[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON VETERANS
HEALTHCARE LEGISLATION
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JUNE 26, 2008
__________
Serial No. 110-95
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
VACANT VERN BUCHANAN, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
June 26, 2008
Page
Legislative Hearing on Veterans Healthcare Legislation........... 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 13
Hon. Shelley Berkley............................................. 6
Prepared statement of Congresswoman Berkley.................. 13
Hon. John T. Salazar, prepared statement of...................... 14
WITNESSES
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D.,
FAAFP, Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 8
Prepared statement of Dr. Cross.............................. 18
______
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 2
Prepared statement of Mr. Blake.............................. 14
Veterans of Foreign Wars of the United States, Christopher
Needham, Senior Legislative Associate, National Legislative
Service........................................................ 3
Prepared statement of Mr. Needham............................ 16
SUBMISSIONS FOR THE RECORD
American Legion, Joseph L. Wilson, Deputy Director, Veterans
Affairs and Rehabilitation Commission, statement............... 19
American Veterans (AMVETS), Raymond C. Kelley, National
Legislative Director, statement................................ 20
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director, statement................................ 21
Miller, Hon. Jeff, Ranking Republican Member, and a
Representative in Congress from the State of Florida, statement 22
National Association of Veterans' Research and Education
Foundations, Barbara F. West, Executive Director, statement.... 23
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Request for Additional Views on H.R. 6366 and Draft
Legislation:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Carl Blake, National
Legislative Director, Paralyzed Veterans of America,
requesting views on H.R. 6366, and Discussion Draft
relating to employment of psychologists by the Department
of Veterans Affairs, letter dated July 2, 2008, and PVA
response letter dated July 8, 2008......................... 26
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Dennis Cullinan,
National Legislative Director, Veterans of Foreign Wars
(VFW), requesting views on H.R. 6366, and Discussion Draft
relating to employment of psychologists by the Department
of Veterans Affairs, letter dated July 2, 2008, and VFW
response................................................... 28
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. James B. Peake,
M.D., Secretary, U.S. Department of Veterans Affairs,
requesting Administration views on H.R. 6366, and
Discussion Draft relating to employment of psychologists by
the Department of Veterans Affairs, letter dated July 2,
2008 [AS OF JANUARY 12, 2009, THE VA FAILED TO PROVIDE THE
ADMINISTRATION VIEWS ON THE TWO BILLS.].................... 29
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Raymond Kelley,
Legislative Director, AMVETS, requesting views on H.R.
6366, and Discussion Draft relating to employment of
psychologists by the Department of Veterans Affairs, letter
dated July 2, 2008, and AMVETS response dated July 8, 2008. 30
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Joe Violante,
Legislative Director, Disabled American Veterans (DAV),
requesting views on H.R. 6366, and Discussion Draft
relating to employment of psychologists by the Department
of Veterans Affairs, letter dated July 2, 2008, and DAV
response dated July 8, 2008................................ 31
LEGISLATIVE HEARING ON VETERANS
HEALTHCARE LEGISLATION
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THURSDAY, JUNE 26, 2008
U.S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:10 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Berkley, and Salazar.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. The hearing will now come to order. I
apologize for the delay. With the July work period coming up,
Members are in other Committees for markups.
But I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for the veterans
service organizations (VSOs), the U.S. Department of Veterans
Affairs (VA), and other interested parties to provide their
views on and discuss draft legislation within the
Subcommittee's jurisdiction in a clear and orderly process.
I do not necessarily agree or disagree with the draft bills
before us today, but I believe that this is an important part
of the legislative process and encourage an open and frank
discussion about the drafts before us today.
We have four drafts before us today. The first draft bill
would expand VA's authority to provide mental health treatment
for family members.
The second draft bill would prohibit the collection of
copayments from catastrophically disabled veterans.
The third draft would authorize nonprofit research and
education corporations in the Department of Veterans Affairs.
And the fourth draft would establish seven consolidated
patient accounting centers to facilitate third-party collection
in the Department of Veterans Affairs.
I understand that the fourth draft I mentioned was not
ready until yesterday, so I do not expect our witnesses to have
prepared statements on this bill. We would, however, appreciate
if the witnesses could provide their views on this bill for the
record.
And I look forward to hearing the views of our witnesses on
the draft legislation before us.
[The prepared statement of Chairman Michaud appears on
p. 13.]
Without any further ado, why don't we start? We have two
witnesses on our first panel, Carl Blake, who is the National
Legislative Director of Paralyzed Veterans of America (PVA),
and Christopher Needham, who is the Senior Legislative
Associate for the Veterans of Foreign Wars of the United States
(VFW).
So I want to thank both of you for coming here today and we
will start with Mr. Blake.
STATEMENTS OF CARL BLAKE, NATIONAL LEGISLATIVE DIRECTOR,
PARALYZED VETERANS OF AMERICA; AND CHRISTOPHER NEEDHAM, SENIOR
LEGISLATIVE ASSOCIATE, NATIONAL LEGISLATIVE SERVICE, VETERANS
OF FOREIGN WARS OF THE UNITED STATES
STATEMENT OF CARL BLAKE
Mr. Blake. Thank you, Mr. Chairman.
On behalf of Paralyzed Veterans of America, I would like to
thank you for the opportunity to testify today on the draft
legislation.
As you mentioned, we will be happy to submit additional
comments on the bill that came out last night.
In accordance with the recommendations of the Independent
Budget for fiscal year 2009, PVA strongly supports the draft
legislation that would prohibit the VA from collecting certain
copayments from veterans who are catastrophically disabled.
This issue has the greatest impact on PVA members.
The current VA healthcare system allows veterans who have a
nonservice-connected catastrophic disability, such as spinal
cord injury, and who have incomes above median tested levels to
enroll in Priority Group 4. Congress granted these
catastrophically disabled veterans this higher priority for
healthcare enrollment because of the unique nature of their
complex disabilities and in recognition of the specialized
services that only the VA healthcare system can provide.
However, being enrolled in Priority Group 4 does not
necessarily exempt PVA members and other catastrophically
disabled veterans from the burden copayments impose. Those PVA
members with nonservice-connected disabilities, who because of
their incomes, would otherwise be classified a Priority Group 7
or 8 can be enrolled in Priority Group 4 but are still subject
to the copayments associated with 7s and 8s.
PVA members go to the VA because there is no other system
in the country that provides the level and quality of spinal
cord injury care offered by the VA. Because of the nature of
their disability, they require a host of pharmaceuticals,
equipment, devices, and supplies to function on a daily basis.
The hardship created by a catastrophic injury or disease is
unique and devastating to the veteran and the family who may be
responsible for his or her care. At a time when the veteran is
in need of specialized assistance to regain some independence
and quality of life, the financial burden of medical bills
should be lifted.
PVA also strongly supports the ``Veterans Nonprofit
Research and Education Corporations Enhancement Act.'' The
purpose of this legislation is to modernize and clarify the
existing statutory authority for VA affiliated, nonprofit
research and education corporations or NPCs.
This bill will allow the NPCs to fulfill their full
potential in supporting VA research and education, which
ultimately results in improved treatment and high-quality care
for veterans while ensuring VA and Congressional competence in
NPC management.
PVA has been a strong supporter of the NPCs since their
inception, recognizing that they benefit veterans by increasing
the resources available to support the VA research program and
to educate VA healthcare professionals.
We urge expeditious passage of this bill so that veterans
may benefit even more from the enhancements in operational
capabilities and oversight that this bill provides.
Chairman Michaud, Ms. Berkley, again I would like to thank
you for the opportunity to testify. I look forward to working
with you and the Subcommittee to see that these bills get moved
forward. And I would be happy to answer any questions that you
might have.
Thank you.
[The prepared statement of Mr. Blake appears on p. 14.]
Mr. Michaud. Thank you, Mr. Blake.
Mr. Needham.
STATEMENT OF CHRISTOPHER NEEDHAM
Mr. Needham. Chairman Michaud, Members of the Subcommittee,
thank you for the opportunity to testify today. The 2.3 million
members of the Veterans of Foreign Wars appreciate the chance
to comment on the important draft bills under consideration.
The first draft would exempt catastrophically disabled
veterans in Priority 4 from having to pay copayments for their
healthcare. The VFW strongly supports this.
The voting delegates to our National Convention have
approved Resolution Number 639, which calls for this exemption.
These veterans have a long list of specialized needs and VA
is uniquely suited to care for them. With their ability to work
impaired, they often lack other forms of health insurance as
well as the financial means to pay for the intensive care they
require.
The VA confers a special status on them by enhancing their
enrollment to protect their eligibility for care, but VA fails
to acknowledge this status when it comes to charging
copayments.
With special care copayments at $50.00 per visit, it does
not take too long before these men and women are suffering
financial burdens of hundreds of dollars.
Approving this bill is the right thing to do as it
eliminates an unfair financial penalty on a group of veterans
who truly demonstrate need.
A second draft bill would expand family access to
counseling services, closing a loophole in the law, which
prevents many families, especially those of Operation Enduring
Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, from
receiving care.
Under current law, which was written before the current
conflicts began, VA is authorized to provide counseling and aid
to families of veterans who lack a diagnosis of service
connection only if the counseling begins while the veteran is
hospitalized. The proposed changes of this bill would strike
that requirement, freeing up VA to provide a broader range of
services to more men and women and the families of those men
and women.
These families might not have access to VA's counseling
services because they are waiting months for VA to provide a
claims rating decision for their loved one or perhaps the
veteran has not yet filed for benefits despite suffering from
some illness or condition.
The need for these expanded services is clear, but the
prevalence of mental health issues among OEF/OIF veterans and
the importance of a safe, stable family life for their
recovery, these services are essential.
From marital counseling to assistance with helping their
loved one deal with the sometimes difficult transition, the
range of services VA can provide would be of great benefit to
the families of any recently separated servicemember.
But it is also important because these stresses and strains
affect not just the veteran, but the families as well. The pain
and emotions involved can be difficult and studies have shown
increasing numbers of servicemembers and their families are
facing marital difficulties and divorce.
Expanding these services to more people would make a
positive difference in the lives of our veterans and is the
right thing to do for their families,who in their own way make
a valuable contribution to the war effort.
The third bill under consideration today involves VA's
nonprofit research corporations. NPCs help VA conduct research
and education and they assist with fund raising, especially
from public and private services that VA otherwise would not
have access to.
The changes proposed by this bill would ultimately make
more funds available for critical research purposes while
tightening up control and oversight of the program in
accordance with the recent VA Inspector General report.
We believe that these changes would greatly benefit the
VA's research programs and America's veterans and we are
pleased to offer our support for it.
Mr. Chairman, this concludes my testimony, and I would be
happy to answer any questions you or the Members of the
Subcommittee may have.
[The prepared statement of Mr. Needham appears on p. 16.]
Mr. Michaud. Thank you both for your testimony.
Talking about looking at the mental health services bill,
the repeated deployment of our veterans in OIF and OEF have
created enormous strains on their families.
What types of services do you think family members need
most? We will start with Mr. Needham.
Mr. Needham. Well, certainly as I said in the statement,
divorce has become sort of an increasing problem. So marital
counseling, sort of family counseling issues sort of dealing
with the transition. How it affects the children as well.
For example, when you were speaking of repeated
deployments, there was testimony earlier before the Committee
that talked about how repeated deployments sort of increases,
greatly increases the chance of post traumatic stress disorder
(PTSD). And obviously PTSD is going to affect not just the
veteran but that family.
So family and marital counseling are definitely one of the
key things that needs to be done.
Mr. Michaud. Mr. Blake.
Mr. Blake. I would also suggest, Mr. Chairman, that some of
the problems that the family members, spouses, and dependents
or children face are not unlike some of the symptoms that many
of the veterans have as it relates to PTSD or other mental
health conditions.
