[Congressional Record Volume 153, Number 178 (Friday, November 16, 2007)]
[Senate]
[Pages S14621-S14627]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




          STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS

      By Mr. DURBIN (for himself and Mr. Burr):
  S. 2376. A bill to establish a demonstration project to provide for 
patient-centered medical homes to improve the effectiveness and 
efficiency in providing medical assistance under the Medicaid program 
and child health assistance under the State Children's Health Insurance 
Program; to the Committee on Finance.
  Mr. DURBIN. Mr. President, we are all aware of the current healthcare 
crisis in our nation. Health care spending continues to rise at an 
unsustainable rate, constituting 16 percent of the Federal budget. 
Health care costs have increased 78 percent since 2001, more than 4 
times the pace of prices and wages.
  One reason for the rise in costs and spending is the increase in 
chronic disease. Heart disease, cancer, and diabetes are the leading 
causes of death and disability in the U.S. They also account for 70 
percent of all deaths in the U.S., or 1.7 million people each year. 
These diseases also make life harder for the 1 of 10 Americans who are 
living with them. The irony, of course, is that chronic diseases are 
both preventable and manageable.
  The quality of our healthcare has not changed substantially despite 
the fact that we live in the wealthiest country in the world with the 
best researchers and medical doctors at our fingertips. At a time when 
both health care costs and chronic illnesses are on the rise, we need a 
better way to provide care.
  Changing the delivery of care is a controversial topic, but it is a 
topic that has gained more traction in recent months. Last week, the 
New York Times published an article titled, ``A Model for Health Care 
That Pays for Quality.'' The article described a new model for 
healthcare, and I quote here, ``to identify the best primary care 
doctors and to steer patients their way. Those doctors, in turn, would 
be paid for more services than are currently reimbursed under typical 
health plan payments for office visits. The idea is to encourage 
doctors to meet with patients for more than a few minutes during an 
office visit and to also compensate them, or nurse coordinators, for 
communicating with patients by phone and e-mail outside office hours.'' 
This is an approach to delivering care that national physician groups 
and patient advocacy organizations call the medical home.
  A medical home is something that those of us who have it take for 
granted. We see the same doctor, in the same setting, for extended 
periods of time. Our medical history is in one place, and even if we 
are seeing specialists or different doctors in the same practice, there 
is continuity in decisions about our health care. This is a medical 
home.
  But many people do not have this luxury. Think about people who move 
from place to place, whose home lives are less than stable, who don't 
have health insurance, whose medical care is sporadic. For these 
members of our community, each visit to a clinic or an emergency room 
means starting over again.
  So, everyone should have access to a medical home. A medical home is 
not only a place, but an approach to providing comprehensive primary 
care that respects, and responds to, individual patient preferences and 
needs and helps patients develop relationships with their providers.
  It sounds easy, but it requires some changes and creative thinking 
and, perhaps most importantly, it requires a commitment by local 
providers to work together. The medical home model makes sense for 
improving health care for everyone. It is a model of care that makes 
sense for stretching our limited Federal health care dollars.
  States like Illinois and North Carolina are already seeing progress 
with implementing the medical home model. Illinois Health Connect is a 
new program at the Illinois Department of Healthcare and Family 
Services that uses the medical home model to deliver primary and 
preventive care for children and adults covered through the All Kids 
program. This emphasis on coordinated and ongoing care is leading to 
better health outcomes, and it's saving money.
  Community Care of North Carolina launched a medical home model in 
1998, through nine physician-led networks. North Carolina started by 
creating medical homes for 250,000 Medicaid enrollees. Today, it is a 
State-wide program that has saved the state at least $60 million in 
Medicaid costs in 2003 and $120 million in 2004.

