[Congressional Record Volume 144, Number 141 (Friday, October 9, 1998)]
[Senate]
[Pages S12231-S12233]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




           THE VA HEALTH CARE SYSTEM AND DR. KENNETH W. KIZER

 Mr. SESSIONS. Mr. President, I rise to make a few remarks 
concerning the VA health care system, a system that is currently 
undergoing dramatic changes and reorganization. I would note that these 
changes, in turn, to include managerial reforms, facility 
consolidations, and reallocation of resources, all initiated by the 
Under Secretary for Health, Dr. Kenneth W. Kizer M.D., M.P.H., are 
having a dramatic impact on when, where, and how VA is providing for 
our veterans, many of whom are in my home state of Alabama.
  The private health care sector is likewise undergoing massive 
managerial and resource changes. We saw evidence earlier this week of 
the erosion in care for elderly Americans, for instance, when a number 
of HMO's decided not to participate any further in Medicare+Choice. 
Over at the VA, using managed care models, Dr. Kizer also shifted 
inpatient care to outpatient care and heightened the focus of primary 
care at the expense of specialty care and specialized services. So 
elderly veterans, and those in speciality care programs around the 
country, are under the same stresses as their civilian neighbors.
  Dr. Kizer apparently likes decentralized decision making, and I 
cannot say that I necessarily disagree with that style. It can be very 
effective at times and in certain organizations. He has given local VA 
managers incentives and authority to design and run their own health 
care operations independent of VA's National Headquarters. In many 
respects these reforms have been beneficial, even bold I am told, 
particularly at a time when the VA budget is under severe stress.
  However, I expressed my personal concern to Dr. Kizer in a phone call 
earlier this week that there is one area where I believe 
decentralization and certainly the shifting of resources is having a 
very negative effect on one of the VA's core missions, and that is, the 
provision of specialized services for veterans with spinal cord injury 
and dysfunction.
  Mr. President, the Congress mandated in P.L. 104-262 that the VA 
would maintain its capacity to provide specialized services, such as 
care given in VA's 23 Spinal Cord Injury (SCI) centers. Many have 
wondered, and rightly so I believe, that budget pressures, 
reorganization and decentralization of management have created the 
incentive for local managers to downgrade these expensive specialized 
programs, generally shifting resources and staff out of one area to 
make up for shortfalls in others areas. Costs are thereby reduced at 
the expense of the care for the veterans who need it the most.
  Specialized programs, including blind rehabilitation, amputation 
care, specialized health programs, as well as spinal cord injury care, 
are core disciplines of the VA health care system. They, least of all, 
should be subject to re-engineering until all aspects of that care have 
been analyzed from a headquarters perspective. I don't think allowing 
numerous mangers to make that kind of decision is in the national 
interest or in the interest of our veterans.
  Former Senator Alan Simpson from Wyoming, then Chairman of the Senate 
Committee on Veterans' Affairs, presided over the passage of the 
legislation protecting specialized services. Addressing this particular 
provision, he said: ``VA is required to maintain special programs (such 
as treatment of spinal cord dysfunction, blind rehabilitation, 
amputation and mental illness) at least at the current level. On a per 
capita basis, these services are expensive to provide and it is not the 
intent of the Committee to allow VA to reduce them in order to pay for 
other kinds of routine care.''
  Mr. President, I am afraid what Senator Simpson and the Congress 
feared could happen to specialized programs in general and spinal cord 
injury programs specifically under VA's current reorganization 
initiatives is, in fact, happening.
  Nearly a month ago, I had a visit from Mr. Aubrey L. Crockett, the 
President of the Mid-South Chapter of Paralyzed Veterans of America. 
Aubrey represents the health care interests of 1830 spinal cord 
dysfunctional veterans in Alabama. As he sat confined to his wheel 
chair, he raised serious concerns that the VA was not maintaining the 
quality and quantity of its specialized health care services for the 
over 120,000 veterans nationwide with spinal cord dysfunction.
  Last month, Gordon Mansfield, the National Executive Director of the 
Paralyzed Veterans of America addressed the same subject from a 
national perspective during hearings on the Hill. PVA's leadership has 
expressed its concerns to me as well. Over 75 percent of their 
membership, a larger percentage than any other veterans service 
organization, rely on the VA for all or part of their specialized 
health care needs. For these individuals with chronic and catastrophic 
disabilities, any erosion in the care they require can be life 
threatening. Aubrey indicated that something as simple as a pad for a 
wheel chair can make a big difference for a veteran.
  I have come to believe that PVA's concerns need to be addressed. I 
further believe that any erosion in staffing, bed availability or the 
quality of care at our nations VA Spinal Cord Injury Centers cannot 
stand without a review of the underlying reasons, and that the VA must 
direct the resources to fix the problems in order to comply with the 
intent of Congress as mandated in the statutes.
  In an era of tight budgets, local hospital administrators and 
managers don't see these programs, such as the Spinal Cord Injury 
programs, as being ``National Programs.'' Ignoring the national 
mandates, local managers acting under Dr. Kizer's administrative 
decentralization guidelines have been left to do whatever they felt was 
warranted. We may disagree on the numbers of reported beds and staff in 
SCI centers, but even GAO has criticized the inaccuracy of VA data 
collection efforts. So, it should not be surprising that a number of 
Senators have questioned VA's procedures and policies as applied to 
managing its specialized programs. Paralyzed veterans, I think, are the 
only true judges of the state of the health care they receive. They are 
the reason the VA health care system exists. If paralyzed veterans have 
a concern then the Congress must listen, and more importantly, if 
warranted we must act on their behalf.
  On September 29, 1998, I wrote to my colleague from Pennsylvania 
Veterans Committee Chairman Arlen Specter expressing my concerns in 
this matter. I indicated that ``I will consider placing a hold on the 
re-nomination'' of Dr. Kenneth Kizer, ``until my concern regarding the 
maintenance of specialized services within the Veterans Health 
Administration is adequately addressed.''
  Mr. President, I want to commend Senator Specter, and the Committee 
for its support in this matter. The Committee met every request I had 
in a timely fashion. Moreover, it helped coordinate a solution 
acceptable to all parties. America's veterans owe Senator Specter a 
debt of gratitude for his hard work on their behalf.
  The solution I had in mind when I wrote to Dr. Kizer was to bring the 
reins of control for SCI programs back to the National Headquarters 
level and