Families certainly deal with depression because of the
strains that the soldiers' or the veterans' condition may place
on the family and other types of symptoms that relate to that.
I think there has been a lot of discussion about--I hate to
say suicidal tendencies, but, you know, suicidal thoughts among
veterans, and I do not think that that would necessarily be
unique to veterans. I think you also find that when the burden
of these mental health issues are weighed on the family that
probably similar symptoms occur within the family members as
well.
I would also encourage the Subcommittee to look at, we have
advocated for expanded caregiver assistance training for family
members or even for nonfamily members who provide caregiver
assistance to the most disabled veterans because we are finding
that in many cases, particularly among the most severely
disabled veterans, their family becomes their caregiver.
And I think through some sort of caregiver assistance
program, they may be reimbursed as a caregiver, that we could
also benefit these families.
Mr. Michaud. And as you both know, PTSD and traumatic brain
injury are the signature wounds of this war. Looking at the
length of the war and what we are seeing, do you think the VA
will need additional resources, funding, or personnel to
execute this legislation and how much of an increase do you
think they will need?
Mr. Needham. I am not sure I can quantify the increase, but
I think that the specific place where, at least the VFW has
seen a dramatic need for increase in personnel is at the Vet
Centers, particularly with the expansion of this family bill.
If the number of family members who are going to receive
care, and they primarily receive it through Vet Centers, is
going to be increased, then personnel at the Vet Centers is
going to increase as well.
What we have seen, at least so far, is that Vet Centers for
the most part are managing sort of with current staff levels.
Certainly there are some cases where, you know, there are
problems, but we have not necessarily seen any sort of long-
term waiting lines.
But as services continue to expand, whether, you know,
expansion of their current obligations, but also sort of as
more and more numbers of returning servicemembers and their
families actually access the current benefits afforded to them,
the staff members are going to need to increase there as well.
Mr. Michaud. Ms. Berkley, have any questions.
Ms. Berkley. Yes, I do. Thank you. Actually, I have a
written statement and then questions, if that is okay.
Ms. Berkley. I know that Mr. Hare has been very concerned,
as you know, and has been on the forefront of fighting for
veterans' mental health needs and additional funding and
access.
Since he is not here, if I could ask a question on his
behalf, and I think I would like to address it to Mr. Needham,
but you are both welcome to answer it.
In regards to OEF/OIF veterans who can receive care for up
to 5 years, current law says that the VA may provide necessary
family mental services.
What would your thoughts be on changing this language to
shall instead of may?
Mr. Needham. That is certainly an interesting possibility.
I do not think we would necessarily or obviously I do not think
we would oppose it.
The catch is, I think, the current system, the way it is
now, the current language can work with proper oversight. I
mean, certainly, you know, VA, I think, by and large has done a
pretty good job lately with mental healthcare issues. But as
you are well aware, in some cases, we have had to sort of drag
them kicking and screaming.
But as long as we have sort of proper oversight and
continued oversight and continued leadership within VA to
tackle these issues, I think finally now we realize the scope
of the problems, then a change in the language might not be
necessary.
Ms. Berkley. Okay. Thank you for your candid remark.
OPENING STATEMENT OF HON. SHELLEY BERKLEY
Ms. Berkley. I was absolutely delighted to learn a few
weeks ago that the Senate passed S. 2162, the ``Veterans Mental
Health Improvement Act.'' I introduced a House companion to
this bill.
This essential legislation increases research on post
traumatic stress disorder and substance use disorders by
establishing at least six National Centers of Excellence on
PTSD and substance use disorders. The bill is designed to focus
on how PTSD and substance use disorders affect each other.
These centers will offer comprehensive inpatient and
residential treatment programs for our returning veterans
diagnosed with PTSD and substance dependency.
This bill also contains a provision to provide for a review
of all residential mental health facilities and to honor Justin
Bailey. And I appreciate Mr. Michaud's help with that.
These provisions, which were also passed by the House in
H.R. 5554, ``The Justin Bailey Substance Use Disorders
Treatment And Prevention Action,'' are vital to ensure that our
veterans receive quality care at these residential mental
health facilities and to make sure that what happened to Justin
does not happen to anyone else.
And I can tell you in a conversation with Justin's father
after the bill passed the House, there was not a dry eye in my
office. He was so pleased and honored that his son's death may
prevent the death of others. And that was very important to
this family.
The Senate amended S. 2162 to include a number of
provisions to make it a package bill. Some other initiatives in
the Senate package include establishing Epilepsy Centers of
Excellence, reimbursements for veterans receiving emergency
treatment in non-VA facilities, homeless veterans' issues, as
well as providing counseling for families of veterans for
nonservice-connected issues.
This is a similar provision to one of the draft bills we
are discussing today. I am hopeful that the House and the
Senate will work together and get this important package to the
President. And I, of course, needless to say, although this is
a very supportive Committee and a wonderful Subcommittee
Chairman, we are all going to support this, I am sure.
Soon it will be 4th of July and we will all be home. Every
4th of July, I go to our homeless veterans' shelter and help
feed our homeless veterans and talk with them. So many of these
homeless vets and mostly, at least in Las Vegas, Vietnam era
veterans, so they are my contemporaries. While I was in
college, they were in Vietnam. I am always amazed at how
intelligent, how forthright, and how conversational they are.
And I keep thinking if not for the grace of God go I.
And I am very happy that this Committee, and this Nation,
appreciate the needs of the veterans coming home and that they
are not, or at least intentionally, being treated the way our
veterans coming home from Vietnam were treated. I think it
created a lasting schism in this country and created
unnecessary pain for thousands and thousands of young men that
were in Vietnam through no choice of their own and came home
badly damaged. And this Nation failed to recognize the damage
emotionally, mentally. And I am hoping that we can make it up
to our Vietnam vets by helping the veterans that are coming
back now.
And thank you both for the extraordinary efforts that you
have put forth to make sure that we are aware of the issues.
Thank you.
[The prepared statement of Congresswoman Berkley appears on
p. 13.]
Mr. Michaud. Mr. Salazar.
Mr. Salazar. Well, thank you, Mr. Chairman.
I just briefly wanted to thank you for your work on
veterans' issues, both of you.
I came in a little bit late. Did we discuss the bill that
is actually introduced by Mr. Buyer to consolidate patient
accounting centers?
Mr. Blake. Mr. Salazar, we did not actually get the bill
until late last night, so we have not really had a chance to
review it. But I think and Mr. Needham also said that we would
be glad to submit some comments after we have a chance to
review the bill.
Mr. Salazar. Okay. I just wanted your reaction to it. I do
not know whether the bureaucracy is actually more simplified by
doing this or if it becomes more cumbersome.
I would really appreciate it if you could review that and
take a look at it and give us an answer. Thank you.
Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much, Mr. Salazar.
I want to thank both of you once again for coming today. I
look forward to your written comments on Mr. Buyer's draft
proposal when it comes out. So, once again, thank you very
much. I appreciate it.
I would like to now hear from the second panel, Dr. Cross,
who is the Principal Deputy Under Secretary for Health, who is
accompanied by Walter Hall, who is the Assistant General
Counsel to the Department of Veterans Affairs, and Gary Baker,
who is the Chief Business Officer for the Veterans Health
Administration (VHA).
I want to welcome you three and look forward to hearing
your comments. And without further ado, Dr. Cross.
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A.
HALL, ASSISTANT GENERAL COUNSEL; AND GARY M. BAKER, CHIEF
BUSINESS OFFICER, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Dr. Cross. Good morning, Mr. Chairman and Members of the
Subcommittee, and thank you for inviting me here today to
present the administration views on several bills that would
affect the Department of Veterans Affairs programs that provide
healthcare benefits and services.
With me today are Walter Hall, Assistant General Counsel,
and Gary Baker, Chief Business Officer of the VHA.
I am pleased to provide the Department's views on the draft
bills under consideration.
Discussion draft one would amend current law to exempt
catastrophically disabled, nonservice-connected veterans and
zero percent service-connected veterans whose incomes place
them in a copayment required status for VA inpatient and
outpatient care.
We recognize that the draft bill is intended to address any
disproportionate financial burden that falls on these seriously
ill and disabled veterans. Because their catastrophic
disabilities are not service connected and because their
incomes exceed VA's mean test for low-income veterans, they are
not exempt from copayment requirements.
We share the Subcommittee's concern that these severely
disabled veterans not be subject to any undue financial burden
as a result of the copayment obligations. However, we are still
in the process of ascertaining these veterans' hospital and
outpatient utilization rates and copayments.
VA has not previously reported amounts and ranges of
copayments by enrollment category. Once we collect and analyze
all the necessary data, we will come back to the Subcommittee
with a recommendation as to the need for this legislation. And
until then, we request that the Subcommittee refrain from
taking action on this draft bill.
Discussion draft two would amend VA's authority to furnish
counseling, training, and mental health services to immediate
family members of veterans receiving VA treatment for a
nonservice-connected disability.
Currently all enrolled veterans other than those receiving
outpatient care for nonservice-connected disabilities are
eligible for these family support services to the extent they
are necessary to the veteran's treatment.
Veterans being treated for nonservice-connected
disabilities are only eligible for these family support
services when they are initiated during the veteran's
hospitalization. The draft bill would make this group of
veterans eligible for needed family support services similar to
other veterans.
VA supports this bill. An enrolled veteran is eligible for
any needed medical treatment regardless of whether the
condition is service connected and consistent with this
principle that family support services should be based on the
medical needs, not on inpatient status or the service
connection designation.
Importantly, these amendments could improve the treatment
outcomes for the affected groups of veterans. We are still
developing costs for this draft bill and we will submit them
for the record as soon as possible.
Discussion draft three would update the law applicable to
VA's nonprofit research and education corporations. VA
affiliated nonprofit research corporations are important to
VA's overall research program because they provide flexible
funding mechanisms for the administration of non-VA funds for
the conduct of VA approved research.
A provision of the discussion draft three would authorize a
single corporation, nonprofit corporation to facilitate the
conduct of research and education at more than one VA Medical
Center.
It would also make it clear that corporations may reimburse
a VA laboratory for the preliminary cost it incurs before a
research project has officially been approved by the Secretary.
VA would also be authorized to reimburse corporations for
costs incurred for the assignment of corporation employees to
VA under ``Intergovernmental Personnel Act 1970.''
Additionally, this draft bill would clarify that
corporations may set fees for certain education and training
programs they administer and retain those funds to offset
program expenses.
We support the provision of the draft bill that would
authorize the establishment of new multi-center, nonprofit
research corporations and the consolidation of existing single-
facility, nonprofit corporations into multi-facility ones. This
offers the prospect of nonprofit corporation assistance in
funding research projects to VA Medical Centers that are unable
to support their own dedicated corporation.
This provision would also provide the system with the tools
needed to consolidate or close nonprofit corporations that are
too small to institute proper internal controls without the
loss of the funding support for VA research and education
programs that the corporation provides.
By requiring the Directors at all Medical Centers supported
by a nonprofit corporation to sit on its Board of Directors,
the provision provides this beneficial increased flexibility
without sacrificing VA oversight.
With respect to the draft bill's remaining provisions, we
ask the Subcommittee to defer further action on this draft bill
in order to give the Department an opportunity to address
underlying structural issues and to formulate policy related to
the governance and finance of the VA affiliated nonprofit
research corporations.
Specifically a Steering Committee, a Steering Committee has
been chartered by the VHA Office of Research and Development to
provide recommendations regarding governance, oversight, and
finance issues related to the corporations by the end of the
fiscal year.
We will be happy to provide you with a copy of the final
report and recommendations.
Mr. Chairman, this concludes my prepared statement. I will
be pleased to answer any questions.
