VA Under Secretary for Health Media Roundtable

Mark Ledesma (VHA Media Relations director): Once the Embargo has been lifted.  And that Embargo topic is going to be concerning centers for Medical Care and Medicaid Services overall hospital ratings as it relates to VA’s ratings under that rating system.  And then after that, Dr. Elnahal will also be discussing some updates to his priorities.  On the line here today also is Dr. Cox, our Assistant Under Secretary for Health for Quality and Patient Safety, who will be helping us explain the CMS star rating and how that relates to VA as well.  Before we get started, I’d like to go over some house-cleaning items. Could we please wait until I call on you?  Use the raise your hand function if you have questions once we get to the Q and A section.  Once I call on you, you can put it down, but please state your name and publication.  And at this moment, please keep your mics on mute so we don’t have any disruptions.  And with that, I’d like to pass it on to Dr. Elnahal.

Dr. Shereef Elnahal (Under Secretary for Health):  Thanks so much, Mark, and good afternoon, everyone.  Really important announcement that we’re gonna make today, and I’m very pleased to be accompanied by Dr. Cox, our Quality and Patient Safety leader across the system.  So, as Mark mentioned, tomorrow CMS will release their annual overall hospital quality star ratings.  This is a rating that they release on a regular basis for private sector hospitals that VA had not participated in until this year.  So, for the first time, an overall star-rating system will be directly comparing our quality and patient safety outcomes with our colleagues in the private sector.  And I’m really pleased to announce that 67% of VA hospitals included in this star rating, which amounts to about 114 VA hospitals received either four or five stars, the top two-star ratings out of five stars.  That is higher than the percentage of private sector institutions that participate in this star rating.  We don’t know exactly what the results of each individual private sector and academic medical institution will be, but we know that this percentage is significantly higher than historical averages that we’ve seen with our private sector counterparts. 

Again, this is the first time VA was included in the CMS star ratings.  It allows Veterans to directly compare our institutions with private sector hospitals.  Remember that we send about a third of our care into the community.  A lot of it is out of necessity because of a lack of availability of services in certain locations, but we are really proud of these results.  The CMS uses five different categories to ultimately comprise this star rating to include mortality outcomes, safety of care, readmission rates, patient experience, and timely and effective care.  Those are the five subcategories of metrics that ultimately feed into the global star ratings.  And so, the more stars, obviously out of five, the higher the performance in the sum total of each of these categories. 

We are not necessarily surprised by these results, but we’re very, very proud of our institutions for achieving them.  In fact, they align with a recent announcement we made earlier this summer on star ratings specific to patient experience when we announced that 72% of our hospitals got either four or five stars. 

Now, a couple of nuances here to be aware of these metrics are related specifically to care in the inpatient acute care setting.  So, you may ask why not every single VA Medical Center was included in these star ratings.  Well, not every VA Medical Center has inpatient acute care.  Some of our institutions are primarily outpatient based and provide residential care of various types to include long-term care, but that is not included in the global CMS star ratings for quality and patient safety.  So about 114 VA hospitals were assessed. 

So obviously, we’re proud of these results, but of course, we do have some one, two, and three-star hospitals.  And for those hospitals, Dr. Cox presides over a national improvement office that is assisting them every day on getting better.  And we’re also not going to be complacent with these outcomes.  It’s often the case that hospitals see that they’re rated highly on these systems. They might get complacent only to see themselves slip.  We are focused squarely on certainly not slipping to the extent that we can on our highly rated institutions.  And of course, we’re coming to the assistance and support of our hospitals that are in the lower star ratings on this system.  And again, very proud of these results.  You will see, hopefully, these results announced tomorrow. CMS will then have the entire compendium of hospitals with a star rating, and we’ll be able to more directly compare globally how many of our hospitals were four or five stars versus the private sector. 

Again, we anticipate that we outperform our counterparts.  I want to pass the baton here to Dr. Jerry Cox for additional comments on these excellent results.  Go ahead, Jerry.       

