Thursday, May 10, 2012

The reason for the announcement






Starting with the US Congress.
US House Rep Johnson: I'm going to start off with a bit of a difficult questions. You know, year after year, in annual budget submissions, in annual performance reports, quarterly reports, Congressional testimony and in countless press releases and statements, the VA has consistently touted the 14 day standard as the number one measure of mental health care access. In a five month investigation; however, the IG found that measure to have no real value and to be essentially meaningless. Mr. Secretary, how is it possible that that's not bubbling up to your level? How is it possible that you don't know that? And who is responsible for misleading Congress and the public on this metric? And how will they be held accountable?
Secretary Eric Shinseki: Uh, Congressman, I, uh, I-I don't think,uh, anyone has, uh, misled Congress here. Doctor Petzel described three methods of, uh, identifying in the scheduling arena. Capacity, desire date, create date. We have -- They have in the mental health areana been using desire date now since 2007 and my understanding this uh goes back to when we had a previous discussion like this. Uhm, I'm not sure how the, uh, results were achieved but it just seems to me that desire date and create date in the report, uh, are brought together in a way, it's hard for me to determine, whether there was a pure assessment of whether desire date was being executed properly, whether staff were properly trained and following the instructions, that would allow us to focus on corrective actions. Right now, part of my discussion with Dr. Petzel is that we're going to sit down with the IG and make sure we come up with a clear standard here so that when we audit in the future, there isn't this confusion about which date we're uh using and we get a cleaner outcome, understanding. I'm not able to address the specifics here but I would assure the Congressman there's no misleading of Congress.
US House Rep Bill Johnson: I can certainly agree that there is no intention to do so but I think we all agree here that the objective is to make sure those veterans that request mental health counseling get it as soon as absolutely possible.
That's from yesterday's US House Veterans Affairs Committee hearing.  US House Rep Bill Johnson was questioning VA Secretary Eric Shinseki.  And it may have wrongly seemed like Shinseki answered Johnson's question.  He did not.
Johnson asked about the figures that were given.  Shinseki attempted to dispute the report from the Office of the Inspector General. He also attempts to push off his Department's problems onto the IG.  There are these different ways of measuring, Shinseki insists.
And we're supposed to say, "Goodness, that is confusing.  That mean old IG!"  But that nonsense is not from the IG.  That is the VA's nonsense.  The VA is the one that wants to bring in "desired date" and other obscuring nonsense.  The IG noted that in the cover letter -- for get the report itself -- back in April: "VHA does not have reliable and accurate method of deteriming whether they are providing patients timely access to mental health care servies.  VHA did not provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment.  As a result, performance measures used to report patient's access to mental health care do not depict the true picture of a patient's waiting time to see mental health provider."  And if Shinseki wants to object to that finding, it's a little too damn late.  As the next sentence notes, "The Under Secretary for Health conccured with the OIG's findings [. . .]"
Congress did not invent the 14% number.  The VA did.  And while Shinseki attempts to distract and pin the blame on the IG, someone whould have asked him what Johnson was originally getting at: How did the VA get this figure they promoted?
It was a false figure.  They promoted it over and over.  Please note, Shinseki rushed to assure that no one with the VA had intentionally tried to mislead Congress.  He didn't say a damn thing about their attempts to mislead the public.  But then, misleading Congress can result in sanctions.  Lying to the public is a just standard politics.
Playing with the numbers and trying to hide behind terms is not leadership.  US House Rep Cliff Stearns, while questioning the reps for the Office of the Inspector General, probably put it best, "Well, I think the bottom line is, you've said it takes 50 days to provide this roughly 200,000 veterans with their full evaluation.  That's what you're saying and that's not good and that should be changed. And I think that's -- no matter what we're talking about, a capacity desire or a create date -- the bottom line is that veterans, almost 200,000, are not getting serviced.  And the Veterans Administration can use whatever terminology and definitions they want, but by golly, these guys -- these guys and gals aren't getting taken care of.  And that's why we're here today."