[The prepared statement of Dr. Cross appears on p. 18.]
Mr. Michaud. Thank you very much, Dr. Cross.
Dealing with the copayment issue, I know you are reviewing
that as far as number of veterans in Priority Group 4. When
will the report be complete dealing with Priority Group 4
veterans?
Dr. Cross. With the catastrophic provisions.
Mr. Michaud. Yes.
Dr. Cross. Our analysis on that is trying to do a better
job of understanding what the individual veterans are
experiencing with this program. We have average figures and we
have some figures that we are not quite comfortable with yet
that are preliminary, that we are still refining.
I would really like to know what the spectrum of those
costs are for veterans and what other sources of care and
support that they have in terms of insurance and other
assistance they receive based on higher income.
Until we get that information, which I hope we can get
toward the end of next week, and we will provide that for you.
[As of January 12, 2009, the VA failed to provide the
administration views on the two bills.]
Mr. Michaud. Okay. Great. Looking at the mental health
service for families, does the VA currently provide any of
these counseling, training, or mental health services for
family members outside of the Vet Centers?
Dr. Cross. Yes, we do. These services are provided for the
service-connected individuals and for the nonservice connected
for inpatients where necessary in conjunction with the
veteran's own treatment.
This is really directed at helping the family understand
and deal with and respond to the veteran's needs and whatever
the illness or injury that the veteran has sustained. And we
are doing that now.
Mr. Michaud. Do you expect that the workload is going to
increase and, if so, by how much and would you need additional
staffing and resources to take care of the additional workload?
Dr. Cross. I believe in our testimony we mentioned that we
are still working on some of the data related to cost. But we
think this is part of our mission to provide this.
And, furthermore, the rule that makes it necessary to start
the process only if the person is an inpatient does not really
respond to the current way that we do medical care.
So much more is being done for outpatients these days.
Procedures that used to be done as inpatient are commonly done
as outpatient circumstances. We need to move with the times and
be able to provide that support for families without getting
tangled up by that rule.
Mr. Michaud. And my only concern is with what is happening
in Iraq and Afghanistan and what we are seeing. And I agree
that family members is a big component of taking care of the
veterans. If you open up access in rural areas to include the
family members, which I think is extremely important, then that
is going to add an additional burden on the VA.
And my concern is that I want to make sure that the VA has
the staffing that it needs to take care of the men and women
that need help. And when you look at the healthcare shortage,
particularly in the mental health area, that could be
problematic.
Dr. Cross. Mr. Chairman, I think it is important that we
clarify the limits on what this would really provide us. I will
ask my associate, Mr. Hall.
Mr. Hall. Yes, sir. This authority would be limited to
providing training and counseling necessary to permit the
family to assist or aid the veteran in his treatment. It does
not authorize the Department to independently care for the
family members.
Mr. Michaud. But in that training and assistance, my
concern is if you are going to do it, that you do it adequately
and in a timely manner.
Will there be additional staffing needs for that? Doctor
are you are saying you can do it within existing resources?
Dr. Cross. We are doing much of it with existing resources
already. Plus we have expanded our mental health staffing quite
a bit. In fact, tremendously. But as I said in my statement, we
still need to look at the resource and cost issues just a bit
more.
Mr. Michaud. Okay. My last question is on the research
provision. The Senate companion bill, S. 2926, has a provision
that would authorize the nonprofit corporations to reimburse
the VA Office of General Counsel for specialized legal services
in regards to review and approval of certain research
agreements.
Is this provision necessary and, if so, can you explain why
that provision is necessary?
Dr. Cross. I will defer to Mr. Hall for that.
Mr. Hall. Sir, we are currently providing those services to
the research corporations. I think the research corporations
are continuously increasing the amount of work they do, the
number of agreements that they are entering into, and it is the
responsibility of the Office of General Counsel to review
those.
I think there is a concern with the attention they get and
the speed with which we are able to address them. We are able
to at this time to get to them all. I think there is always
some concern that we could do them more quickly with more
resources.
Mr. Michaud. Thank you.
Ms. Berkley.
Ms. Berkley. I just want to thank all of you for being
here, and I have no additional questions.
Mr. Michaud. Mr. Salazar.
Okay. Once again, I want to thank you, Dr. Cross, and Mr.
Baker and Mr. Hall for accompanying Dr. Cross, and for coming
here this morning. We look forward to working with you as we
move forward on these draft proposals.
Does the Counsel for the Minority side have any questions?
If there are no further questions, this hearing is
adjourned. Thank you.
[Whereupon, at 10:46 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for the VSOs, the VA
and other interested parties to provide their views on and discuss
draft legislation within the Subcommittee's jurisdiction in a clear and
orderly process.
I do not necessarily agree or disagree with the draft bills before
us today, but I believe that this is an important part of the
legislative process that will encourage frank discussions and new
ideas.
We have four draft bills before us today. These draft bills:
Expand VA's authority to provide mental health treatment
for family members
Prohibit the collection of copayments from
catastrophically disabled veterans
Authorize non-profit research and education corporations
in the Department of Veterans Affairs
Establish seven ``Consolidated Patient Accounting
Centers'' to facilitate 3rd party collections in the Department of
Veterans Affairs
I understand that the fourth bill that I mentioned (on the
establishment of Consolidated Patient Accounting Centers) was not ready
until yesterday and I do not expect our witnesses to have prepared
statements on this bill. We would, however, appreciate it if the
witnesses would provide their views on this bill for the record.
I look forward to hearing the views of our witnesses on the draft
legislation before us.
Prepared Statement of Hon. Shelley Berkeley,
a Representative in Congress from the State of Nevada
Mr. Chairman,
I am pleased to know that a few weeks ago the Senate passed S.
2162, the Veterans Mental Health Improvements Act. I introduced a House
companion to this bill, H.R. 4053. This essential legislation increases
research on post-traumatic stress disorder (PTSD) and substance use
disorders.
By establishing at least six national centers of excellence on PTSD
and substance use disorders, the bill is designed to focus on how PTSD
and substance use disorders affect each other. These centers will offer
comprehensive inpatient and residential treatment programs for our
returning heroes diagnosed with PTSD and substance dependency.
This bill also contains a provision to provide for a review of all
residential mental health facilities and to honor Justin Bailey. These
provisions which were also passed by the House in H.R. 5554, the Justin
Bailey Substance Use Disorders Treatment and Prevention Act, are vital
to ensure that our veterans receive quality care at these residential
mental health facilities and to make sure that what happened to Justin
does not happen to anyone else.
The Senate amended S. 2162 to include a number of provisions to
make it a package bill. Some other initiatives in the Senate package
include establishing epilepsy centers of excellence, reimbursements for
veterans receiving emergency treatment in non-VA facilities, homeless
veteran issues, as well as providing counseling for families of
veterans for non-service connected issues. This is a similar provision
to one of the draft bills we are discussing today.
I am hopeful that the House and the Senate will work together to
get this important package to the President and I encourage Members of
the Committee to support this initiative.
Prepared Statement of Hon. John T. Salazar,
a Representative in Congress from the State of Colorado
Thank you Mr. Chairman,
My district has one of the largest veteran populations in the state
of Colorado.
Rural health care, homelessness, improving research are constant
priorities.
I am interested in hearing the discussion on the mental healthcare
for families.
As a veteran I know the impact that military service has on
families.
Long deployments have also been hurting families in rural districts
like mine where many people are farmers and small business owners.
It is important that we address the total impact that extended
tours are having on our servicemen and women.
I also look forward to reviewing how we can better support
research.
Veterans deserve research that is prepared for tomorrow's
challenges.
Mr. Chairman, I thank you for the opportunity to discuss these
bills and make sure that they serve the many unique needs of our
veterans.
It is an honor to serve the heroes that have served our Nation.
Prepared Statement of Carl Blake,
National Legislative Director, Paralyzed Veterans of America
Chairman Michaud, Ranking Member Miller, Members of the
Subcommittee, on behalf of Paralyzed Veterans of America (PVA) I would
like to thank you for the opportunity to testify today on the proposed
legislation that is meant to enhance the health care services available
to veterans. We appreciate the efforts of this Subcommittee to address
the varying needs of the men and women who are currently serving in the
War on Terror as well as those men and women who served during past
conflicts.
Prohibition of Co-payments for Catastrophically Disabled Veterans
In accordance with the recommendations of The Independent Budget
for FY 2009, PVA strongly supports the draft legislation that would
prohibit the Department of Veterans Affairs (VA) from collecting
certain copayments from veterans who are catastrophically disabled.
This issue has the greatest impact on PVA members. The current VA
health care system allows veterans who have a non-service connected
catastrophic disability, such as spinal cord injury, and who have
incomes above means tested levels to enroll in Priority Group 4.
Because of their designation as catastrophically disabled any PVA
members not eligible for health care in Priority Group 1 can enroll in
the system in Priority Group 4. Congress granted these catastrophically
disabled veterans this higher priority for health care enrollment
because of the unique nature of their complex disabilities and in
recognition of the specialized services that only the VA health care
system can provide.
However, being enrolled in Priority Group 4 does not necessarily
exempt PVA members and other catastrophically disabled veterans from
the burden copayments impose. Those PVA members with non-service
connected disabilities, who because of their incomes would otherwise be
classified as Priority Group 7 or 8, can be enrolled in Priority Group
4 but are still subject to Priority Group 7 or 8 copayments. PVA
members go to the VA because there is no other system in the country
that provides the level and quality of spinal cord injury care. Over 80
percent of our members use the VA for all or part of their care.
Because of the nature of their disabilities they require a host of
pharmaceuticals, equipment, devices and supplies to function on a daily
basis. As stated in The Independent Budget for FY 2009:
The hardship [created] by a catastrophic injury or disease is
unique and devastating to the veteran and the family who may be
responsible for his or her care. At a time when the veteran is
in need of specialized assistance to regain some independence
and quality of life, the financial burden of medical bills
should be lifted. Any veteran determined by VA to be
catastrophically disabled and placed in the priority group 4
should be afforded the same benefits as if rated as entitled to
Aid & Attendance to eliminate medical/prescription co-pays and
provide assistance with travel for that care.
PVA looks forward to working with the Subcommittee to ensure that
those veterans who are already struggling with the hardships associated
with a catastrophic disability are relieved of this additional burden.
We believe that it is simply the right thing to do.
Counseling for Family Members of Veterans Receiving Non-Service
Connected Treatment
The proposed legislation would expand the authority of the VA to
provide counseling for family members of veterans receiving non-service
connected medical treatment. Currently, the VA provides consultation,
counseling and training to family members of veterans being treated by
the VA for a service-connected disability when those services for the
family members support the veteran's treatment.
Likewise, the VA is authorized to provide consultation, counseling
and training for a veteran's family, if the veteran has a non-service
connected disability as long as the veteran is receiving hospital care
and the services were initiated during the veteran's hospitalization
and if their continuation on an outpatient basis is essential to permit
the discharge of the veteran from the hospital. The proposed
legislation would eliminate the criteria for hospital care and expand
the authority of the VA to provide these essential services to family
members.
PVA supports this proposal. We have, along with the co-authors of
The Independent Budget, called for continued support for family
services to benefit the spouses and dependents who are dealing with the
struggles faced by the veteran. However, it is imperative that adequate
resources be devoted to these family support services if Congress
chooses to expand this authority.
The ``Veterans Nonprofit Research and Education Corporations
Enhancement Act''
PVA strongly supports the ``Veterans Nonprofit Research and
Education Corporations Enhancement Act.'' The purpose of this
legislation is to modernize and clarify the existing statutory
authority for VA-affiliated nonprofit research and education
corporations (NPCs). This bill will allow the NPCs to fulfill their
full potential in supporting VA research and education, which
ultimately results in improved treatments and high quality care for
veterans, while ensuring VA and congressional confidence in NPC
management.