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  Thanks, Dr. Elnahal, and good afternoon, everybody.  Nice to have a chance to speak with you today.  Let me just elaborate on a couple of the points that Dr. Elnahal made.  The first is you might be asking why is this the first time that VA Medical Centers are being included in the CMS assessment of hospitals.  And the fact is, we’ve been working with CMS for about five years now to get to this point.  It involved federal rulemaking, and it wasn’t until 2021 that a final rule was published that allowed VA to be incorporated into the CMS rating system, and that leads to the release tomorrow here in July of 2023 of that first set of ratings.  But this is something that we have welcomed, that we have sought, and as Dr. Elnahal said, we’re very pleased to be able to be compared on an apples-to-apples basis with the private sector. 

He also mentioned about a month ago, CMS released the results of another set of surveys that resulted in another set of star ratings.  And so, just to try to avoid confusion between these two releases, the June announcement about the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, or HCAP survey, was the result of surveys of patients, so consumers of healthcare. And the ratings that were derived from those surveys are basically from Veterans assessing their satisfaction with the care that they received at VA hospitals.  And in all ten of the elements, the dimensions of patient satisfaction, VA outperformed the private sector according to our own patients.  These CMS star ratings that will be announced tomorrow reflect CMS’s assessment of the quality of care at VA hospitals.  So not our consumers or our Veterans, but rather a comparison in those five categories that Dr. Elnahal mentioned directly, head-to-head with private hospitals on mortality, safety of care, readmission rates, the patient experience, which was the focus of the HCAP survey, and then timely and effective care. 

So, we already knew we were doing well in terms of patient satisfaction, patient experience, based on the HCAP survey results from last month.  Now we’re very pleased to see that other elements, other aspects of care, quality, and safety also compare favorably.  And VA is a learning system.  We are dedicated to continuous improvement.  In fact, we’ve been on what we call a journey towards becoming a high-reliability organization for more than four and a half years now, working with every single medical center to improve the quality of care and to reduce, avoidable harm to Veterans.  And so, we’re pleased to see that these CMS star ratings validate, I think, the impact of some of that work, but that also only energizes us to further make sure that we are providing the safest and most effective care to Veterans.  Thanks, Dr. Elnahal.
        

Dr. Shereef Elnahal (Under Secretary for Health):   Thank you Dr. Cox.  And again, really appreciate your team’s posture of support to our medical centers and clinics across the country.  And of course, your team also assisted in making sure that CMS got all the data they needed.  Again, Dr. Cox mentioned this was a five-year journey that got us up to this point.  But now Veterans have a direct ability to compare options.  And frankly, I’ve always said that Veterans deserve the best institutions, providing them the care that they’ve earned. 

And overall, these results show that we are getting better and better at achieving that goal.  Again, these results are nowhere near perfect.  We have institutions that need to do a lot better, and we have institutions that continue to focus on continuous improvement so that we never become complacent with our outcomes.  The tie-in here to a systematic review that we just released a couple of months ago of over 40 peer-reviewed studies that showed that care was at least at the same level of quality, if not better, in multiple different spheres of care, was a precursor to this.  And so, while we’re not surprised, we are very proud of our teams who’ve achieved this result.  And we will continue to try to get better every single day. 

I’ll then now talk about our progress with hiring, which continues to be a priority as we build capacity to fully and faithfully execute on the PACT Act.  Right now, we’ve hired more than 43,000 new employees from outside of our system on pace to far surpass our 52,000 hiring goal by September 30 of this year.  And specifically, we’ve hired 24,609 new employees in what we call our Big Seven occupations, the frontline jobs that either involve direct care provision to Veterans and clinics and hospitals, or those frontline jobs that directly support that environment of care.  And so, we are well ahead of pace, specifically on nurses and medical support assistance.  The latter is the job of schedulers and folks who assist top licensed clinicians in the clinic, keep clinics moving.  And all of these occupations were ahead of pace against our goals. 

Among the most important goals we’ve hit is our total employee onboard growth goal, our end strength.  So, we have grown our workforce by 4.9% since October 1 of last year, well surpassing our entire fiscal year goal of only 3% growth.  And we are not stopping.  We need to hire as many employees as possible to be able to fully and faithfully execute on the increasing care demands that we are seeing among our existing base of Veterans, as overall, on average, they are getting older across the Veteran population.  But we are also welcoming many additional new entrants into the system because of the PACT Act.  So, I’ll go quickly into our progress on the PACT Act right now.