[[Page S12232]]

in the process elevate the controls over policy and resources and 
restore a greater degree of national guidance and oversight. In doing 
so, I hoped we would be guaranteeing for some time to come that these 
changes would meet the needs of our paralyzed veterans and conform to 
the mandated statutes.
  Mr. President, I am pleased to report that Dr. Kizer has responded to 
my concerns with a suggested list of administrative and policy changes 
that would bring additional control over the spinal cord injury 
program.
  I request that my letter to Dr. Kizer dated October 5, 1998, and his 
letter of policy recommendations dated October 8, 1998 be printed in 
the Record immediately following this statement.
  I believe I have Dr. Kizer's commitment to a series of positive 
improvements to our specialized programs. I look forward to seeing the 
fruits of his labor and those of the departments he supervises. 
Similarly, and with the help of the Senate Committee on Veterans' 
Affairs, I intend to keep a close watch on these policy changes and the 
Spinal Cord Injury Program in particular. I have no intention of 
letting Aubrey or the other 1830 Spinal Cord dysfunctional veterans in 
Alabama down. This body needs to make certain that the VA is 
maintaining its capacity to provide specialized health care services 
and that it is doing as much as it can to care for all our 26 million 
veterans--all the time. That has always been the intent of Congress and 
I am certain it always will be.
  The letters follow:


                                         United States Senate,

                                  Washington, DC, October 5, 1998.
     Dr. Kenneth W. Kizer, M.D.,
     Special Assistant to the Secretary, Department of Veterans 
       Affairs, 810 Vermont Avenue NW, Washington, DC.
       Dear Dr. Kizer; I am glad we had a brief chance to speak 
     this afternoon. As I told you, I am ready to remove my hold 
     on your re-nomination for the position of Under Secretary for 
     Health once you clarify for me in writing what action(s) you 
     and the Department intend to take to comply with the 
     statutory mandates for the specialized treatment and 
     rehabilitative needs of disabled veterans (including veterans 
     with spinal cord dysfunction, blindness, amputation and 
     mental illness) identified in section 1706, Title 38 U.S.C. 
     and staffing requirements in section 7306 (f), Title 38 
     U.S.C.
       VA's massive reorganization efforts coupled with chronic 
     budget pressures have placed great stress on management and 
     patients alike. While many of my colleagues have complimented 
     you on your management initiatives, Alabama's paralyzed 
     veterans are concerned that in the VA's haste to re-engineer 
     itself, managers are shifting vital resources and staff out 
     of specialized programs. I think we would both agree that 
     SCI, blind rehabilitation, amputation care, and special 
     mental health programs are the core of the VA health care 
     system. Alabama veterans over and over again have told me 
     that this type of care cannot be matched anywhere outside VA. 
     Hence, you can well understand why I am interceding on their 
     behalf.
       In order for me to release my hold on your re-nomination, I 
     would appreciate your response as soon as possible. In 
     addition to my overall compliance concerns, I would 
     appreciate it if you would specifically address the 
     establishment of a centralized operational authority for the 
     SCI program; the resources and authority necessary to run 
     that program office to include such oversight as treatment 
     guidelines, staffing and bed modeling; relationship to local 
     and regional managers, and compliance reporting procedures or 
     other actions the Department deems necessary to comply with 
     this management structure.
           Sincerely,