Since passage of P.L. 100-322 in 1988 (codified at 38 U.S.C.
Sec. 7361-7368), the NPCs have served as an effective ``flexible
funding mechanism for the conduct of approved research and education''
performed at VA medical centers across the Nation. NPCs provide VA
medical centers with the advantages of on-site administration of
research by nonprofit organizations entirely dedicated to serving VA
researchers and educators, but with the reassurance of VA oversight and
regulation. During 2007, 84 NPCs received nearly $230 million and
expended funds on behalf of approximately 5,000 research and education
programs, all of which are subject to VA approval and are conducted in
accordance with VA requirements.
NPCs provide a full range of on-site research support services to
VA investigators, including assistance preparing and submitting their
research proposals; hiring lab technicians and study coordinators to
work on projects; procuring supplies and equipment; monitoring the VA
approvals; and a host of other services so the principal investigators
can focus on their research and their veteran patients.
Beyond administering research projects and education activities,
when funds permit, these nonprofits also support a variety of VA
research infrastructure expenses. For example, NPCs have renovated
labs, purchased major pieces of equipment, staffed animal care
facilities, funded recruitment of clinician-researchers, provided seed
and bridge funding for investigators, and paid for training for
compliance personnel.
Although the authors of the original statute were remarkably
successful in crafting a unique authority for VA medical centers,
differing interpretations of the wording and the intent of Congress,
gaps in NPC authorities that curtail their ability to fully support VA
research and education, and evolution of VA health care delivery
systems have made revision of the statute increasingly necessary in
recent years. This legislation contains revisions that will resolve all
of these and will allow the NPCs to better serve VA research and
education programs while maintaining the high degree of oversight
applied to these nonprofits.
The legislation reinforces the idea of ``multi-medical center
research corporations'' which provides for voluntary sharing of one NPC
among two or more VA medical centers, while still preserving their
fundamental nature as medical center-based organizations. Moreover,
accountability will be ensured by requiring that at a minimum, the
medical center director from each facility must serve on the NPC board.
This authority will allow smaller NPCs to pool their administrative
resources and to improve their ability to achieve the level of internal
controls now required of nonprofit organizations.
The legislation also clarifies the legal status of the NPCs as
private sector, tax exempt organizations, subject to VA oversight and
regulation. It also modernizes NPC funds acceptance and retention
authorities as well as the ethics requirements applicable to officers,
directors and employees and the qualifications for board membership.
Moreover, it clarifies and broadens the VA's authority to guide
expenditures.
We would urge the Subcommittee to reconsider one substantive change
that the Subcommittee's draft bill makes to its Senate companion, S.
2926. That is, deletion of the provision that would authorize the NPCs
to reimburse the VA Office of General Counsel for specialized legal
services in regard to review and approval of certain research
agreements. While we would agree that the VA Office of General Counsel
is obligated and funded to provide these services, the funds generated
by these reimbursements would provide it with additional training and
staffing resources to meet the high demand for these services which we
understand may be obtained exclusively from VA attorneys. We also
understand that the foundations are in favor of making these
reimbursements and that because in most cases the cost may be passed
through to sponsors in the form of a legal review fee, there would be
little or no impact on the funding available for the conduct of the
research itself. In our view, this reimbursement authority would be
appropriate and PVA would concur with adding the necessary provisions
to the Subcommittee's discussion draft.
PVA has been a strong supporter of the NPCs since their inception,
recognizing that they benefit veterans by increasing the resources
available to support the VA research program and to educate VA health
care professionals. We urge expeditious passage of this proposed bill
so that veterans may benefit even more from the enhancements in
operational capabilities and oversight that this bill provides.
Chairman Michaud and Ranking Member Miller, we appreciate the
emphasis you have placed on providing for the needs of the men and
women who have served and continue to serve in harm's way. We look
forward to working with you to ensure that the best quality health care
services are made available to them.
Thank you again for the opportunity to testify. I would be happy to
answer any questions that you might have.
Prepared Statement of Christopher Needham,
Senior Legislative Associate, National Legislative Service,
Veterans of Foreign Wars of the United States
Mr. Chairman and Members of the Subcommittee:
On behalf of the 2.3 million men and women of the Veterans of
Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to
thank you for the opportunity to provide our views on the draft bills
under consideration at today's hearing. All three would make meaningful
changes in the law, improving the quality of health care this Nation's
veterans receive at the Department of Veterans Affairs (VA). We urge
quick passage of all three.
Draft Bill, Family Counseling
The VFW is pleased to support this legislation, which would expand
the counseling services that VA provides to family members of sick and
disabled servicemembers.
Currently, VA provides limited services to family members, under
certain circumstances. This bill would strike two of the requirements
for veterans not yet rated as service-connected--that the family
members begin counseling while the veteran is still hospitalized, and
that the services are necessary for the veteran to adjust outside the
hospital. Striking these two requirements would greatly expand the
range of services VA could provide, and would be of great benefit to
veterans, especially those returning from the front lines of Iraq and
Afghanistan.
This section of the law was crafted before the current conflicts
began, and it needs to be updated to reflect the changes in the needs
of veterans. In the case of a returning servicemember who is in need of
care, many are not rated as service connected because either they have
not yet applied for benefits, or because of the length of time it takes
VA to produce a decision on a claim. This same veteran may also not be
hospitalized for their condition, instead receiving limited outpatient
treatments. In both cases, the support VA can provide to the veteran's
family is limited.
We have seen with this conflict--especially with mental health
issues--that families are at the forefront of providing care and easing
the servicemember's transition back into civilian life. Their spouses
and loved ones can provide a safe, stable and supportive network, and
their involvement can only improve the effectiveness of the treatment
that veterans receive.
Beyond that, the stresses and strains of frequent deployments and
the transition period affect families as well. The impact of the
conflict extends beyond the deserts of Iraq and mountains of
Afghanistan, right into each family's front door. Numerous studies have
shown that increasing numbers of separating servicemembers are facing
marital problems and difficulties at home, at a time when the stability
of family is often so essential.
Expanding the range of services we provide to the families of our
veterans is the right thing to do for all. This bill would make a
meaningful difference in the lives of thousands of men and women, and
we urge its quick passage.
Draft Bill, Eliminating Co-Payments for Catastrophically Disabled
Veterans
The VFW is happy to offer our strong support for this draft
legislation, which would exempt catastrophically disabled veterans in
enrollment priority category four from having to pay hospital or
nursing home copayments. This bill is clearly the right thing to do as
it eliminates an unfair financial penalty on a group of veterans who
demonstrate true need.
These catastrophically disabled veterans were placed in category
four to protect their enrollment status. This group of veterans has a
long list of special needs, many of which VA is uniquely suited to
address. For great numbers of them, VA is their safety net. With their
inability to work, they often lack other forms of health care
insurance, but also the financial means to pay for the intensive health
care services their conditions require. If VA is there to, in part,
provide care for those who have the greatest need, then changing this
policy is entirely justified.
The nature of their disabilities means that these men and women
require intensive and lifelong care. VA acknowledges their unique needs
by providing the specialized services to them, but at the same time, VA
fails to recognize their special circumstances by charging them
copayments.
The VFW has had a longstanding resolution in support of this
concept. Most recently, the voting delegates to our 108th National
Convention approved Resolution 639, calling for this exemption. I would
note that our resolution also requests that this exemption be extended
to those low-income, pension-eligible veterans in category five. They,
too, have a demonstrated need for VA health care services and finances
can often be a deterrent to receiving their earned health care. We
would ask the Subcommittee to consider this issue.
Draft Bill, Nonprofit Research and Education Corporations
The VFW is pleased to offer our support for the draft bill on
nonprofit research and education corporations. The changes this bill
would make would strengthen and improve VA's nonprofit research
corporations (NPCs). NPCs help VA to conduct research and education and
assist in the raising of funds for VA's essential projects from sources
VA otherwise might not have access to, to include private and public
funding sources. NPCs also provide administrative support and services,
freeing up VA researchers to focus on their projects and patients.
The legislation would allow for the creation of multi-medical
center NPCs. This would let several smaller facilities pool their
resources to improve management or staffing. We believe that this would
streamline the administration of these organizations, reducing
overhead, but also tightening up their control, especially in
accordance with the recent VA Inspector General report.
This bill would also reaffirm that NPCs are 501(c)(3) organizations
that are not owned or controlled by the federal government. This is
important to ensure that they are able to receive funding from all
sources and to clarify their purpose in accordance with various state
laws and private foundation regulations.
Ultimately, the bill would make more funds available for critical
research purposes. It would also improve the accountability and
oversight of these corporations, requiring more information in their
annual reports and periodic audits of their activities. Together, these
changes would greatly benefit America's veterans.
We strongly support this legislation, and urge the Subcommittee to
report it favorably.
Mr. Chairman, this concludes my testimony. I would be happy to
answer any questions that you or the Members of the Subcommittee may
have. Thank you.
Prepared Statement of Gerald M. Cross, M.D., FAAFP,
Principal Deputy Under Secretary for Health,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Subcommittee:
Mr. Chairman, thank you for inviting me here today to present the
Administration's views on several bills that would affect Department of
Veterans Affairs (VA) programs that provide veteran healthcare benefits
and services. With me today are Walter Hall, Assistant General Counsel,
and Gary Baker, Chief Business Officer, Veterans Health Administration.
I am pleased to provide the Department's views on the 3 draft bills
under consideration by the Subcommittee.
Discussion Draft #1. Catastrophically Disabled Veterans' Exemption from
Certain Copayment Requirements
Discussion Draft #1 would amend current law to exempt a veteran who
is catastrophically disabled from having to pay copayments that would
otherwise apply to inpatient and outpatient services that the veteran
receives through the Department.
Mr. Chairman, we recognize that the draft bill is intended to
address any disproportionate financial burden that falls on these
seriously ill and disabled veterans because their very complex medical
needs compel their high use of the VA healthcare system. The draft bill
is targeted at the approximately 25,000 veterans who because of their
conditions rely on VA healthcare services more than any other veteran-
population enrolled in our system. Because their catastrophic
disabilities are not service-connected and because their incomes exceed
VA's means test level for low-income veterans, they are not exempt from
the copayment requirements.
We share the Subcommittee's concern that these severely disabled
veterans not be subject to an undue financial burden as a result of the
copayment obligations that apply to their receipt of inpatient and
outpatient care. However, we are still in the process of ascertaining
these veterans' hospital and outpatient utilization rates and
copayments. VA has not previously tracked amounts and ranges of
copayments by enrollment category. Without that data, we cannot
determine the extent of their copayment liability or project the
estimated loss in revenue that would be associated with this bill's
enactment. Once we have had an opportunity to collect and analyze all
of the necessary data, we will come back to the Subcommittee with a
recommendation as to the need for this legislation or any other
approach that the administration believes, based on the confirmed data,
might be an appropriate means of protecting these veterans from undue
copayment burden. Until then, we therefore request that the
Subcommittee refrain from taking action on this draft bill.
Discussion Draft #2. Counseling, Training, and Mental Health Services
for Immediate Family Members of Veterans Receiving Treatment
for a Non-Service Connected Disability
Discussion Draft #2 would amend VA's authority to furnish
counseling, training, and mental health services to immediate family
members of veterans receiving VA treatment for a non-service connected
disability. Currently, all enrolled veterans other than those who are
receiving outpatient care for non-service connected disabilities are
eligible for these family support services to the extent they are
necessary to the veterans' treatment. Veterans being treated for non-
service connected disabilities are only eligible for these family
support services only to the extent they are necessary in connection
with the veteran's treatment and if they were initiated during the
veteran's hospitalization and their continued provision on an
outpatient basis is deemed essential to permit the discharge of the
veteran from the hospital. The draft bill would eliminate the
requirements that the services be initiated during the veteran's
hospitalization and deemed essential to permit the veteran's discharge,
thus making the eligibility criteria the same for all veterans.