I’m excited to be testifying with my colleague, the Under Secretary for Benefits, Josh Jacobs, in a hearing tomorrow before the Senate Veterans Affairs Committee.  But some highlights on our progress that I intend to talk about tomorrow.  The first is that we’ve surpassed 4 million toxic exposure screenings.  Again, our goal for the entire fiscal year ending September 30th of this year was 4 million.  And so, we reached that goal at least two and a half months in advance of what our target was.  These are veterans who are coming in through their routine care, mostly primary care.  But we’ve since extended into our different specialty care services and mental health for this type of screening, where we canvass the list of exposures covered.  As presumptive under the PACT Act and ask Veterans if they remember being exposed to such toxins during their services. Toxins like Burn Pits, Agent Orange, contaminated water from Camp Lejeune, radiation, and others. 

And we have still over 40% of Veterans, amounting to about 1.7 million Veterans across the country, who tell us that they’re concerned that they may have been exposed to one of these toxins.  And so, what happens after that is a permanent record of that exposure, which will assist clinicians in the longitudinal course of care in incorporating that knowledge and factoring in that knowledge throughout that course of care.  For example, you might have a low threshold to screen for cancer or do additional laboratory tests knowing that many different cancers are presumptively associated with burn pit exposure under the PACT Act.  On top of that, we have a process with VBA whereby every single Veteran who endorses that they’ve been exposed to a toxin receives a letter from VBA explaining exactly how to apply for benefits, additional benefits on top of their existing healthcare benefits to see if more benefits are. 

And so, one example I often talk about is a Veteran out of Illinois who has a history of multiple myeloma, which is a type of blood cancer, but also has an extensive cardiovascular history, including hypertension.  He was not considered service-connected for these conditions before, and so he would have to pick and choose which appointments he went to because he had to pay copays every time he went to the VA for his care.  On top of that, he’d have to subsidize his own transportation to clinics that he needed to go to because he did not qualify for Beneficiary travel.  Again, associated with his lack of service connection for these conditions. But because both hypertension and multiple myeloma are presumptively associated now with Agent Orange, he was able to be service-connected for these conditions and for his service. 

So, imagine that scaled to over a million Veterans who are telling us that they’ve been exposed to a toxin and are receiving a letter from VBA inviting them to apply for additional benefits.  We’re also in the middle of Summer Vet Fest, which is an extensive outreach campaign we’re doing ahead of the August 9 deadline for Veterans benefits being backdated to August 10 of last year, which is the date that the President signed the PACT Act into law. Veterans who applied for PACT Act benefits before, on or before August 9 have the opportunity to have their benefits backdated to August 10 of last year, which could be a huge advantage to Veterans if they take advantage of this window right now.  Now, Veterans can still apply after August 10 of this year, but again will not have that opportunity to backdate their benefits to August of last year.  So, we’re really pushing the needle here on as many outreach events as possible.  Sum total that we’ve done since the PACT Act was signed is over 2000 of these outreach events, which invariably involve VHA staff doing toxic exposure screenings, but also VBA staff to assist Veterans who want to apply for claims under the PACT Act.  At Summer Vet Fest, we’re going to end up doing over 100 of these events.  We’ve already done over 70 this summer so far leading up to the August 9 deadline to have your benefits backdated. 

And finally, the other really important date to remember is September 30, when the one-year special enrollment eligibility window closes on post-911 veterans who separated from service more than ten years ago.  Between September 30 of 2001 and September 30 of 2013. Before the PACT Act, these folks had five years for an opportunity to directly enroll in VA Healthcare after they separated.  For Veterans who missed that opportunity before, they have a chance right now to still enroll for healthcare again if they separated on or before September 30 of 2013. That window to directly enroll in VA Healthcare will close on September 30.  So, part of our outreach and targeted messaging and communication is to that specific cohort of Veterans in particular, so that we can maximize the number of vets who take this opportunity. 