Minutes before US House Rep Johnson went to his line of questioning, Shinseki was declaring, "My guess here is we're doing good work, we're just not able to document it."
Is that your guess?  Are you paid to guess or are you paid to suprevise?
The metrics have never been in place and that's not just my opinion, that's the opinon of the Senate Veterans Affairs Committee based on their own public statements in one hearing after another.  Shinseki was appointed by Barack Obama to supervise the VA.  Supervision is not a guess.  Shinseki's gotten a pass from the press from early on.  When the fall of 2009 rolled around and veterans were without GI Bill checks, when they couldn't afford housing, when this situation continued through Christmas -- as many veterans stated to the press and to Congress, their kids had to do without Christmas because they still hadn't gotten their checks for the semester they'd just completed, they'd had to borrow money to pay for that. When all of that came out, something came out with it.
Eric Shinseki admitted that, shortly after being confirmed to his post by the Senate, he was informed that there would be problems with the checks that fall.  That the system wasn't ready for it.  He knew that and Congress repeatedly asked him if there were any problems, repeatedly asked if help was needed and he said no and no and no over and over.  Then when the problem emerged, VA tried to play dumb for months.
Secretary Eric Shinseki: I'm looking at the certificates of eligibility uh being processed on 1 May and enrollments 6 July, checks having to flow through August. A very compressed timeframe. And in order to do that, we essentially began as I arrived in January, uh, putting together the plan -- reviewing the plan that was there and trying to validate it. I'll be frank, when I arrived, uh, there were a number of people telling me this was simply not executable. It wasn't going to happen. Three August was going to be here before we could have everything in place. Uh, to the credit of the folks in uh VA, I, uh, I consulted an outside consultant, brought in an independent view, same kind of assessment. 'Unless you do some big things here, this is not possible.' To the credit of the folks, the good folks in VBA, they took it on and they went at it hard. We hired 530 people to do this and had to train them. We had a manual system that was computer assisted. Not very helpful but that's what they inherited. And we realized in about May that the 530 were probably a little short so we went and hired 230 more people. So in excess of 700 people were trained to use the tools that were coming together even as certificates were being executed. Uhm, we were short on the assumption of how many people it would take.
Let's remember too what the VA did in real time: Blamed veterans.  They did the form wrong or it was the schools!  It was everybody but the VA.  No.  As Shinseki finally admitted in an open hearing -- with the press taking a pass on it -- he knew when he started the job.  He heard it from VA employees, he went to an outside consultant who told him the same thing.  Never did he inform Congress of that before the press started reporting what was happening. 
That's not leadership. 
And over and over, this is the pattern with Shinseki who is supposed to be supervising the VA.  The Walter Reed Army Medical Center scandal pre-dates Shinseki.  But there will be many scandals after Shinseki's out of office that result from the lack of supervision right now.
Yesterday morning, as he called the hearing to order, Chair Jeff Miller noted why they were meeting.
Chair Jeff Miller: I think most of the Committee knows that two weeks ago the VA Inspector General released a report reviewing veterans access to mental health care -- something that we're all very interested in, as are all veterans and Americans across this country.  And I've got to say that the findings in the report are really more than troubling.  That's probably an understatement to just call them troubling.  And one of the most disturbing things that the IG discovered is that more than half of the veterans who seek mental health care through the VA wait an average of 50 days --  50 days --  to receive a full mental health evaluation.  So let me be real clear from the outset, a veteran who comes to the VA for help should never, never under any circumstance have to wait almost two months to receive the evaluation they have asked for and begin the treatment they need.  I don't believe anybody in this room thinks there is any excuse for that type of delay.
