 1998, The American Legion began expressing concerns regarding VA physicians and medical specialists staffing shortages within the Veterans Health Administration (VHA). This was accomplished by monitoring the progress in establishing patient centered primary care within each Veterans Integrated Service Network (VISN), including both rural and urban localities as well as ensuring that the model of care features both the quality and efficient combination of medical physicians and other medical specialists that are tailored to the needs of the local veteran’s population.
From the inception of The American Legion’s System Worth Saving (SWS) Program in 2003, to its transformation to the Veterans Benefit Centers (VBCs) in 2014, The American Legion has tracked and reported staffing shortages at every VA medical facility across the country and submitted those to Congress, VA Central Office (VACO), and to the President of the United States. Through numerous SWS hospital site visits, and now regular VBC visits, The American Legion has dedicated considerable resources to monitoring the Veterans Health Administration (VHA) healthcare system.
Unfortunately, there are no easy solutions for VA when it comes to effectively and efficiently recruiting and retaining medical staff to treat the growing number of veterans that are entering the VA healthcare system. The American Legion believes that access to basic health care services offered by qualified primary care providers should be available locally as often as possible. VHA is still struggling to achieve the appropriate balance of primary care and medical specialists across the country.
In 2004, The American Legion urged the VA to develop an aggressive strategy to recruit, train, and retain advanced practice nurses (APN’s), registered nurses (RN’s), licensed practical nurses (LPN’s), and nursing assistants (NA’s) to meet the inpatient and outpatient health care needs of veterans. The Legion fully supports VA’s education-assistance programs for APNs, RNs, LPNs, and NA’s. We also urged VA to provide equitable and competitive wages for Advanced Practice Nurses (APNs), Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and nursing assistants.
The American Legion has also studied the problems faced by veterans who reside in rural areas. Rural veterans struggle to find timely and quality VA health care that meets their individual health care needs. VA medical centers in rural areas have concerns regarding recruiting and retaining qualified medical and clinical providers as a result of not having the ability to offer attractive resources for these professionals to live and practice in rural communities. In The American Legion’s 2012, SWS Report on Rural Healthcare, The American Legion found that:
“[Department of Veteran Affairs Medical Centers (VAMCs)] in rural America, recruitment and retention of primary and specialty care providers has been a constant challenge. Some clinicians prefer to practice in more urban settings with more research opportunities and quality of life that urban settings provide.” 
In 2014, The American Legion published a SWS report titled “Past, Present, and Future of VA Healthcare”, which noted several challenges VA still faced:
· Several VAMCs continue to struggle to fill critical leadership positions across multiple departments.
· These gaps have caused communication breakdowns between medical center leadership and staff that work within these departments.
During our 2013 site visit to the Huntington VA Medical Center in Huntington, West Virginia, we recommended that, “VHA conducts a rural analysis for hard to recruit areas and look into different options to support VAMCs in getting talent they need to better serve veterans." VHA needs to ensure that veteran health care is consistent across each Veterans Integrated Support Network (VISN).
In December 2014, The American Legion conducted a veteran’s town hall and site visit at the Mann-Grandstaff VA Medical Center in Spokane at the request of the Department’s of Washington, Idaho, and Oregon. At the town hall meeting, American Legion members and staff met with the medical center’s leadership team. Veterans from Washington, Idaho, and Oregon, all of whom use the medical center in Spokane to receive their health care, were provided an opportunity to participate in a facilitated discussion about the Spokane VA hospital to discuss the decision to reduce their Emergency Room (ER) operating hours.
According to VAMC leadership in Spokane, the ER was being closed because the facility lacked sufficient staff Emergency Room physicians to operate the ER effectively. According to the medical center director, this was due to the recent loss of ER physicians and not a cost factor. The American Legion inquired why it would take so long to hire ER physicians, and was informed by the director that there was a critical shortage of ER doctors in the Spokane area. The American Legion’s team visited several neighboring local hospitals in the area. The following information was discovered during the visits:
- Neither of the hospitals in the Spokane area were experiencing a shortage of ER doctors
- Area hospitals that were visited have existing contractual relationships with the Spokane VA to swap services, and would certainly consider revisiting that agreement to help out VA in this instance, yet these agreements had not been acted on in some time
- Area hospitals that were visited told us that if VA were to contact them, that they would have doctors who would be willing to moonlight at VA’s ER until they were able to hire the necessary staff to fill shortages
- One Medical Staff Director told us that she has had no problems whatsoever finding qualified ER doctors, and that she uses several contracting agencies that have never had a problem filling their requests. This particular director went on to say that if the contract company that VA is currently using isn’t able to provide qualified ER docs immediately, then VA should find another company immediately.