So, with that, I will pass it to Mark and all of you for questions.  Thank you so much.
      

Mark Ledesma (VHA Media Relations director): Great. Floor is open.  For questions again, please use the raise your hand function and I’ll call on you.  Ellen, go ahead.

Ellen Milhiser (Congressional Synopsis):  Hi, I’m sorry, I can’t get the camera to work today, but how many of your hospitals are in the one to two-star ratings and are they located in particular parts of the country?

Dr. Shereef Elnahal (Under Secretary for Health):  Dr. Cox, do you have that information? 
       

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):   I do. So as Dr. Elnahal stated, two-thirds of VA hospitals received four or five stars, 15% received three stars, 11% two stars, and only 8% one star.  So that’s nine one-star facilities out of the 141 VA facilities that received a rating.  That distribution, again, is skewed towards the higher end for VA compared to non-VA, but the distribution of both the lower end and the upper end covers our entire system.  So, it’s not necessarily the case that larger or more urban facilities scored higher or that smaller and more rural facilities scored lower.  It’s a mix across the board. 

And once CMS releases all of the details tomorrow, you’ll be able to see exactly which of those facilities are in which of those categories.  I wanted to mention also, as Dr. Elnahal did earlier, that we have had a preview of what these ratings are going to be.  We’ve identified those nine lowest rated one-star facilities and have already begun intensively working to support them.  We’ve obtained and can mirror CMS’s methodology so we can help those facilities understand why they’re rated low, and which measures they need to work on to be rated more highly in the future. I’d also like to make the point that as with any data reporting systems, there’s a lag.  So, the ratings that will be released tomorrow are based on measures that were reported at least twelve months ago. So, it’s about a one-year lag based on measures from July of 2022 or earlier, which means that things might have changed in the last year.  Some of those one- or two-star facilities, if they were reported on today, might fare higher.  And for that matter, some of the four- and five-star facilities might have slipped a little bit, but we’ll be able to continue to work with all of them as we now enter into this new system.

Ellen Milhiser (Congressional Synopsis):  You speaking about the data lag actually brings up my next question.  How many of those one- and two-star facilities are locations that you had already identified as needing help and had already been working on the issues that CMS flagged?

Dr. Shereef Elnahal (Under Secretary for Health):  That’s a great question. And it’s a mixed bag.  So, you are referring to the fact that we have had for many years our own internal system for performance measurement and assessing the quality of care at facilities that’s referred to as the SAIL methodology.  And there is not a direct correlation between how a VA facility fares in SAIL versus how many stars they get from CMS. In fact, you know, the CMS methodology is very different, uses different measures, is weighted differently, and so it produces different results.

Ellen Milhiser (Congressional Synopsis):  If I can ask just one more fast question. I know that CMS’s star ratings is geared towards the Medicare program–heavily geared towards the Medicare program, which deals with geriatric issues.  The Veterans’ population does have a lot of more younger patients and has other issues.  Do you think that that might have impacted any of these ratings?

Dr. Shereef Elnahal (Under Secretary for Health):  Well, CMS assigns Star ratings to any acute care hospital that accepts Medicare payment.  That doesn’t necessarily mean that the majority of their patients are elderly.  And in fact, it’s true also that within the VA system, we have a number of older Veterans with complex multiple medical conditions.  So, it’s hard to say that there’s a direct correlation, but I don’t see that as having been a big factor.

Ellen Milhiser (Congressional Synopsis): Thank you so much.

Dr. Shereef Elnahal (Under Secretary for Health):  You’re welcome.

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  I will add, though, that we have an excellent geriatrics and extended care team. And we do consider ourselves at the tip of the spear for Veterans over the age of 65 and all of their care needs.  And on top of that, I do think there was considerable overlap between what we call tiers of need.  We’ve identified hospitals that have needed assistance in quality improvement and patient safety for some time. And those in the highest tier of need ended up receiving a lot of assistance and ultimately have gotten better, who may be on that one-star list right now because of the data lag phenomenon.  So, we do hope that that will be reflected in future iterations of the Star rating.  But in a way, it was validating for us to know that we had identified many of these one-star facilities as needing assistance for quite some time and have been offering that assistance and have been seeing improvements since then.