VA supports Discussion Draft #2. Over the last decades, VA has
successfully transformed its delivery of healthcare services from an
inpatient-based model to an outpatient-based model. This has
significantly increased our efficiencies, increased veterans' access to
care, and aligned our system with the healthcare industry at large.
However, as a result, some families have become ineligible for
counseling, training, and other family support services that are
essential to the veterans' treatment simply because their loved ones'
care was for a non-service connected disability that was provided on an
outpatient basis. The draft bill would eliminate vestiges of an old
system that no longer have any place in today's VA healthcare system.
An enrolled veteran is eligible for any needed medical treatment,
regardless of whether the condition is service-connected. It is
incongruent to still base eligibility for needed family support
services on the service-connected nature of the veteran's disability.
As long as the family support services are necessary in connection with
the veteran's treatment, it should be irrelevant whether the disability
under treatment is service-connected and whether it was provided in
hospital. Importantly, these amendments could improve the treatment
outcomes for the affected group of veterans.
We are still developing costs for this draft bill and will submit
them for the record as soon as possible.
Discussion Draft #3. Veterans Nonprofit Research and Education
Corporations Enhancement Act of 2008
Discussion Draft #3 would update the law applicable to VA's
nonprofit research and education corporations (corporations). VA-
affiliated nonprofit research corporations are critical to VA's overall
research program because they provide flexible funding mechanisms for
the administration of non-VA funds for the conduct of VA-approved
research.
A provision of Discussion Draft #3 would authorize a single
corporation to facilitate the conduct of research and education at more
than one VA medical center. It would also make it clear that
corporations may reimburse a VA laboratory for the preliminary costs it
incurs before a research project has been officially approval by the
Secretary. VA would also be authorized to reimburse corporations for
costs incurred for the assignment of corporation employees to VA under
the Intergovernmental Personnel Act 1970 (IPA).
Additionally, this draft bill would clarify that corporations may
set fees for certain education and training programs they administer
and retain those funds to offset program expenses.
We support the provision of the draft bill that would authorize the
establishment of new multi-center non-profit research corporations
(NPCs) and the consolidation of existing single facility NPCs into
multi-facility NPCs. This offers the prospect of NPC-assistance in
funding research projects to VA medical centers (VAMCs) that are unable
to support their own dedicated corporation. This provision would also
provide the system with the tools needed to consolidate or close NPCs
that are too small to institute proper internal controls without the
loss of the funding support for VA research and education programs that
the NPCs provide. By requiring the Director of all VAMCs supported by
an NPC to sit on its board of directors, the provision provides this
beneficial increased flexibility without sacrificing VA oversight.
With respect to the draft bill's remaining provisions, we ask the
Subcommittee to defer further action on this draft bill in order to
give the Department an opportunity to address underlying structural
issues and to formulate policy related to the governance and finance of
the VA affiliated non-profit research corporations. A steering
Committee has been chartered by the Veterans Health Administration
Office of Research and Development, to provide recommendations
regarding governance, oversight, and finance issues related to the
corporations by the end of the fiscal year. We will be happy to provide
you with a copy of their final report and recommendations.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to answer any questions you or any of the Members of the
Subcommittee may have.
Statement of Joseph L. Wilson,
Deputy Director, Veterans Affairs and Rehabilitation
Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
view on the three pieces of draft legislation being considered by the
Subcommittee today. The American Legion commends this Subcommittee for
holding a hearing to discuss these very important and timely issues.
Prohibition on Collection of Copayments from Veterans Catastrophically
Disabled
This bill seeks to prohibit the Secretary of Veterans Affairs from
collecting certain copayments from veterans who are catastrophically
disabled. Veterans who are categorized by the Department of Veterans
Affairs (VA) as Priority Group Four are also the catastrophically
disabled. These veterans depend on the VA health care system as their
primary source of health care support.
The American Legion, in this case, believes VA should discontinue
and further disallow the collection of copayments and other relative
fees as this unconscionable action is warrantless when measured against
the sacrifices veterans made in serving this Nation. We hereby urge the
enactment of this bill, which will alleviate the added fiscal strain
veterans and their families are enduring.
Veterans Nonprofit Research and Education Corporations Enhancement Act
of 2008
This bill seeks to modify and update the provisions of law relating
to nonprofit research and education corporations, and for other
purposes.
The American Legion has no position on this piece of legislation.
Provision of Counseling for Family Members of Veterans Receiving Non
Service-Connected Treatment
This bill seeks to expand the authority of the Secretary of
Veterans Affairs to provide counseling for family members of veterans
receiving nonservice-connected treatment. During site visits to various
VA Medical Centers, Vet Centers, and Community Based Outpatient Clinics
(CBOCs), The American Legion has recognized many gaps in services to
families of veterans; mainly due to the absence of legislation which
would allow complete counseling of the veteran's loved ones throughout
the VA Medical System.
After all, the family, who began as a support system, may
potentially suffer as a result of illnesses and injuries sustained by
the veteran during his or her deployment in theater. If lack/absence of
counseling is the result, this in turn weakens the family unit;
subsequently the veteran may suffer further ordeals, which renders the
veteran's transition futile.
The American Legion therefore urges this Subcommittee to pass this
legislation, which would allow the provision of adequate counseling for
family members of veterans receiving nonservice-connected treatment. We
also urge DoD and VA to enhance and further create family support
programs to improve the quality-of-life for all veterans and their
families.
Again, thank you Mr. Chairman for allowing The American Legion this
opportunity to present its views on the aforementioned issues. We look
forward to working with the Subcommittee to help increase and improve
access to quality care for our Nation's veterans.
Prepared Statement of Raymond C. Kelley,
National Legislative Director, American Veterans (AMVETS)
Chairman Michaud, Ranking Member Miller, thank you for holding this
important hearing today. AMVETS is pleased to provide our views on
pending health care legislation.
AMVETS wholly supports draft legislation that would prohibit the
collection of copayments from veterans who are catastrophically
disabled. As co-authors of the Independent Budget, AMVETS believes that
the hardship endured by a catastrophic injury or disease is devastating
to the veterans and the family left responsible for care. Waiving
copayments for these veterans and their families can help alleviate the
financial burden assumed by the need for specialized assistance.
Veterans enrolled in health care eligibility category 4 should be
exempt from all health-care copayments and fees.
AMVETS supports draft legislation that would grant greater
authority of the Secretary of Veterans Affairs to provide counseling
for family members of veterans receiving non-service connected
treatment. Currently, the Department of Veterans Affairs provides
counseling and training to family members only if the veteran is
receiving hospital care or if the services were rendered during the
veteran's hospitalization and continuation is necessary in order to
permit discharge from the medical facility. This legislation would
remove those two stipulations. AMVETS supports any family services,
including counseling, that will help alleviate problems experienced by
veterans.
AMVETS also supports the ``Veterans Nonprofit Research and
Education Corporations Enhancement Act of 2008.'' This legislation
seeks to modify and update provisions relating to nonprofit research
and education corporations operating within the Department of Veterans
Affairs. Currently these research and education corporations provide
on-site administration of research entirely dedicated to VA researchers
and educators. They prepare and submit research proposals, hire lab
technicians and study coordinators to work on projects, procure
supplies and equipment, and monitor VA approvals. Having these
corporations benefits veterans by increasing the resources available to
support VA research programs and education. They serve as a vital tool
to improving the quality of healthcare being rendered to veterans in VA
facilities.
This legislation provides for voluntary sharing of each corporation
among two or more VA medical centers, or ``multi-medical center
research corporations''. Accountability is maintained by requiring a
center director from each facility serves on the Board of Directors. It
also clarifies the legal status of these corporations as a private
501(c)(3) overseen by the VA.
Different interpretation of the language and intent of Congress in
creating these corporations has necessitated clarification through this
bill. Gaps in authority restrict their capacity to fully support VA
research and education. This bill will resolve these matters and
strengthen the service to VA research.
Mr. Chairman, this concludes my testimony. I will be happy to
answer any questions regarding our opinion on these matters.
Statement of Adrian M. Atizado,
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this important legislative hearing of the Committee on
Veterans' Affairs' Subcommittee on Health. DAV is an organization of
1.3 million service-disabled veterans, and devotes its energies to
rebuilding the lives of disabled veterans and their families.
You have requested testimony today on three draft bills primarily
focused on healthcare services for veterans under the jurisdiction of
the Veterans Health Administration, Department of Veterans Affairs
(VA). This statement submitted for the record reviews our positions on
all of the proposals before you today, and we offer them for your
consideration.
Draft Bill to Expand VA Authority to Provide Consultation, Counseling,
Training and Mental Health Services for Family Members of
Veterans Receiving Nonservice-Connected Treatment
As this Subcommittee is aware of the importance of families in the
recovery of disabled veterans, VA is able to provide limited services
to family members, which includes members of the immediate family, the
legal guardian of a veteran, or the individual in whose household the
veteran certifies an intention to live. In recent years, VA has
included families in mental health evaluations, participation in
treatment planning, and collaboration in monitoring treatment outcomes.
Such services are provided to families only when their involvement is
included in a treatment plan designed to benefit the veteran.
Section 1782(a) of title 38, United States Code, provides, in
general, that the family members of a veteran being treated for a
service-connected disability may receive consultation, counseling,
training and mental health services in support of the veteran's
treatment. Section 1782(b) pertains to veterans receiving hospital care
for a non-service connected disability. In this instance, VA is
authorized to provide those same services to family members if the
services were initiated during the veteran's hospitalization and their
continuation on an outpatient basis is essential to permit the
discharge of the veteran from the hospital.
The draft bill for consideration in today's hearing would seek to
eliminate the aforementioned criteria, and to conform section 1782 to
the provision of services more consistent with medical necessity by
expanding VA's authority to provide mental health services for family
members of veterans receiving treatment for nonservice-connected
ailments. While DAV has no adopted resolution from our membership
pertaining to this measure, it appears beneficial because some veterans
may have a pending claim for service connection of the disability for
which he or she is seeking VA care. Other veterans may not be aware
that they may have a meritorious service-connected claim to a
disability for which they are receiving nonservice-connected treatment.
While the measure would provide needed care to disabled veterans,
we urge this Subcommittee to ensure additional workload be met with
appropriate resources in light of VA testimony that, ``funding family
readjustment services wholly unrelated to the veteran's readjustment
needs would divert medical care funds needed for veterans' health
care.'' Moreover, such resources should allow VA to be the primary
provider of such services and where, on occasion, non-VA providers
would be necessary for the provision of care, it is essential that such
providers have the proper training and that VA provide the appropriate
oversight.
Draft Bill to Prohibit VA From Collecting Certain Copayments From
Veterans Who Are Catastrophically Disabled
In conjunction with DAV's national resolution from our membership
calling for legislation to repeal all copayments for military retirees
and veterans' medical services and prescriptions, and as part of The
Independent Budget (IB), the DAV fully supports this draft bill, one
that meets the IB recommendation that veterans designated by VA as
being catastrophically disabled for the purpose of enrollment in health
care eligibility category 4 should be exempt from all health care
copayments and fees.
The Veterans Nonprofit Research and Education Corporations Enhancement
Act of 2008 (Draft bill)
This measure would modernize and enhance oversight and reporting
requirements of nonprofit research and education corporations that
support VA biomedical research by managing extramural grant funds made
available to VA principal investigators. It would also provide new
guidance and policy requirements for the operation of these
corporations within the VA research program, and would be responsive to
recent recommendations for improved accountability within some of these
corporations made by the VA Inspector General.