[[Page S14622]]

  Cost savings is not the only benefit. Several studies show that the 
medical home approach improves quality of care. Early analyses are 
finding that having regular access to a particular physician through 
the medical home is associated with earlier and more accurate 
diagnoses, fewer emergency room visits, fewer hospitalizations, lower 
costs, better care, and increased patient satisfaction. Many studies 
conclude that having both health insurance and a medical home leads to 
improved overall health for the entire population, which brings down 
the cost of care and reduces health care disparities.
  Today, I am proud to be joined by my colleague Senator Richard Burr 
of North Carolina to introduce the Medical Homes Act of 2007. This bill 
would make it easier for other states to implement a medical home 
model, much like Illinois and North Carolina have. Congress passed a 
medical home demonstration project for Medicare last year. The Medical 
Homes Act of 2007 would do this for Medicaid and SCHIP beneficiaries by 
making Federal funding available for a demonstration project in 8 
States to provide care through patient-centered medical homes.
  The approach we propose requires a per-member, per-month care 
management fee to help pay for participating doctors and provides 
initial start-up funding for participating States. The startup funds 
are used for the purchase of health information technology, primary 
care case managers, and other uses appropriate for the delivery of 
patient-centered care.
  If patients, provider, payers, and the government work together to 
create a system that values the patient more than payments and the 
health outcome of the patient more than the number of patients seen, we 
can really change the way primary care is provided. I urge my 
colleagues to support the Medical Homes Act of 2007 and help stabilize 
healthcare delivery for low-income and elderly Americans.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 2376

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medical Homes Act of 2007''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) Medical homes provide patient-centered care, leading to 
     better health outcomes and greater patient satisfaction. A 
     growing body of research supports the need to involve 
     patients and their families in their own health care 
     decisions, to better inform them of their treatment options, 
     and to improve their access to information.
       (2) Medical homes help patients better manage chronic 
     diseases and maintain basic preventive care, resulting in 
     better health outcomes than those who lack medical homes. An 
     investigation of the Chronic Care Model discovered that the 
     medical home reduced the risk of cardiovascular disease in 
     diabetes patients, helped congestive heart failure patients 
     become more knowledgeable and stay on recommended therapy, 
     and increased the likelihood that asthma and diabetes 
     patients would receive appropriate therapy.
       (3) Medical homes also reduce disparities in access to 
     care. A survey conducted by the Commonwealth Fund found that 
     74 percent of adults with a medical home have reliable access 
     to the care they need, compared with only 52 percent of 
     adults with a regular provider that is not a medical home and 
     38 percent of adults without any regular source of care or 
     provider.
       (4) Medical homes reduce racial and ethnic differences in 
     access to medical care. Three-fourths of Caucasians, African 
     Americans, and Hispanics with medical homes report getting 
     care when they need it in a medical home.
       (5) Medical homes reduce duplicative health services and 
     inappropriate emergency room use. In 1998, North Carolina 
     launched the Community Care of North Carolina (CCNC) program, 
     which employs the medical home concept. Today CCNC includes 
     14 networks, that include all Federally qualified health 
     centers in the State, covering 740,000 recipients across the 
     entire State. An analysis conducted by Mercer Human Resources 
     Consulting Group found that CCNC resulted in $244,000,000 in 
     savings to the Medicaid program in 2004, with similar results 
     in 2005 and 2006.
       (6) Health information technology is a crucial foundation 
     for medical homes. While many doctor's offices use electronic 
     health records for billing or other administrative functions, 
     few practices utilize health information technology 
     systematically to measure and improve the quality of care 
     they provide. For example, electronic health records can 
     generate reports to ensure that all patients with chronic 
     conditions receive recommended tests and are on target to 
     meet their treatment goals. Computerized ordering systems, 
     particularly with decision-support tools, can prevent medical 
     and medication errors, while e-mail and interactive Internet 
     websites can facilitate communication between patients and 
     providers and patient education.

     SEC. 3. MEDICAID AND SCHIP DEMONSTRATION PROJECT TO SUPPORT 
                   PATIENT-CENTERED PRIMARY CARE.