Mark Ledesma (VHA Media Relations director): Thanks for your question, Ellen.  Patricia, you have next.

Patricia Kime (Military.com):  Yes, thank you so much for doing this.  My first question is we often cite that like there’s 152 major medical centers that VA has, but you’re saying the Star ratings are only for 141.  Where are the other nine?  And if they’re major medical centers, I’m assuming they have intern–they have inpatient services?

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  So, let me try to answer that one as well.  It depends on how you count VA medical centers.  Some of our healthcare systems actually have more than one hospital associated with them.  So, there are either 170 or 171 hospitals in the VA healthcare system or about 136 systems. In any case, CMS is reporting on individual hospitals, and 141 were rated and 23 were not.  So that adds up to 164.  The reasons for not being rated are generally because those hospitals didn’t submit measures that met the threshold for CMS to be included in their Star rating system.  And as Dr. Elnahal mentioned, it’s a system of evaluating acute care hospitals only.  So, CMS excludes things like purely mental health facilities.  And some of our facilities have very little inpatient care, but may have an inpatient mental health unit, or they may be an ambulatory surgery center, which again, are excluded by CMS. Or in the case of the private sector, CMS excludes psychiatric hospitals.  So, some of our hospitals just didn’t meet the criteria or didn’t report enough measures that CMS considers because of the type of services and the scope of services that they offer.

Patricia Kime (Military.com):  Okay.  And you said five years ago you all started pursuing this, you know, getting included.  Can you explain why you decided to do that?  And does it have anything to do with–there was a big blow up about the internal ratings years ago.  And if I do the math, it’s kind of almost at the same time that you all started pursuing this.  Can you sort of talk about why you decided to try to get involved with the CMS and address the changes that you might have made to the system after USA Today did all its reporting on your internal system?

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  Well, I can’t say that I know all the reasons why we wanted to pursue affiliation with CMS other than to allow Veterans and family members and caregivers to be able to make that direct head-to-head comparison.  So, it’s–it’s favorable for us to be able to be compared directly with the private sector.  But I don’t [crosstalk] Go ahead, Dr. Elnahal.

Dr. Shereef Elnahal (Under Secretary for Health):  Of course.  And the only thing I would add is we have a method of measuring performance in many other areas that used to underlie the VA specific Star rating called SAIL.  We decided strategically that if we’re going to be participating in the Star rating, it should be, you know, commensurate with how all hospitals are measured in the country so that we could provide some context to Veterans on quality and patient safety at their hospital.  But we still use SAIL, again, which underlied the previous system for improvement work.  So, SAIL incorporates things like access to care and performance in mental health and ambulatory care and preventative care and screening, things that are really important for Veteran care that aren’t necessarily incorporated in the global CMS hospital quality Star ratings.  And so, we’re much more comprehensive on our efforts with improvement, and we do measure a large swath of other areas and hold ourselves accountable for continuous improvement in those areas.

Patricia Kime (Military.com):  Okay, just one more question.  When these ratings come out, obviously, Veterans who go to the top hospitals are going to be thrilled, and there will be Veterans who either it’s no surprise that they get a one-star rating or that is their hospital.  So, what do you tell Veterans?  How are you all going to react to this?  And what do you say to Veterans who are like, what are you going to do to improve my hospital?

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  So, I will just say up front that I believe Veterans should continue to pursue care, that overall, their care will be safe and effective regardless of the star rating, and regardless of some of these metrics.  Again, we know that hospitals across the country have a lot of work to do, especially in the wake of the pandemic on improving hospital quality and patient safety.  We are being as transparent as we possibly can by participating in the global CMS Star rating program.  But know that your doctors, your clinicians, who see you every day, are still dedicated to providing you that excellent care.  This is just one picture of many that allows us to evaluate and continuously improve that care environment.  But this is definitely not a reason to choose or not choose to receive care at the VA.  It’s extremely important for Veterans to continue to receive that care for their own health.  And again, we are in a posture here of constantly surfacing where we can do better, interpreting that data, and then taking action to make sure that it is improved.  Thank you. 