- Both hospitals said that they would be willing to work with VA to help with their staffing needs.
- Both hospitals that were visited stated that they would never consider reducing ER hours as a viable option based on the existing business climate
The American Legion met again with the Mann-Grandstaff VA Medical Center Director and senior leadership. After sharing our findings and research with them, and offering to assist and facilitate introductions or host meetings, the Mann-Grandstaff medical center ignored our suggestions and continues to have an Urgent Care Center, rather than a true Emergency Department. Originally, the center Director told us that she would be able to have the ER fully operational “by spring”, however after continued follow up by The American Legion, we now understand that the emergency room will not be opened any time before October 2015. This date is contingent on recruiting quality staff.
On January 30, 2015, the VA’s Office of Inspector General (VAOIG) released their determination of the “Veterans Health Administration’s Occupational Staffing Shortages,” as required by Section 301, of the “Veterans Access Choice and Accountability Act (VACAA) of 2014”. With this report, VAOIG determined that the five occupations with the largest staffing shortages were Medical Officers, Nurses, Physician Assistants, Physical Therapists, and Psychologists. The OIG recommended that the “Interim Under Secretary for Health continue to develop and implement staffing models for critical need occupations.” Ultimately, if the VA continues to struggle with retention and recruitment, the trend of closures (or continued closures) for multiple departments within VAMCs nationwide will continue.
With the passage of Public Law 113-146, the “Veterans Access, Choice, and Accountability Act (VACAA) of 2014”, VA was empowered to hire, and given funding to hire, more than 10,000 medical professional and staff as well as to expand their training programs within the clinical areas to meet the overall health care needs of their enrolled veterans. The Veterans Choice Act also directed VA to increase the number of Graduate Medical Education (GME) residency positions by up to 1,500, and the law extended the VA’s existing Health Professionals Educational Assistance Program (HPEAP) from December 31, 2014 to December 31, 2019. The Choice Act also doubled the maximum reimbursement ceiling for the Education Debt Reduction Program (EDRP) from $60,000 to $120,000.
In The American Legion’s 2012 SWS “Quality of Care and Patient Satisfaction” report, it was recommended that VA Central Office (VACO) should create a VHA Executive Hiring Task Force to assess the numbers of vacancies and positions with acting staff across the country and to swiftly hire these positions as permanent positions. Additionally, a policy should be developed and enforced on succession planning for hiring executive leadership and critical hospital staffing positions. We also recommended that VHA convene a hiring and tracking task force to monitor and speed up the hiring of primary and specialty care positions, as well as establish strategies to expedite the hiring of critical health-care positions such as doctors and nurses. 
The American Legion urges Congress to develop a recruitment and retention strategy to incentivize medical providers to practice in rural communities, as well as ensure that each Community-Based Outpatient Clinic (CBOC) has adequate staff and direct communication between the CBOC’s and medical center’s Rural Health Consultants (RHCs). Furthermore, The American Legion encourages the VA, specifically VHA, to allow military education, training, and experience to be considered towards a license or certification for healthcare and non-healthcare related positions that requires licenses or credentials. And finally, The American Legion urges VA to work more comprehensively with community partners when struggling to fill critical shortages within VA’s ranks. VA is FAILING in many of these areas while neighboring hospitals offer to help, yet VA remains undeterred and rebuffs assistance.
In January of this year, a veteran called the emergency room from their parking lot in Seattle Washington because his ankle was broken and he needed assistance getting inside. He was told to call 911.
The American Legion understands that filling highly skilled vacancies at premiere VA hospitals around the country is challenging. We also expect VA to do whatever legally permissible to ensure that veterans have access to the quality healthcare they have come to expect from VA. VA leadership needs to do more to work with community members and stakeholders.
As always, The American Legion thanks this subcommittee for the opportunity to explain the position of the 2.3 million veteran members of this organization.
For additional information regarding this testimony, please contact Mr. Warren J. Goldstein at The American Legion’s Legislative Division at (202) 861-2700 or firstname.lastname@example.org
 The American Legion 2012 System Worth Saving Report on Rural Health Care: http://www.legion.org/sites/legion.org/files/legion/publications/sws-rural-healthcare-report-2012-web.pdf
 The American Legion 2013 System Worth Saving Report on Huntington VA Medical Center: http://www.legion.org/sites/legion.org/files/legion/publications/SWS%20Report%202013%20-%20Huntington.pdf
 Department of Veterans Affairs, Office of Inspector General, Report No. 15-00430-103: “OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages”: http://www.va.gov/oig/pubs/VAOIG-15-00430-103.pdf
The American Legion System Worth Saving Quality of Care and patient Satisfaction: http://www.legion.org/sites/legion.org/files/legion/publications/swsreport2012_0.pdf