       (a) Definitions.--In this section:
       (1) Care management model.--The term ``care management 
     model'' means a model that--
       (A) uses health information technology and other 
     innovations such as the chronic care model, to improve the 
     management and coordination of care provided to patients;
       (B) is centered on the relationship between a patient and 
     their personal primary care provider;
       (C) seeks guidance from--
       (i) a steering committee; and
       (ii) a medical management committee; and
       (D) has established, where practicable, effective referral 
     relationships between the primary care provider and the major 
     medical specialties and ancillary services in the region.
       (2) Health center.--The term ``health center'' has the 
     meaning given that term in section 330(a) of the Public 
     Health Service Act (42 U.S.C. 254b(a)).
       (3) Medicaid.--The term ``Medicaid'' means the program for 
     medical assistance established under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.).
       (4) Medical management committee.--The term ``medical 
     management committee'' means a group of local practitioners 
     that--
       (A) reviews evidence-based practice guidelines;
       (B) selects targeted diseases and care processes that 
     address health conditions of the community (as identified in 
     the National or State health assessment or as outlined in 
     ``Healthy People 2010'', or any subsequent similar report (as 
     determined by the Secretary));
       (C) defines programs to target diseases and care processes;
       (D) establishes standards and measures for patient-centered 
     medical homes, taking into account nationally-developed 
     standards and measures; and
       (E) makes the determination described in subparagraph 
     (A)(iii) of paragraph (5), taking into account the 
     considerations under subparagraph (B) of such paragraph.
       (5) Patient-centered medical home.--
       (A) In general.--The term ``patient-centered medical home'' 
     means a physician-directed practice or a health center that--
       (i) incorporates the attributes of the care management 
     model described in paragraph (1);
       (ii) voluntarily participates in an independent evaluation 
     process whereby primary care providers submit information to 
     the medical management committee of the relevant network;
       (iii) the medical management committee determines has the 
     capability to achieve improvements in the management and 
     coordination of care for targeted beneficiaries (as defined 
     by Statewide quality improvement standards and outcomes); and
       (iv) meets the requirements imposed on a covered entity for 
     purposes of applying part C of title XI of the Public Health 
     Service Act (42 U.S.C. 300b-1 et seq.) and all regulatory 
     provisions promulgated thereunder, including regulations 
     (relating to privacy) adopted pursuant to the authority of 
     the Secretary under section 264(c) of the Health Insurance 
     Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2 
     note).
       (B) Considerations.--In making the determination under 
     subparagraph (A)(iii), the medical management committee shall 
     consider the following:
       (i) Access and communication with patients.--Whether the 
     practice or health center applies both standards for access 
     to care for and standards for communication with targeted 
     beneficiaries who receive care through the practice or health 
     center.
       (ii) Managing patient information and using information 
     management to support patient care.--Whether the practice or 
     health center has readily accessible, clinically useful 
     information on such beneficiaries that enables the practice 
     or health center to comprehensively and systematically treat 
     such beneficiaries.
       (iii) Managing and coordinating care according to 
     individual needs.--Whether the practice or health center--

       (I) maintains continuous relationships with such 
     beneficiaries by implementing evidence-based guidelines and 
     applying such guidelines to the identified needs of 
     individual beneficiaries over time and with the intensity 
     needed by such beneficiaries;
       (II) assists in the early identification of health care 
     needs;
       (III) provides ongoing primary care; and
       (IV) coordinates with a broad range of other specialty, 
     ancillary, and related services.

       (iv) Providing ongoing assistance and encouragement in 
     patient self-management.--Whether the practice or health 
     center--

[[Page S14623]]

       (I) collaborates with targeted beneficiaries who receive 
     care through the practice or health center to pursue their 
     goals for optimal achievable health;
       (II) assesses patient-specific barriers; and
       (III) conducts activities to support patient self-
     management.

       (v) Resources to manage care.--Whether the practice or 
     health center has in place the resources and processes 
     necessary to achieve improvements in the management and 
     coordination of care for targeted beneficiaries who receive 
     care through the practice or health center.
       (vi) Monitoring performance.--Whether the practice or 
     health center--

       (I) monitors its clinical process and performance 
     (including process and outcome measures) in meeting the 
     applicable standards under paragraph (4)(D); and
       (II) provides information in a form and manner specified by 
     the steering committee and medical management committee with 
     respect to such process and performance.