If the topic seems familiar, it was the same for the April 25th Senate Veterans Affairs Committee hearing.  If you missed those hearings, you can refer to  "Fire everyone at the VA,"    "Scott Brown: It's clearly not working (Ava),"   "VA paid out nearly $200 million in bonuses last year (Wally)" and that week's Wednesday's snapshot. and Friday snapshot.   The hearing was made up of three panels.  The first panel was Shinseki and the VA's Robert Petzel, Mary Schohn, Antonette Zeiss, Annie Spiczak and, from the Office of Inspector General, John Daigh and Linda Halliday.  The second panel was noted in yesterday's snapshot, in Kat's "Congress Member Gone Wild" and in "Congress is supposed to provide oversight."  The witnesses were Dr. Nicole Sawyer,Group Health Cooperative's Diana Birkett Rakow, Dr. James Schuster and Health Net Federal Services' Thomas Carrato.  The third panel was the Disabled American Veterans' Joy Ilem,  Paralyzed Veterans of America's Alethea Predeoux and Wounded Warrior Project's Ralph Ibson.
From the first panel, we'll note this exchange.
Chair Jeff Miller: You talked about the press release April 19th.  You've acknowledged also that there's about a 15 -- I think it's 1500 mental health staff vacancies.  It could be more or less.  And you're staffing, your testimony today talks about maybe hiring more than 1900.  So what I'd like -- an answer is, I know you're going to try to fill the 1500 vacancy that exists.  You're going to add additional 1900-plus staff.  And the question is: Is that correct?  Then a couple of other things.  How quickly do you think VA can hire the additional staff?  Where are you going to put the additional staff?  And how will you be able to measure the impact they will have on improving care? 
Mr. Chairman, let me just make an opening statement here and then I'm going to call on Ms. Annie Spiczak who does the recruiting and retention personnel work for us because you're asking to see what tools we have and what our expectation here is?  We think that we'll get most of that done in the next six months but some of these specialities are difficult to recruit and  I would, be honest with you, I'm not sure I can pin a date when all of them will be in.  But the vast majority of the work will be done in the next six months.  Some of this may carry over into the second quarter of FY13.  Let me call on Ms. Spiczak to talk about the process here.
Annie Spiczak: Thank you, Secretary.  Uh, sir, I would say that we have a four-fold strategy to recruit and hire the mental health professionalsthat we need in VHA. Uh, the first part of that strategy is to have a very robust marketing and advertising campaign to do that outreach to mental health providers and providers by the use of USA Jobs, using social media, getting all of those vacancy announcements posted to specialty sites and job boards. The second part of that is using our national recruiters. We have 21 dedicated health care recruiters and they are very involved with the VISNs and the medical center directors to recruit those hard to fill positions -- especially our psychiatrists and our psychologists.  Thirdly, we're going to recruit from our active pipeline of trainees and residents.  VHA has a very robust training program and they are an integral part to filling that pipeline of our workforce.  And, fourthly, we're going to ensure that we have complete involvement and support of VA leadership.
Chair Jeff Miller: I guess --
Secretary Eric Shinseki:  Mr. Chairman, I'm going to call on Dr. Petzel to just add some concluding thoughts here.  But I would also point out the, uh, national recruitment program, the 21 high quality recruiters that Ms. Spiczak referred to, all are veterans.  18 of them have extensive experience in recruiting.  And for any new individual who joins the team,  they go through a training program and oversight, mentoring by some of the old timers, so this is a pretty robust crew that we're talking about.  Dr. Petzel?
Dr. Robert Petzel:  Thank you, Mr. Secretary.  Mr. Chairman, I just wanted to add briefly, the VA trains -- has 1,000 psychiatric residency positions.  We have over 730 internship positions for clinical psychologists, just to mention a couple of the positions.  We're the largest trainer of mental health professionals in the country.  And this group of trainees is the primary place that we're going to be recruiting those individuals to fill those 1900 jobs. And the last thing I'd like to add is that  the most difficult to recruit group is the psychiatrists. Particularly in more remote and rural areas.  And we have recently sent a memo to the Secretary which I believe he has signed or is about to sign to change the pay table for psychiatrists and to make available other incentives so that we can compete more equitably with the private sector and DoD in terms of recruiting  psychiatrists.