Mark Ledesma (VHA Media Relations director): Thanks, Patricia. Leo, you’re up next.

Leo Shane (Military Times): Yeah, hi.  Thanks for doing the call here.  Question for you about the hiring levels.  You said you’re almost at 5% from last October.  That’s way above the goal of 3%, but you said you’re still looking to hire more and looking to expand more.  What’s the–what’s the cap–what’s the goal?  If 3% wasn’t the goal, how do you know when you have enough folks and you’re not just hiring for the sake of hiring?

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  Yeah, 3% was the goal, Leo. We had estimated in the beginning of this fiscal year that we would need to hire at least 50,000 external hires per year for the next five years to catch up to Veteran care demand, whether it’s from the PACT Act or again, from increasing demands per Veteran already in our system because they are aging on average.  Right.  We are retaining employees, though, at higher rates than we anticipated.  And so that, on top of our record hiring numbers for the first nine months of any fiscal year in this agency’s history, has led to us getting to the 4.9% level.  Now we’re still deciding what next fiscal year’s hiring goals will be.  My thinking on this is that we should be specific and targeted on occupations where we’re still falling short.  So, for example, nursing assistants, LPNs, we’re seeing global healthcare workforce shortages in these very critical occupations, and we’re slightly behind schedule in those types of jobs, mostly for that reason.  So, there will be jobs for whom we need significantly more people.  And where I specifically want to focus is on ambulatory support staff, especially in the primary care setting, to alleviate some of the administrative burden on our frontline primary care providers.  And so, we’re still thinking about that strategically, and we’ll come out with our hiring goals within the next couple of months.

Leo Shane (Military Times): Okay, so this doesn’t work like military end strength, for example, where when you hit that goal, you stop.  This is something that, since you’re looking years ahead, if you’re hiring a few more people this year and you need to scale back in coming years because you’ve got enough people, you can do that.  This is just get people in and there’ll be roles for them?

Dr. Gerard R. Cox (Assistant USH for Quality and Patient Safety):  Yeah.  And so, each medical center is also hiring strategically, right, because not every medical center has the same gaps in particular types of staff, you know, certain types of care are more prevalent.  Veterans demand specific types of care differently in different geographic areas.  And so, for each medical center, there’s still a strategy behind who they’re hiring.  But we recognized, again, right after the PACT Act was passed and even before that, that we were going to need to staff up significantly no matter what.  We honed in on the big seven occupations, which we knew specifically, we needed to hire at least 30,000 of those. And we will hopefully hit that target this year.  But again, we’re constantly looking at this question strategically.

Leo Shane (Military Times):  Okay, thanks.

Mark Ledesma (VHA Media Relations director): Thanks, Leo.  Barry, you’re up next.

Bari Faye Dean (Becker’s Healthcare):  Hi, thanks.  This is Barry Sadeen, Becker’s healthcare. Hi, Dr. Elnahal again, and very nice to meet you, Dr. Cox.  Follow-up to our call earlier, I guess, the end of last week with regard to the way the VA works with acute care hospitals in the country.  As you know, my beat is specifically healthcare leaders in hospitals.  And I was just wondering, beyond the mental health care program that we have discussed, I was–what are the fastest ways that hospitals that do not–that are not in the same communities with VA facilities, how can they work best with the VA?

Dr. Shereef Elnahal (Under Secretary for Health):   Well, you know, many institutions, Barry, have services that we may not have in that particular market.  So, especially in those instances, we often rely on our private sector partners to deliver that aspect of their care.  I will say that it is still incumbent upon us to fully coordinate that care and make sure that the Veteran is getting what they need in a timely way, even if they’re not within our walls or our clinics for that type of care.  But there’s always a reason to collaborate for Veteran patients.  We know, for example, that in particular rural areas where we may not have any infrastructure, a clinic or a medical center, there may be a private sector hospital that sees a large bulk of our Veterans who live there.  And so that necessity to collaborate is especially important where we don’t have infrastructure because we know that Veterans will rely at least for pieces of their care on their local community hospitals and clinics.  Hope that helps.