       (6) Personal primary care provider.--The term ``personal 
     primary care provider'' means--
       (A) a physician, nurse practitioner, or other qualified 
     health care provider (as determined by the Secretary), who--
       (i) practices in a patient-centered medical home; and
       (ii) has been trained to provide first contact, continuous, 
     and comprehensive care for the whole person, not limited to a 
     specific disease condition or organ system, including care 
     for all types of health conditions (such as acute care, 
     chronic care, and preventive services); or
       (B) a health center that--
       (i) is a patient-centered medical home; and
       (ii) has providers on staff that have received the training 
     described in subparagraph (A)(ii).
       (7) Primary care case management services; primary care 
     case manager.--The terms ``primary care case management 
     services'' and ``primary care case manager'' have the meaning 
     given those terms in section 1905(t) of the Social Security 
     Act (42 U.S.C. 1396d(t)).
       (8) Project.--The term ``project'' means the demonstration 
     project established under this section.
       (9) SCHIP.--The term ``SCHIP'' means the State Children's 
     Health Insurance Program established under title XXI of the 
     Social Security Act (42 U.S.C. 1396aa et seq.).
       (10) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (11) Steering committee.--The term ``steering committee'' 
     means a local management group comprised of collaborating 
     local health care practitioners or a local not-for-profit 
     network of health care practitioners--
       (A) that implements State-level initiatives;
       (B) that develops local improvement initiatives;
       (C) whose mission is to--
       (i) investigate questions related to community-based 
     practice; and
       (ii) improve the quality of primary care; and
       (D) whose membership--
       (i) represents the health care delivery system of the 
     community it serves; and
       (ii) includes physicians (with an emphasis on primary care 
     physicians) and 1 representative from each part of the 
     collaborative or network (such as a representative from a 
     health center, a representative from the health department, a 
     representative from social services, and a representative 
     from each public and private hospital in the collaborative or 
     the network).
       (12) Targeted beneficiary.--
       (A) In general.--The term ``targeted beneficiary'' means an 
     individual who is eligible for benefits under a State plan 
     under Medicaid or a State child health plan under SCHIP.
       (B) Participation in patient-centered medical home.--
     Individuals who are eligible for benefits under Medicaid or 
     SCHIP in a State selected to participate in the project shall 
     receive care through a patient-centered medical home when 
     available.
       (C) Ensuring choice.--In the case of such an individual who 
     receives care through a patient-centered medical home, the 
     individual shall receive guidance from their personal primary 
     care provider on appropriate referrals to other health care 
     professionals in the context of shared decisionmaking.
       (b) Establishment.--The Secretary shall establish a 
     demonstration project under Medicaid and SCHIP for the 
     implementation of a patient-centered medical home program 
     that meets the requirements of subsection (d) to improve the 
     effectiveness and efficiency in providing medical assistance 
     under Medicaid and child health assistance under SCHIP to an 
     estimated 500,000 to 1,000,000 targeted beneficiaries.
       (c) Project Design.--
       (1) Duration.--The project shall be conducted for a 3-year 
     period, beginning not later than October 1, 2009.
       (2) Sites.--
       (A) In general.--The project shall be conducted in 8 
     States--
       (i) four of which already provide medical assistance under 
     Medicaid for primary care case management services as of the 
     date of enactment of this Act; and
       (ii) four of which do not provide such medical assistance.
       (B) Application.--A State seeking to participate in the 
     project shall submit an application to the Secretary at such 
     time, in such manner, and containing such information as the 
     Secretary may require.
       (C) Selection.--In selecting States to participate in the 
     project, the Secretary shall ensure that urban, rural, and 
     underserved areas are served by the project.
       (3) Grants and payments.--
       (A) Development grants.--
       (i) First year development grants.--The Secretary shall 
     award development grants to States participating in the 
     project during the first year the project is conducted. 
     Grants awarded under this clause shall be used by a 
     participating State to--

       (I) assist with the development of steering committees, 
     medical management committees, and local networks of health 
     care providers; and
       (II) facilitate coordination with local communities to be 
     better prepared and positioned to understand and meet the 
     needs of the communities served by patient-centered medical 
     homes.