                                                Jeff Sessions,

     U.S. Senator.
                                  ____



                               Department of Veterans Affairs,

                                  Washington, DC, October 8, 1998.
     Hon. Jeff Sessions,
     U.S. Senate,
     Washington, DC.
       Dear Senator Sessions: I wanted to follow-up with you in 
     writing to underscore my commitment to maintaining capacity, 
     improving access, and enhancing coordination of care to meet 
     the specialized needs of our most vulnerable veterans. I 
     believe that we do not differ in our views that maintaining 
     the Veterans Health Administration's (VHA) specialized 
     programs is of paramount importance.
       As I have said on several occasions, I believe VHA's 
     programs and services for certain special disability groups 
     are the heart of the Department of Veterans Affairs' (VA) 
     health care program. These special VA programs include those 
     for veterans with spinal cord injury, blindness, traumatic 
     brain injury, amputations, serious mental illness and post 
     traumatic stress disorder. It would be unthinkable for VHA to 
     retreat from its commitment to the specialized needs of 
     veterans who rely on VA for these services. Further, it is my 
     intent to take advantage of opportunities to improve and 
     provide better services, as science and new technologies 
     advance.
       I share your interest in ensuring that VA is in compliance 
     with current laws related to specialized programs. It is my 
     understanding that the Department currently is in compliance 
     with the law, as outlined below. Additionally, I intend to 
     implement additional measures should I be confirmed for a new 
     4-year term.
       As required by legislation, the Department has submitted 
     two reports to Congress on maintaining our capacity for these 
     specialized programs--one in May 1997 and one in June 1998. 
     Our reports to Congress document compliance with 38 U.S.C. 
     Sec. 1706, which requires the maintenance of capacity for 
     specialized services. Nationally, the number of veterans 
     treated in the six programs was maintained or increased for 
     all categories but amputation, which declined by 2%. (Of 
     note, this latter statistic is, in fact, a positive finding 
     since it reflects the greater emphasis that has been placed 
     on preserving limbs, and better management of veterans at 
     risk for amputation, which has resulted in fewer amputations 
     per year.) Still, we recognize that VA's data gathering and 
     validation can be improved and that the multiple data sources 
     and different ways of interpreting data have given rise to 
     several issues and concerns related to reporting capacity. In 
     early December 1998, VA will convene a national data summit 
     to review and find solutions to address these issues, and we 
     are inviting to participate in this conference a wide 
     array of stakeholders (e.g., veterans service 
     organizations, Congress, and the Inspector General) who 
     review our data to assess quality and system improvements.
       I understand that you also are concerned about compliance 
     with 38 U.S.C. Sec. 7306, which addresses the expertise of 
     VHA Headquarters staff in specialized services. VHA 
     Headquarters staff includes highly qualified representation 
     in all specialized programs: Chief Consultant, Mental Health 
     Strategic Healthcare Group; Chief Consultant, Prosthetics and 
     Sensory Aids Strategic Healthcare Group; Clinical Program 
     Manager, Spinal Cord Injury and Disorders Strategic 
     Healthcare Group; and Director, Blind Rehabilitation Service. 
     These individuals have substantive expertise and policy 
     guidance and provide critical oversight of these specialized 
     programs. In response to a wholly separate inquiry from that 
     raised by your concerns, I have been advised that the VA's 
     General Counsel confirmed VHA's compliance with 38 U.S.C. 
     Sec. 7306 in an August 14, 1998, memorandum.
       Effective management of our specialized programs is a VHA-
     wide responsibility. VHA has a management structure that 
     physically places personnel in a decentralized manner, as 
     appropriate. In our experience, we have found that we often 
     get better program leadership when individuals remain 
     clinically active. In the case of the Chief Consultant, 
     Spinal Cord Injury and Disorders, Dr. Margaret Hammond, a 
     national SCI expert, serves in this capacity from the Seattle 
     VA Medical Center. Dr. Hammond's efforts have been widely 
     praised, including by many members of the Paralyzed Veterans 
     of America.
       While VA is in compliance with current law, I believe that 
     some additional measures could be taken to reinforce our 
     ongoing commitment to SCI programs. Accordingly, I intend to 
     take the following steps to strengthen Headquarters' role in 
     these matters, should I be reconfirmed for a full term as 
     Under Secretary for Health.
       First, decision-making authority for any SCI-related 
     mission changes, construction, staffing, or bed level 
     proposals will be centralized to Headquarters. In the future, 
     before a VISN will be allowed to make changes, it must have 
     the approval of the Under Secretary for Health, following 
     consultation with the Chief Consultant, SCI/D and Chief 
     Officer, Patient Care Services. A directive to all network 
     offices and facilities will be issued to effect this.
       Second, national guidelines will be developed so that 
     patient referral procedures are uniform across the VA 
     healthcare system and to ensure that complex specialty care 
     is provided at the appropriate site. Additionally, SCI health 
     care Circular M2, Part 24 will be revised and updated. Dr. 
     Margaret Hammond, Chief Consultant, SCI/D, will lead these 
     efforts, which will involve the full range of stakeholders in 
     the process.
       Third, some weeks ago I directed VHA's Chief Officer, 
     Patient Care Services to contract with an outside consultant 
     to look at capacity and quality of VA care for veterans with 
     spinal cord dysfunction. Until this study has been 
     undertaken, reviewed, and evaluated, the expired directive 
     related to nurse staffing levels for SCI units will be 
     reissued. Additionally, to improve oversight and management, 
     the SCI/D Strategic Healthcare Group staff will be increased. 
     The Chief Network Officer will also be asked to identify a 
     single individual among his Headquarters staff to coordinate 
     local SCI issues with the Chief Consultant SCI/D and the 
     Under Secretary for Health.
       Finally, SCI operating beds will be removed from the 
     performance measure for bed occupancy that is contained in 
     network directors' performance contracts, or the measure will 
     be dropped altogether. The following performance indicators 
     related to SCI/D are already in place for fiscal year 1999, 
     and the network directors' accountability for these will be 
     closely scrutinized: admission within 24 hours for acute 
     care; an appointment with a specialist in 7 days; and 
     transfer of semi-emergent care to an SCI unit within two 
     weeks.

[[Page S12233]]

       In summary, I believe VA services for SCI are already 
     second to none, but we continue to seek opportunities to 
     improve. Currently, VA cares for veterans with spinal cord 
     dysfunction in 23 SCI centers, 29 SCI support clinics, and 
     120 primary care teams at non-SCI center facilities. With 
     respect to capacity, from fiscal year (FY) 1996 to FY 1997, 
     VA treated 4% more SCI patients and applied 3% more dollars 
     to SCI care, although the number of beds and staff were 
     decreased. A notable improvement in timeliness from FY 1996 
     to FY 1997 also was achieved for SCI patients. For acute 
     care, meeting the ``timeliness for admission' standard (one 
     day) improved from 41% to 91%, and for routine care meeting 
     the `timeliness of appointments' standard improved from 87% 
     to 100%. It is my intent that the new program enhancements 
     will build upon these measures, resulting in improved 
     clinical outcomes and enhanced quality of care.
       Again, thank you for sharing your commitment to VA's 
     services for special veteran populations--a commitment with 
     which I fully concur. Please do not hesitate to contact me if 
     you wish to meet or further discuss these matters.
           Sincerely,
     Kenneth W. Kizer.

                          ____________________