Chair Jeff Miller:  Ms. Spiczak, how long does it take for VA to fill a vacancy like the 1500 that are open now for mental health professionals.  What's the average time that those positions have remained vacant?
Annie Spiczak:  Sir, it takes anywhere from four to six but for some of our hard to fill positions, it can take up to a year to fill those positions.
Chair Jeff Miller: Have you ever been even close to 100% staffed at the full level with the 1500 that you currently have?
Annie Spiczak:  Sir, we'll always have a turnover rate, a vacancy rate that we're always trying to close that gap but you have my commitment that we're going to work very hard to close that.
Chair Jeff Miller:  At what level is the vacancy rate?  Is it more at the upper level, the lower tier, I hate to say 'lower tier,' but, obviously, the psychiatrist level downward?  Which is the higher rate?  Is it the psychiatrist or is it the person in the --
Annie Spiczak: No, sir. Our turnover rate in FY 2011 for mental health professionals was 7.23%.  And the Bureau of Labor Statistics for the health care industry shows a 28% turnover rate.
Chair Jeff Miller: Then I guess the last question that I'd like to ask in this round is how are we going to pay for the extra 1900 mental health care professionals?
Secretary Eric Shinseki:  For that question, I'm going to call on Dr. Petzel.
Dr. Robert Petzel:  Thank you, Mr. Secretary.  Mr. Chairman, we, uh, have estimated that, uh, cost in Fiscal Year 12 will be relatively small because it's going to take some time to get these people on board and we will use money that we have available in 12.  We expect that this will not exceed 29 million and may be a bit less than 29 million dollars. In fiscal year 13, we're going to separately identify the funding for this initiative as part of each one of the VISNs allocations and then the VISNs will receive a hiring target based on their allocation and we're going to keep very close track of that hiring target.  Ms. Spiczak can give more detail about how we're going to do that, but we're basically going to be daily looking at how they're meeting that hiring target.   We've identified -- We will identify each one of these positions  electronically on USA Jobs by special number so that we can track all of the 1900 new people as well as all of the vacancies that exist right now.
Secretary Eric Shinseki:  Mr. Chairman, just a data point. Psychiatrists are the toughest to recruit and I think under this new model we say it's about 57 that we're going to go after in this group of 1900. Of 57, 37 have already been recruited.  7 are already serving. 30 are being on-boarded and so we're beginning to hone in on this most difficult recruiting challenge and working it down.  So there's some evidence that we can recruit to what we need here.
That's about as much garbage I can take in one excerpt.  Where to begin?  Annie Spiczak asserts, "Our turnover rate in FY 2011 for mental health professionals was 7.23%. And the Bureau of Labor Statistics for the health care industry shows a 28% turnover rate."  No, they don't.  During the long, long break in the hearing for votes, I called the Bureau of Labor Statistics to check that.  28%?  It was 21.9% in 2006, the highest its been in the last ten years.  In 2010, the turnover rate was 15.8% and in 2011, the turnover rate was 15.5%.  In addition, I was told Spiczak's number for the VA was "questionable" and was asked if I thought they were counting "positions" because if they were doing it that way, all those empty positions would artificially reduce the turnover rate.  I asked for an example on that.  If there are 800 positions and only 100 are filled, are you dealing with the turnover rate of that 100 staff or are you using positions and acting as though you have 800 positions?  If you're going by positions -- and including empty positions -- you can artificially reduce the turnover rate.  If that doesn't make sense, blame me and not the Buereau of Labor Statistics which was very helpful.  (Until yesterday's hearing, I hadn't even registered on the term "turnover rate."  The BLS was very helpful in explaining that but if there's a mistake in this paragraph, it's on me and on my misunderstanding the BLS.  And though I did get a name from a mutual friend and call and speak to that person, I was also told that the BLS works very hard to assist everyone with answers and that they do so via the phone and via e-mail.)

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