       (ii) Second year funding.--The Secretary shall award 
     additional grant funds to States that received a development 
     grant under clause (i) during the second year the project is 
     conducted if the Secretary determines such funds are 
     necessary to ensure continued participation in the project by 
     the State. Grant funds awarded under this clause shall be 
     used by a participating State to assist in making the 
     payments described in paragraph (B). To the extent a State 
     uses such grant funds for such purpose, no matching payment 
     may be made to the State for the payments made with such 
     funds under section 1903(a) or 2105(a) of the Social Security 
     Act (42 U.S.C. 1396b(a); 1397ee(a)).
       (B) Additional payments to personal primary care providers 
     and steering committees.--
       (i) Payments to personal primary care providers.--

       (I) In general.--Subject to subsection (d)(6)(B), a State 
     participating in the project shall pay a personal primary 
     care provider not less than $2.50 per month per targeted 
     beneficiary assigned to the personal primary care provider, 
     regardless of whether the provider saw the targeted 
     beneficiary that month.
       (II) Federal matching payment.--Subject to subparagraph 
     (A)(ii), amounts paid to a personal primary care provider 
     under subclause (I) shall be considered medical assistance or 
     child health assistance for purposes of section 1903(a) or 
     2105(a), respectively, of the Social Security Act (42 U.S.C. 
     1396b(a); 1397ee(a)).
       (III) Patient population.--In determining the amount of 
     payment to a personal primary care provider per month with 
     respect to targeted beneficiaries under this clause, a State 
     participating in the project shall take into account the care 
     needs of such targeted beneficiaries.

       (ii) Payments to steering committees.--

       (I) In general.--Subject to subsection (d)(6)(B), a State 
     participating in the project shall pay a steering committee 
     not less than $2.50 per targeted beneficiary per month.
       (II) Federal matching payment.--Subject to subparagraph 
     (A)(ii), amounts paid to a steering committee under subclause 
     (I) shall be considered medical assistance or child health 
     assistance for purposes of section 1903(a) or 2105(a), 
     respectively, of the Social Security Act (42 U.S.C. 1396b(a); 
     1397ee(a)).
       (III) Use of funds.--Amounts paid to a steering committee 
     under subclause (I) shall be used to purchase health 
     information technology, pay primary care case managers, 
     support network initiatives, and for such other uses as the 
     steering committee determines appropriate.

       (4) Technical assistance.--The Secretary shall make 
     available technical assistance to States, physician 
     practices, and health centers participating in the project 
     during the duration of the project.
       (5) Best practices information.--The Secretary shall 
     collect and make available to States participating in the 
     project information on best practices for patient-centered 
     medical homes.
       (d) Patient-Centered Medical Home Program.--
       (1) In general.--For purposes of this section, a patient-
     centered medical home program meets the requirements of this 
     subsection if, under such program, targeted beneficiaries 
     designate a personal primary care provider in a patient-
     centered medical home as their source of first contact, 
     comprehensive, and coordinated care for the whole person.
       (2) Elements.--
       (A) Mandatory elements.--
       (i) In general.--Such program shall include the following 
     elements:

       (I) A steering committee.
       (II) A medical management committee.
       (III) A network of physician practices and health centers 
     that have volunteered to participate as patient-centered 
     medical homes to provide high-quality care, focusing on 
     preventive care, at the appropriate time and place in a cost-
     effective manner.
       (IV) Hospitals and local public health departments that 
     will work in cooperation with the network of patient-centered 
     medical homes to coordinate and provide health care.
       (V) Primary care case managers to assist with care 
     coordination.
       (VI) Health information technology to facilitate the 
     provision and coordination of health care by network 
     participants.

[[Page S14624]]