The basic statutory authority for these corporations was enacted in
1988, so this bill would be the first significant amendment to that
statute. If enacted, this bill would authorize the corporations to
fulfill their full potential in supporting VA biomedical research and
education, the results of which would improve treatments and promote
higher quality care for veterans, while underwriting VA and
Congressional confidence in these corporations' management of public
and private funds.
We note one significant difference between the Subcommittee's draft
bill and its Senate companion bill. S. 2926 would authorize the VA
research and education foundations to reimburse the VA Office of
General Counsel for certain specialized legal services rendered to the
foundations in connection with establishing and administering research
and education agreements entered into by the foundations with other
partners in conducting VA research. This provision is absent from this
Subcommittee's legislation. We understand that the foundations need
these services, and would be required to pay private attorneys for
them, and that the Office of General Counsel, in providing these
services, has expended considerable resources in aiding these
foundations to execute and administer research and education
agreements. We also understand that the foundations are in agreement on
such reimbursements. It would seem equitable that the foundations be
authorized to reimburse those costs to the Office of General Counsel,
and thus, DAV would have no objection to these Senate provisions being
added into this bill.
While DAV has no adopted resolution on this particular legislation,
DAV is a strong supporter of a robust VA biomedical research and
development program, and we believe enactment of this bill would be in
that program's best interest. Therefore, DAV would have no objection to
enactment of this bill.
Mr. Chairman, again, DAV appreciates the Subcommittee's interest in
these issues, and we appreciate the opportunity to present the DAV's
views, which we hope will be helpful.
Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health
Thank you, Mr. Chairman.
I would like to welcome our colleague from Florida, Vern Buchanan
to the Subcommittee on Health. Having served 6 years in the Air
National Guard, Vern brings with him strong military values and
experience that will be an asset to our Subcommittee and our Nation's
veterans.
Mr. Chairman, we have worked well together this year to move
legislation for the benefit of our veterans, and I look forward to
continuing to work in a bipartisan manner as we consider four draft
legislative proposals today.
One of the bills before us today would prohibit collecting
copayments from catastrophically disabled veterans enrolled in priority
group 4. There are about 25,000 veterans in Priority Group 4 who have
been determined to be catastrophically disabled and are still subject
to copay requirements. This legislation would ensure that copay rules
do not apply to any Priority Group 4 veterans.
A second bill would expand VA's authority to provide services to
family members of veterans seeking services for non-service connected
conditions.
We will also examine legislation to clarify and update provisions
of law authorizing VA-affiliated Nonprofit Research and Education
Corporations (NPCs). In 2006, VA's NPCs reported over $230 million in
revenues to support VA-approved research and education activities.
These NPCs work in coordination with VA Medical Centers, and it is
important that we provide effective oversight to ensure the proper
management of these corporations.
Additionally, a fourth bill, H.R. 6366, the Veterans Revenue
Enhancement Act of 2008 was recently added to the Subcommittee's
agenda, and provided to our witnesses yesterday. The Government
Accountability Office (GAO) reported this month that problems in
billing processes at VA continue to impair VA's ability to maximize
collections from third-party insurance companies. They estimated that
1.2 to 1.4 billion dollars are going uncollected. GAO did note,
however, that a congressionally mandated Mid-Atlantic Consolidated and
Revenue Improvement Demonstration Project increased cash collections
using effective cycle management tools and process standardization.
This demo collected an additional seven million dollars. The bill would
require VA within 5 years to establish not more that seven consolidated
patient accounting centers modeled after this successful Mid-Atlantic
Consolidated Patient Accounting Center in Asheville, North Carolina. I
understand that given the short time to respond our witnesses may not
be able to comment on this legislation today. However, I would
appreciate and request that your views be provided for the record
following the hearing.
Statement of Barbara F. West,
Executive Director, National Association of Veterans'
Research and Education Foundations
Chairman Michaud and Members of the Committee on Veterans Affairs
Subcommittee on Health, thank you for the opportunity to present a
statement on behalf of the National Association of Veterans' Research
and Education Foundations (NAVREF) in regard to the Discussion Draft of
the ``Veterans Nonprofit Research and Education Corporations
Enhancement Act of 2008.''
NAVREF is the membership organization of the 84 VA-affiliated
nonprofit research and education corporations (NPCs) originally
authorized by Congress under Public Law 100-322, and currently codified
at sections 7361 through 7368 of the United States Code. NAVREF's
mission is to promote high quality management of the NPCs and to pursue
issues at the Federal level that are of interest to its members. NAVREF
accomplishes this mission through educational activities for its
members and interactions and advocacy with agency and congressional
officials. Additional information about NAVREF is available on its Web
site at www.navref.org.
Background about the NPCs
In 1988, Congress allowed the Secretary of the Department of
Veterans Affairs to authorize ``the establishment at any Department
medical center of a nonprofit corporation to provide a flexible funding
mechanism for the conduct of approved research and education at the
medical center.'' [38 U.S.C. Sec. 7361(a)] At this time, 84 NPCs
provide their affiliated VA Health Care Systems and medical centers
with a highly valued means of administering non-VA Federal research
grants and private sector funds in support of VA research and
education. The fundamental purpose of the nonprofits is to serve
veterans by supporting VA research and education to improve the quality
of care that veterans receive.
Last year, the NPCs collectively administered $230 million with
expenditures that supported nearly 5,000 VA-approved research and
education programs. These nonprofits are dedicated solely to supporting
VA and veterans. This includes providing VA with the services of nearly
2,500 without compensation (WOC) research employees who work side-by-
side with VA-salaried employees, all in conformance with the VA
background, security and training requirements such appointments
entail.
Beyond administering research projects and education activities
these nonprofits support a variety of VA research infrastructure and
administrative expenses. They have provided seed and bridge funding for
investigators; staffed animal care facilities; funded recruitment of
clinician researchers; paid for research administrative and compliance
personnel; supported staff and training for institutional review boards
(IRBs); and much more.
Legislation Would Enhance and Clarify NPC Authorities
The Discussion Draft heading correctly states that the purpose is
to ``modify and update'' the 1988 statute, but it also modernizes and
clarifies the statute after nearly 20 years of experience under its
current terms. The NPCs have already proven themselves to be valued and
effective ``flexible funding mechanisms for the conduct of approved
research,'' and this legislation will further enhance their value to
VA.
The objectives of this legislation are consistent with the findings
in the recently released VA Office of Inspector General (OIG) review of
five NPCs and VHA's oversight of them. VHA is working hard to address
the shortcomings in oversight that the OIG identified. And NAVREF and
the NPCs are working equally hard to ensure that NPCs have appropriate
controls over funds and equipment (including strengthening the
documentation for all transactions), and that all NPC officers,
directors and employees are certifying their awareness of the
applicable Federal conflict of interest regulations. While NAVREF
firmly believes that NPC boards and administrative employees strive to
be conscientious stewards of NPC funds, NAVREF thanks the OIG for its
thorough review of those five NPCs and for bringing to light these
areas in need of improvement.
It is noteworthy for the Subcommittee that the OIG report cited no
actual misuse of funds or instances of conflicts of interest, dual
compensation of Federal employees or fraud. However, we take very
seriously the OIG finding that these NPCs nonetheless did not have
adequate controls over some of the funds they manage. We believe that
two major provisions in the Discussion Draft directly address this
finding.
First, section 2 allows formation of ``multi-medical center
research corporations'' (MMCRCs). That is, two or more VA medical
centers may share one NPC, subject to board and VA approval, while
preserving their fundamental nature as medical center-based
organizations. This will allow interested VA facilities with small
research programs to join with larger ones. Or several smaller
facilities may pool their resources to support management of one NPC
with funds and staffing adequate to ensure an appropriate level of
internal controls, including segregation of financial duties.
Second, the last item in section 5(a) of the Discussion Draft
addresses the OIG criticism by broadening VA's ability to guide NPC
expenditures. The only constraint on VA is that such guidance must be
consistent with other Federal and state requirements as specified in
laws, regulations, executive orders, circulars and directives--of which
there are many--applicable to other 501(c)(3) organizations. The
purpose of this limitation is to avoid the possibility of imposing on
NPCs conflicting requirements or reducing their ability to remain
independent ``flexible funding mechanisms.''
The Discussion Draft provides a number of other welcome
enhancements to the NPC authorizing statute.
Section 4(b)(2) of the draft legislation broadens the
qualifications for the two mandatory non-VA board members beyond
familiarity with medical research and education. This will allow NPCs
to use these board positions to acquire the legal and financial
expertise needed to ensure sound governance and financial management.
Section 4(c) of the draft legislation also deletes the
overly broad stipulation in the current statute that these non-VA board
members may not have ``any financial relationship'' with any for-profit
entity that is a source of funding for VA research or education. This
absolute prohibition conflicts with regulations applicable to Federal
employees with respect to conflicts of interest, which are invoked for
all NPC directors and employees in section 7366(c)(1) of title 38,
United States Code. Unlike the deleted provision, Federal conflict of
interest regulations provide means of recusal as well as de minimus
exceptions. Additionally, the prohibition has been interpreted to apply
to any individual who has ever accepted compensation or reimbursement
from a for-profit sponsor of VA research for purposes unrelated to VA
research, thereby eliminating many otherwise desirable and qualified
individuals from serving on NPC boards.
Section 5(a) also increases the efficiency of NPC
administration of funds generated by educational activities. This
clause allows NPCs to charge registration fees for the education and
training programs they administer, and to retain such funds to offset
program expenses or for future educational purposes. However, it also
explicitly sustains the existing prohibition against NPCs accepting
fees derived from VA appropriations.
Additionally, section 5(a) of the draft legislation
includes authority for VA to reimburse NPCs for the salary and benefits
of NPC employees loaned to VA under Intergovernmental Personnel Act
(IPA) assignments conducted in accordance with section 3371 of title 5,
United States Code. This provision responds to recent OIG questions
asking whether such reimbursements are allowable and permits VA to
continue to benefit from this efficient and cost-effective mechanism to
acquire the temporary services of skilled research personnel.
We note that the Discussion Draft omits the clauses contained in
the Senate companion bill, S. 2926, that would provide NPCs with
authority to reimburse the Office of General Counsel (OGC) for legal
services related to review and approval of Cooperative Research and
Development Agreements (CRADAs), the form of agreement used to
establish terms and conditions for industry-funded studies performed at
VA medical centers and administered by NPCs. While we agree that OGC is
already obligated to review these agreements without reimbursement, the
funds generated under this provision would help OGC to staff Regional
Counsel offices to accommodate the substantial workload these
agreements entail and to provide training for VA attorneys in CRADA
requirements and related VA policies. The NPCs support making these
reimbursements. We encourage the Subcommittee to include the necessary
provisions in the next version of the Discussion Draft.
The proposed legislation also contains a number of useful
clarifications of NPC status and purposes.
Section 2(c) codifies--without changing--the legal status
of the NPCs as state-chartered, independent organizations exempt from
taxation under section 501(c)(3) of the Internal Revenue Service (IRS)
code and subject to VA oversight and regulation. This clause codifies
the congressional intent, previously expressed in the House report that
accompanied the original NPC authorizing statute (H. Rept. 100-373),
that nonprofits established under this authority would not be
corporations controlled or owned by the Government. As a result, this
draft legislation resolves longstanding differences of opinion among
stakeholders, overseers and funding sources about the legal status of
NPCs.
Section 3(a)(1) of the draft legislation establishes that
in addition to administering research projects and education
activities, NPCs may support ``functions related to the conduct of
research and education.'' This resolves differences of opinion about
the allowability of NPC expenditures that support VA research and
education generally, such as purchase of core research equipment used
by many researchers for many projects, and enhances the value of NPCs
to VA facilities.