Bari Faye Dean (Becker’s Healthcare):  It does.  Follow-up question is, how would you suggest those hospitals get more involved so that they can get paid for the work that they provide and perhaps publicize the fact that they are a resource?

Dr. Shereef Elnahal (Under Secretary for Health):  So, you know, what I would say is reach out to your local VA Medical Center leadership if you are in an institution especially that continues to see Veterans or more Veterans, to see what we can do to collaborate.  We can share information about the PACT Act.  We can share information about the fact that we now cover all emergent suicide care, suicide ideation, attempted suicide for almost every Veteran in the country as a result of Compact Act 201.  So that is an opportunity for us to either pay for that care or provide the care ourselves within our own infrastructure.  So, there’s always work to be done to share information, especially about new policy and new benefits.  The PACT Act represents a lot of new benefits and opportunities to enroll in VA and so that local cooperation could mean everything for Veterans in those regions who often again depend on community providers for their care.

Bari Faye Dean (Becker’s Healthcare):  Thank you.

Mark Ledesma (VHA Media Relations director): Thank you, Barry. Justin, you’re up next.

Justin Doubleday (Federal News Network): Hi, thanks for doing this.  I just wanted to follow up quickly on hiring.  I know that, you know, getting the time to hire down was a big initiative.  Do you have any updated numbers on that?  And then more specifically those trends across different occupations?

Dr. Shereef Elnahal (Under Secretary for Health):  So, we are now at a median of about 168 days for time to fill–still much too long.  However, it was an improvement from April when we were at 179 days and definitely an improvement over January when we were even longer.  So, we recently put out a standardized hiring process with accompanying training and technical assistance to every HR department in every VISN in the country.  And we also have new training on a standard process available to hiring managers at the actual medical centers and clinics who are interviewing candidates and trying to bring people on.  So, we’re focused on a lot of training and process improvement and standardization.  We saw this phenomenon, as I mentioned before, where because we had a record number of applications for a lot of our jobs, because we needed to bring many more people into a process that wasn’t fully baked and improved yet, we actually saw time to fill slightly increase before it decreased again this year.  So, it may be another couple of months before we see demonstrable improvements to a point that we find satisfactory for time to fill.  But it’s definitely an area where we need to improve. We’re not where we need to be yet there. 

Justin Doubleday (Federal News Network):  Thanks. And just a quick follow-up.  Do you see any overlap between the positions, the occupations that you’re short on, that you’re looking at prioritizing for next year in time to fill or are those issues not connected?

Dr. Shereef Elnahal (Under Secretary for Health):  Well, some of the big seven occupations involve licensed clinicians, and there are many extra steps. Every time you bring on somebody who is licensed, you have to do undergo a process called Credentialing and Privileging, where we look up your record, out of state licensing boards, and we just verify whether there’s any tort claims against clinicians, et cetera.  All of these things take time and add time to the process for bringing on clinicians.  So, yes, unfortunately, there is overlap between folks who require number of extra steps to verify that they meet our suitability standards and the big seven occupations.  But I’m still proud of where we are in actually increasing the number of employees on board in our top priority occupations.  We just have to do it faster and more efficiently, and that’s the next focus for us.

Justin Doubleday (Federal News Network):  Thank you.

Mark Ledesma (VHA Media Relations director): Thank you all.  I don’t see any more questions.  Give it a few–well, if there are no other questions, I’d like to reiterate that the CMS announcement is embargoed.  Please hold off on publishing your stories.  What we will do is, my colleague Rachael Burden, who you actually received the invite for this call, she will send an email to you all to notify you when that embargo has been lifted so you’d be clear to go ahead and publish your stories. With that, is there anything else?

Dr. Shereef Elnahal (Under Secretary for Health):  Thanks, Mark.  Appreciate this interaction we have every month here.  We’ll continue to do this.  And thanks very much for your time today.  We’re really excited about these results out of the CMS Star ratings, but again, we’re not complacent.  We’ll continuously improve and take advantage of the fact that our teams continue to want to get better on behalf of Veterans. Thank you so much for your time today.  Take care.