       (ii) Multiple locations in the state.--In the case where a 
     State operates a patient-centered medical home program in 2 
     or more areas in the State, the program in each of those 
     areas shall include the elements described in clause (i).
       (B) Optional elements.--Such program may include a non-
     profit organization that--
       (i) includes a steering committee and a medical management 
     committee; and
       (ii) manages the payments to steering committees described 
     in subsection (c)(3)(B)(ii).
       (3) Goals.--Such program shall be designed--
       (A) to increase--
       (i) cost efficiencies of health care delivery;
       (ii) access to appropriate health care services, especially 
     wellness and prevention care, at times convenient for 
     patients;
       (iii) patient satisfaction;
       (iv) communication among primary care providers, hospitals, 
     and other health care providers;
       (v) school attendance; and
       (vi) the quality of health care services (as determined by 
     the relevant steering committee and medical management 
     committee, taking into account nationally-developed standards 
     and measures); and
       (B) to decrease--
       (i) inappropriate emergency room utilization, which can be 
     accomplished through initiatives, such as expanded hours of 
     care throughout the program network;
       (ii) avoidable hospitalizations; and
       (iii) duplication of health care services provided.
       (4) Payment.--Under the program, payment shall be provided 
     to personal primary care providers and steering committees 
     (in accordance with subsection (c)(3)(B)).
       (5) Notification.--The State shall notify individuals 
     enrolled in Medicaid or SCHIP about--
       (A) the patient-centered medical home program;
       (B) the providers participating in such program; and
       (C) the benefits of such program.
       (6) Treatment of states with a managed care contract.--
       (A) In general.--In the case where a State contracts with a 
     private entity to manage parts of the State Medicaid program, 
     the State shall--
       (i) ensure that the private entity follows the care 
     management model; and
       (ii) establish a medical management committee and a 
     steering committee in the community.
       (B) Adjustment of payment amounts.--The State may adjust 
     the amount of payments made under (c)(3)(B), taking into 
     consideration the management role carried out by the private 
     entity described in subparagraph (A) and the cost 
     effectiveness provided by such entity in certain areas, such 
     as health information technology.
       (e) Evaluation and Project Report.--
       (1) In general.--
       (A) Evaluation.--The Secretary, in consultation with 
     appropriate health care professional associations, shall 
     evaluate the project in order to determine the effectiveness 
     of patient-centered medical homes in terms of quality 
     improvement, patient and provider satisfaction, and the 
     improvement of health outcomes.
       (B) Project report.--Not later than 12 months after 
     completion of the project, the Secretary shall submit to 
     Congress a report on the project containing the results of 
     the evaluation conducted under subparagraph (A). Such report 
     shall include--
       (i) an assessment of the differences, if any, between the 
     quality of the care provided through the patient-centered 
     medical home program conducted under the project in the 
     States that provide medical assistance for primary care case 
     management services and those that do not;
       (ii) an assessment of quality improvements and clinical 
     outcomes as a result of such program;
       (iii) estimates of cost savings resulting from such 
     program; and
       (iv) recommendations for such legislation and 
     administrative action as the Secretary determines to be 
     appropriate.
       (2) Sense of the senate.--It is the sense of the Senate 
     that, during the next authorization of SCHIP, titles XIX and 
     XXI of the Social Security Act (42 U.S.C. 1396 et seq.; 
     1397aa et seq.) should be amended, based on the results of 
     the evaluation and report under paragraph (1), to establish a 
     patient-centered medical home program under such titles on a 
     permanent basis.
       (f) Waiver.--
       (1) In general.--Subject to paragraph (2), the Secretary 
     shall waive compliance with such requirements of titles XI, 
     XIX, and XXI of the Social Security Act (42 U.S.C. 1301 et 
     seq.; 1396 et seq.; 1397aa et seq.) to the extent and for the 
     period the Secretary finds necessary to conduct the project.
       (2) Limitation.--In no case shall the Secretary waive 
     compliance with the requirements of subsections (a)(10)(A), 
     (a)(15), and (bb) of section 1902 of the Social Security Act 
     (42 U.S.C. 1396a) under paragraph (1), to the extent that 
     such requirements require the provision of, and reimbursement 
     for services described in section 1905(a)(2)(C) of such Act 
     (42 U.S.C. 1396d(a)(2)(C)).
                                 ______
                                 