Section 5(a) ascertains that all NPC-administered
research projects must undergo ``scientific'' rather than ``peer''
review. This change recognizes that peer review is not necessary or
appropriate for all research projects administered by NPCs. However,
the draft legislation leaves in place the overarching requirement for
VA approval and the medical center's Research and Development Committee
remains in a position to determine on a case-by-case basis whether a
project also requires peer review as a condition of approval for NPC
administration.
In addition to these enhancements and clarifications, this draft
legislation reorganizes the NPC authorizing statute to put all
provisions regarding their establishment and status in one section;
describes their purposes in another; and gathers in one section the
clauses enumerating their powers. Many other revisions are largely
technical and conforming amendments.
Proposed Legislation Preserves Measures Providing Oversight of NPCs
The proposed legislation statute makes no changes in VA's power to
regulate and oversee the NPCs. Further, NPC records remain fully
available to the Secretary and his designees; to the Inspector General;
and to the Government Accountability Office (GAO). Likewise, NPCs are
still required to undergo an annual audit by an independent auditor in
accordance with the sources--Federal or private--and amount of its
prior year revenues, and they must submit to VA the resulting audit
report along with detailed financial information and descriptions of
accomplishments.
In the wake of the Sarbanes-Oxley Act and new Federal Accounting
Standards Board (FASB) requirements and auditing standards, even the
most basic form of nonprofit audit has become an effective means for
assessing an organization's financial controls. Additionally, as more
NPCs assume responsibility for Federal grants, a higher percentage of
NPC funds are subject to Generally Accepted Government Accounting
Standards (GAGAS) and OMB Circular A-133, the most rigorous and
comprehensive level of auditing standards. These audits are
comprehensive and provide a sound framework for examining an
organization's controls over funds as well as compliance with program
requirements.
Conclusion
In conclusion, NAVREF urges the Subcommittee to approve the
Discussion Draft for introduction and enactment at the earliest
possible opportunity. The NPCs are already a highly efficient means to
maximize the benefits to VA of externally funded research conducted in
VA facilities, ably serving to facilitate research and education that
benefit veterans. Additionally, they foster vibrant research
environments at VA medical centers, enhancing VA's ability to recruit
and retain clinician-investigators and other talented staff who in turn
apply their knowledge to state-of-the-art care for veterans.
Twenty years after the VA-NPC public-private partnership was first
authorized by Congress, and co-incident with the expiration of
authority to establish new NPCs, this is a timely opportunity to update
and clarify the NPCs' enabling legislation. This draft legislation will
accomplish those objectives. Experience working within the current
statute has brought to light its many strengths, but also areas that
will benefit from modification, enhancement and updating, particularly
in light of the increasing complexity of both research and nonprofit
compliance. We believe enactment of the proposed legislation,
preferably including authority for NPCs to reimburse OGC for certain
legal services, will allow NPCs to better achieve their potential to
support VA research and education while ensuring VA and congressional
confidence in their management.
NAVREF thanks the Subcommittee and its staff members for their work
on the Discussion Draft. We look forward to working with the Members of
the Subcommittee and the Senate Committee on Veterans Affairs toward
enactment of the final legislation. Please direct any questions you may
have to NAVREF Executive Director Barbara West at 301-656-5005 or
[email protected].
Committee on Veterans' Affairs
Washington, DC
July 2, 2008
Carl Blake
National Legislative Director
Paralyzed Veterans of America
801 18th Street, NW
Washington, D.C. 20006-3517
Dear Mr. Blake:
Thank you for your testimony at the House Committee on Veterans'
Affairs Subcommittee on Health legislative hearing that was held on
July 26, 2008.
To ensure that the Subcommittee has Paralyzed Veterans of America
(PVA)'s views on all of the bills that were discussed at this hearing,
I request that you please provide a statement for the record on the
following two bills that are enclosed with this letter:
1. H.R. 6366, Veterans Revenue Enhancement Act of 2008
2. Discussion Draft, To Amend Title 38, United States Code,
relating to employment of psychologists by the Department of Veterans
Affairs
I would appreciate receiving your statement by July 8, 2008
Again, thank you for your testimony. I look forward to reading your
comments on these additional bills. If you have any questions or
concerns, please don't hesitate to contact Chris Austin, Executive
Assistant to the Subcommittee on Health at (202) 225-9154.
Sincerely,
Michael H. Michaud
Chairman
______
Paralyzed Veterans of America
Washington, DC
July 8, 2008
Honorable Michael H. Michaud
Chairman
House Committee on Veterans' Affairs
Subcommittee on Health
335 Cannon House Office Building
Washington, DC 20515
Dear Chairman Michaud:
On behalf of Paralyzed Veterans of America (PVA), I would like to
thank you again for the opportunity to testify before the House
Committee on Veterans' Affairs, Subcommittee on Health at the hearing
held on June 26, 2008. We appreciate your efforts to continue to
improve the health care services available to the men and women who
have honorably served and are currently serving.
Following the hearing, you submitted an additional inquiry
regarding two additional proposed bills--H.R. 6366, the ``Veterans
Revenue Enhancement Act'' and a draft bill regarding employment of
psychologists at the Department of Veterans Affairs (VA)--that were not
received by PVA prior to the hearing. We would like to offer our views
on these two bills. Our statement for the record on the two proposed
bills is attached.
PVA looks forward to working with you and Ranking Member Miller to
ensure that the most appropriate enhancements are made to the VA health
care system. Thank you again.
Sincerely,
Carl Blake
National Legislative Director
______
H.R. 6366, the ``Veterans Revenue Enhancement Act''
PVA has no objection to the proposed bill that would require the
Department of Veterans Affairs (VA) to consolidate its patient
accounting centers into seven regional locations. These locations would
be required to conduct industry-modeled billing and collection
activities. It is a well-known fact that the VA has historically done a
poor job in achieving its third-party collections estimates. While in
recent years there has been some improvement, the VA continues to leave
a significant amount of money that could be used to enhance the quality
of health care services on the table.
This legislation would expand the concept of the Consolidated
Patient Accounting Center (CPAC) that was included as a demonstration
project in the Conference Report accompanying Public Law 109-114.
Subsequent to the enactment of that law, the VA created the Mid-
Atlantic Consolidated Patient Accounting Center demonstration project
located in Asheville, North Carolina. With establishment of the Center,
third-party collections at the medical facilities in VISN Six have
greatly improved. Using the CPAC in Asheville as a model, the VA could
significantly improve its collections systemwide.
The ``Department of Veterans Affairs Psychologist
Employment Fairness Act''
PVA believes that the intent of this legislation is to remove
psychologists from the Hybrid Title 38 system used to hire and promote
certain health care professionals in the VA. As explained by the
American Psychological Association (APA) at a hearing held by the
Subcommittee on May 22, the hybrid model requires Professional
Standards Boards to make recommendations on employment, promotion and
grade for psychologists, and is still more subjective than a pure Title
38 program. The APA explained that implementation of the new Title 38
Hybrid boarding process has been extremely variable and chaotic across
the system. As such, we have no objection to this legislation.
Committee on Veterans' Affairs
Washington, DC
July 2, 2008
Dennis Cullinan
National Legislative Director
Veterans of Foreign Wars (VFW)
200 Maryland Avenue, N.E.
Washington, D.C. 20002
Dear Mr. Cullinan:
Thank you for the testimony provided by Christopher Needham, Senior
Legislative Associate, National Legislative Service, at the House
Committee on Veterans' Affairs Subcommittee on Health legislative
hearing that was held on July 26, 2008.
To ensure that the Subcommittee has VFW's views on all of the bills
that were discussed at this hearing, I request that you please provide
a statement for the record on the following two bills that are enclosed
with this letter:
1. H.R. 6366, Veterans Revenue Enhancement Act of 2008
2. Discussion Draft, To Amend Title 38, United States Code,
relating to employment of psychologists by the Department of Veterans
Affairs
I would appreciate receiving your statement by July 8, 2008.
Again, thank you for your testimony. I look forward to reading your
comments on these additional bills. If you have any questions or
concerns, please don't hesitate to contact Chris Austin, Executive
Assistant to the Subcommittee on Health at (202) 225-9154.
Sincerely,
Michael H. Michaud
Chairman
______
Comments of the Veterans of Foreign Wars of the U.S. On Additional
Bills
Following the June 26, 2008 Subcommittee on Health Hearing
H.R. 6366
The VFW has no position on the ``Veterans Revenue Enhancement
Act.'' This bill would create seven centralized patient accounting
centers that would attempt to enhance VA's ability to collect from
third parties.
These centers were first devised as a demonstration project that
has been occurring in Asheville, NC. The aim is to standardize
collection practices in a central location, using private sector
business practices to improve the rate of collections from third party
insurers for the non-service-connected care certain veterans receive.
The appeal of this approach is that the enhanced collections are
returned to the department for use in health care delivery. With the
increased emphasis on collections as part of the appropriations
process, ensuring that VA gets every projected dollar is critical. We
have argued that these collected dollars should be a supplement to the
regular appropriations, but in the years where Congress has not agreed,
it only serves to increase the importance of VA collecting every dollar
possible.
We do wonder whether the centralization of these processes is
necessary though. Were the standardized processes and business
practices utilized in Asheville applied to every VA medical center,
wouldn't it be likely that their collection efforts be improved? It is
likely that VA managers could use the lessons learned from the
demonstration projects to improve practices throughout the system
without consolidation. With steady leadership and oversight--similar to
the level of oversight the Committee has used over the last 7 years or
so to move VA's collections efforts from their initial dreadful state--
perhaps consolidation would not be necessary.
Draft Bill, Relating to the Employment of VA Psychologists
The VFW is pleased to support this draft bill, which would enhance
VA's ability to recruit and retain psychologists. The bill would shift
psychologists into the appointment category that includes doctors,
dentists and optometrists. We believe that this change would increase
VA's ability to recruit and retain high quality psychologists,
something that the system greatly needs--especially with the demand for
mental health services expected to rise dramatically in the coming
years.
In testimony by the American Psychological Association before an
April 2008 Senate Veterans Affairs Committee hearing, Dr. Randy Phelps
explained that the current Hybrid Title 38 hiring practices were having
a negative effect on psychologists within VA. They claim that the
hiring authority is resulting in lower pay, more paperwork hassles and
bureaucratic procedures that prevent or curtail promotions. Together,
these hurt VA's ability to recruit and retain these essential health
care personnel, at a time when VA needs more of them than ever.
With the increased attention paid to mental health, and the growing
demands veterans have for these kinds of services, putting
psychologists on par with other essential health care personnel makes
sense. Mental health care is part of the total health care package and
its practitioners deserve the same level of benefits and the same type
of compensation system.
One of the biggest complaints about the level of mental health
services veterans have is with access. VA has made great efforts to
increase the number of psychologists within the system--over 800 new
hires since 2005--but VA must certainly do more. To do this properly,
VA must continue to provide a competitive work environment on par with
what is available in the private sector. This legislation would be a
step in that direction, and we urge its passage.
Committee on Veterans' Affairs
Washington, DC
July 2, 2008
Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Washington, DC 20240
Dear Secretary Peake:
Thank you for the testimony provided by Gerald M. Cross, M.D.,
FAAFP, Principal Deputy Under Secretary for Health, Veterans Health
Administration, who was accompanied by Walter A. Hall, Assistant
General Counsel, and Gary M. Baker, Chief Business Officer, Veterans
Health Administration, at the House Committee on Veterans' Affairs
Subcommittee on Health legislative hearing that was held on July 26,
2008.
To ensure that the Subcommittee has the Department of Veterans
Affairs' (VA) views on all of the bills that were discussed at this
hearing, I request that you please provide a statement for the record
on the following two bills that are enclosed with this letter:
1. H.R. 6366, Veterans Revenue Enhancement Act of 2008
2. Discussion Draft, To Amend Title 38, United States Code,
relating to employment of psychologists by the Department of Veterans
Affairs
I would appreciate receiving your statement by July 8, 2008.
Again, thank you for your testimony. I look forward to reading your
comments on these additional bills. If you have any questions or
concerns, please don't hesitate to contact Chris Austin, Executive
Assistant to the Subcommittee on Health at (202) 225-9154.
Sincerely,
Michael H. Michaud
Chairman
[AS OF JANUARY 12, 2009, THE VA FAILED TO PROVIDE THE ADMINISTRATION
VIEWS ON THE TWO BILLS.]
Committee on Veterans' Affairs
Washington, DC
July 2, 2008
Raymond Kelley
Legislative Director
American Veterans (AMVETS)
4647 Forbes Boulevard
Lanham, MD 20706
Dear Mr. Kelley:
Thank you for your testimony at the House Committee on Veterans'
Affairs Subcommittee on Health legislative hearing that was held on
July 26, 2008.
To ensure that the Subcommittee has Paralyzed Veterans of America
(PVA)'s views on all of the bills that were discussed at this hearing,
I request that you please provide a statement for the record on the
following two bills that are enclosed with this letter:
1. H.R. 6366, Veterans Revenue Enhancement Act of 2008
2. Discussion Draft, To Amend Title 38, United States Code,
relating to employment of psychologists by the Department of Veterans
Affairs
I would appreciate receiving your statement by July 8, 2008.
Again, thank you for your testimony. I look forward to reading your
comments on these additional bills. If you have any questions or
concerns, please don't hesitate to contact Chris Austin, Executive
Assistant to the Subcommittee on Health at (202) 225-9154.
Sincerely,
Michael H. Michaud
Chairman
______
Statement for the Record of
Raymond C. Kelley, AMVETS National Legislative Director
before the
House Veterans' Affairs Committee
Subcommittee on Health
Concerning H.R. 6366 and the ``Department of Veterans
Affairs Psychological Fairness Act''
Thursday, July 8, 2008
Chairman Michaud, Ranking Member Miller, thank you for providing
added time to respond to these two pieces of legislation
AMVETS wholly supports H.R. 6366, the ``Veterans Revenue
Enhancement Act of 2008,'' which would require VA to establish no more
than seven consolidated patient accounting centers within the next 5
years. The General Accounting Office (GAO) has recently estimated VA
has not collected 1.2 to 1.4 billion dollars through third party
collections. For VA to maintain its world class status of exceptional
care, it is important to continually improve all areas of their
operations. This includes collecting from third party insurance
companies. This unrecovered revenue would greatly assist in fully
funding the needs of our veterans.
AMVETS holds no official position on the ``Department of Veterans
Affairs Psychologist Employment Act.'' However, AMVETS would like to
point out the fact that moving Psychologist to the ``pure title 38''
would make it harder to hire and retain these professionals who are at
a critical need at this time.
Mr. Chairman, this concludes my testimony. I will be happy to
answer any questions regarding our opinion on these matters.
Committee on Veterans' Affairs
Washington, DC
July 2, 2008
Joe Violante
Legislative Director
Disabled American Veterans (DAV)
807 Maine Avenue, S.W.
Washington, D.C. 20024-2410
Dear Mr. Violante:
Thank you for your testimony at the House Committee on Veterans'
Affairs Subcommittee on Health legislative hearing that was held on
July 26, 2008.
To ensure that the Subcommittee has Paralyzed Veterans of America
(PVA)'s views on all of the bills that were discussed at this hearing,
I request that you please provide a statement for the record on the
following two bills that are enclosed with this letter:
1. H.R. 6366, Veterans Revenue Enhancement Act of 2008
2. Discussion Draft, To Amend Title 38, United States Code,
relating to employment of psychologists by the Department of Veterans
Affairs
I would appreciate receiving your statement by July 8, 2008.
Again, thank you for your testimony. I look forward to reading your
comments on these additional bills. If you have any questions or
concerns, please don't hesitate to contact Chris Austin, Executive
Assistant to the Subcommittee on Health at (202) 225-9154.
Sincerely,
Michael H. Michaud
Chairman
Prepared Statement of Adrian M. Atizado,
Assistant National Legislative Director of
the Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
submit testimony for the record on legislation before the Committee on
Veterans' Affairs Subcommittee on Health. DAV is an organization of 1.3
million service-disabled veterans, and devotes its energies to
rebuilding the lives of disabled veterans and their families.
You have requested testimony on two bills primarily focused on
health care services for veterans under the jurisdiction of the
Veterans Health Administration (VHA), Department of Veterans Affairs
(VA). This statement submitted for the record reviews our positions on
both proposals, and we offer them for your consideration.
The Department of Veterans Affairs Psychologist Employment Fairness Act
(Draft Bill)
The need to increase psychologist staffing levels in response to
the increasing demand for the care they provide is apparent. This
measure would amend title 38, United States Code, Sec. 7401 by moving
VA's appointment authority of psychologists from hybrid title 38 to
``pure title 38.'' The intended flexibility of the hybrid model
requires Professional Standards Boards to make recommendations on
hiring, pay grade and promotion for medical care providers, which is
more subjective than pure title 38 where recruitment, promotion and
retention is based solely on the individual's qualifications.
DAV does not have a resolution on this particular issue, therefore,
we can take no official position. However, we note that although
psychologists remain the only doctoral health care providers in VA who
remain in hybrid title 38, this legislation would allow psychologists
to avoid the well documented delays in the hybrid title 38 boarding
process. Moreover, with VHA as the single largest employer of
psychologists in the Nation, this bill would in turn subject
psychologists to the erosion of collective bargaining rights being
experienced by pure title 38 health care providers, which this
Subcommittee is aware.
H.R. 6366, the Veterans Revenue Enhancement Act of 2008
In 1986, Congress authorized legislation giving VA authority to
bill private insurers for care provided to insured nonservice-connected
veterans. In 1990, this authority was expanded to allow VA to collect
for the treatment of nonservice-connected conditions of insured
service-connected veterans. In 1997, Public Law 105-33 established the
current Medical Care Collections Fund (MCCF) and authorized VA to
retain all collections from insurers as well as other revenues such as
veterans' copayments and deductibles. The funds collected may only be
used for providing VA medical care and services and for VA expenses for
identification, billing, auditing and collection of amounts owed the
federal government.
Before the MCCF was established, VA was allowed to keep only enough
collections to cover administrative collection costs and was required
to deposit the remainder in the U.S. Treasury. This law also granted VA
authority to begin billing reasonable charges versus reasonable costs
for care. Reasonable charges are based on the amounts that insurers pay
for the same care provided by private industry health care providers in
a given geographic area.
Funds collected through MCCF are used as an offset rather than a
supplement to annual discretionary appropriations for VA's medical care
budget. The efficient and timely collection of these reimbursable costs
greatly benefits the VHA in meeting the demands of an increasingly
overburdened system. The DAV, in concert with the Independent Budget,
believes that it is the responsibility of the Federal Government to
fund the cost of veterans' health care. Therefore, we urge Congress to
provide a sufficient, timely and predictable medical care budget fully
funded by direct appropriations.
Although the VA has the legal authority to collect third-party
payments for certain types of care, Congress should consider any funds
derived from third-party collections as a supplement, not a substitute
for appropriations. In the same vein, we are opposed to Congress and
the administration, using collections or projections of collection, to
reduce appropriations.
Although VA has attempted to implement more effective billing
practices and systems, it has historically been unable to meet its
collection goals.
Having accurate information on third party insurance, such as the
type of policy and the types of services covered, patient copayments
and deductibles, and preadmission certification requirements, is key to
VA's MCCF program. VA's ability to accurately document the nonservice-
connected care provided to insured veterans and assign the appropriate
codes for billing purposes is essential to third-party collections.
Although VA can bill only for nonservice-connected care, we
occasionally hear reports from service-connected disabled veterans
indicating that VA is billing their insurance company for treatment of
service-connected conditions. In addition, failure to properly document
care can lead to missed opportunities to bill for care, billing
backlogs, overpayments by insurers, or denials of VA bills.
With the establishment of the VA's Chief Business Office (CBO), an
expanded revenue optimization plan had been formulated that combines
the 2001 Revenue Improvement Plan, the 2003 Revenue Action Plan, and a
series of additional tactical and strategic objectives targeting a
combination of immediate, mid-term, and long-term improvements to the
broad range of business processes encompassing VA revenue activities.
In 2004, CBO began conducting a demonstration pilot to demonstrate
improved revenue performance, increase collections and ultimately
establish consistent, nationally deployable business practices. Meeting
these expectations would serve to validate the viability and
effectiveness of creating an industry-modeled regionalized Consolidated
Patient Account Center (CPAC) with application of industry based
performance measures, supported by organizationally aligned remote
intake, utilization review and customer service functions.
Subsequent to a number of hearings conducted by the House Committee
on Veterans' Affairs Subcommittee on Oversight and Investigations on
VA's progress in third party collections programs, the ``Revenue
Improvement Demonstration'' provision in Conference Report 109-305, in
which the conferees modified the original provision in House Report
109-95, recommended VA initiate a new pilot program that will provide a
comprehensive restructuring of the complete revenue cycle including
cash-flow management and accounts receivable processes in certain VA
hospitals. Due to similar objectives, CPAC was selected to be the host
site for the Revenue Improvement Demonstration Project (RIDP).
The CPAC pilot was planned in three phases. Completed on September
30, 2006, Phase I began with the activation of the Mid-Atlantic CPAC in
Asheville, North Carolina, by converting the Veterans Integrated
Service Network (VISN) 6 Centralized Revenue Unit, which only served
VISN 6 facilities (8 VA Medical Centers), into the first CPAC. Phase II
would take place in VISN 11, a non-consolidated VISN. As the pilot
progresses, an evaluation is to be conducted before proceeding to the
next phase. Phase III would concentrate on a national expansion.
Coinciding with the oversight hearings, previous reports by the
Government Accountability Office (GAO) in September 2001, January and
May 2003, and July 2004, describe weaknesses in VA's revenue cycle
including inadequate patient intake procedures for gathering insurance
information, insufficient physician documentation of specific medical
care provided, a shortage of qualified coders, billing backlogs, missed
billing opportunities, and inadequate pursuit of accounts receivable.
We understand a recent GAO report reiterates previous findings that
VA's third-party billing and collection processes continue to be
ineffective and limit the revenue received by VA from third-party
insurance companies.
With the establishment by VA of the Mid-Atlantic CPAC, the
collection of third-party revenues has improved significantly at the
medical centers in VISN 6; however, we note that problems continue to
persist related to unpaid bills such as coding, billing, and
documentation errors. GAO also found a lack of adequate management and
accountability and oversight such as VA's requirement for medical
center accounts receivable staff to make up to three followup contacts
in a timely manner and document such followups with third-party
insurers on unpaid amounts and to document the details.
VA medical centers subject to GAO's report indicate the followup
failure rate is due to inadequate staffing, where VA shifted non-
revenue functions from billing and collections staff to other medical
center personnel to provide greater focus on the revenue function.
Additionally, they determined that there are no established formal
policies and procedures such for proper oversight to maximize the
third-party insurer billing and collection processes by medical centers
or VHA.
We urge this Subcommittee to provide VA the necessary resources and
continued oversight to address the abovementioned concerns when
considering H.R. 6366, which would authorize VA to establish no more
than seven CPACs. Any loss of third-party revenue has a tremendous
impact on VA medical care since such collections are being used as a
substitute for, not a supplement to, direct medical care
appropriations.
Mr. Chairman, again, DAV appreciates the Subcommittee's interest in
these issues, and we appreciate the opportunity to present the DAV's
views, which we hope will be helpful.