      By Mr. DURBIN (for himself and Mr. Obama):
  S. 2377. A bill to amend title 38, United States Code, to improve the 
quality of care provided to veterans in Department of Veterans Affairs 
medical facilities, to encourage highly qualified doctors to serve in 
hard-to-fill positions in such medical facilities, and for other 
purposes; to the Committee on Veterans' Affairs.
  Mr. DURBIN. Mr. President, today I am introducing legislation along 
with Senator Obama that will address some serious deficiencies we have 
found in the Veterans Administration's health care quality assurance 
efforts. Over the past several months, we have learned of problems in 
the hiring practices and quality of care at the veterans hospital in 
Marion, IL. What we have learned suggests that there are flaws that 
could equally affect the hiring and quality assurance programs in other 
VA hospitals.
  The problems at Marion first came to light in August after the VA 
became aware that there had been an abnormal spike in deaths at the 
hospital the previous winter. A doctor was practicing at Marion even 
though a year earlier he had agreed to stop practicing medicine in 
Massachusetts. This fact came to light only after he had resigned from 
Marion because he was being sued for malpractice involving a case at 
Marion. It turned out that he had been involved in at least nine other 
cases at Marion in which the patient died, and he had been the subject 
of at least two malpractice settlements and a disciplinary action in 
Massachusetts before moving to Illinois.
  The VA initiated an investigation and has taken steps to protect the 
patients at Marion. All but the most simple outpatient surgeries have 
been suspended, one doctor has resigned, four others have had their 
privileges restricted, and four top staff members have been temporarily 
reassigned.
  The VA's Inspector General is conducting a thorough investigation and 
I am looking forward to considering his conclusions. But we know enough 
to take action now. And we must take action now because what happened 
at Marion may not be an isolated case. The same problems may exist at 
other VA hospitals as well.
  The legislation we are introducing has three main objectives. First, 
it would improve the process of vetting doctors applying to and working 
in the VA. Second, it would expand the quality control programs in the 
VA health care system. And third, it would create incentives to 
encourage high-quality doctors to practice at veterans hospitals.
  The VA's standards for evaluating employment applicants must be 
strengthened. When the doctor whose problematic service brought this 
issue to light was hired by the VA, he had two malpractice payments on 
his record, but he had only disclosed one to the VA. He was also under 
investigation by the Massachusetts medical board for gross incompetence 
in several cases that led to the deaths of patients. This was not 
disclosed to the VA.
  Our legislation will fix this problem. It will require all physician 
applicants to the VA, and all doctors practicing in the VA, to disclose 
any judgments, settlements, disciplinary actions, and open 
investigations involving them. In addition, each doctor would be 
required to make a written request to the State medical board of any 
State in which they have held a license, requesting that the board 
release this same information to the VA.
  Now, as a lawyer, I understand the caution that must be used when 
dealing with investigations that are not complete and judgments that 
are not final. But doctors and hospitals understand and work with 
confidential information all the time. VA officials with hiring 
authority will keep this information confidential and will be able to 
differentiate between a frivolous lawsuit and a case that should raise 
real concern. Before we entrust our Nation's veterans to a doctor, the 
VA should know all the pertinent information about that individual. 
Before the VA hires a physician, it should be required to examine this 
kind of information to make sure the physician should not be 
disqualified from employment in the VA.
  In addition, our bill requires doctors employed by the VA to be 
licensed in the state in which they practice.
  The bill's second objective is to improve the VA's quality assurance 
program. Our legislation would establish a quality assure officer at 
each VA medical facility, in each Veterans Integrated Service Network, 
VISN, region,

[[Page S14625]]

and at the VA national headquarters. These officers would establish and 
carry out a quality assurance program at each VA medical facility.
  Over the year and a half that this doctor practiced at Marion, at 
least a few of the nurses had concerns about his skills and competence 
and raised those concerns with the hospital leadership. They were 
ignored. This is absolutely unacceptable.
  Concerns about the quality of care in a VA facility should never go 
unexamined. If local hospital officials will not listen, another avenue 
should be available for raising these concerns. Our legislation would 
allow employees to raise quality of care concerns to the local quality 
assurance officer and the regional quality assurance officer, ensuring 
that there is a place employees can go and know that their concerns 
will be considered.
  In addition, we would require that the quality assurance program at 
each hospital include a mechanism for the peer review of physicians in 
the hospital. At Marion, it appears that any kind of peer review 
program that might have been present was either dormant or ignored. As 
a result, early warning signs were missed that might have saved lives.
  Our measure would require that the quality assurance officers be 
licensed physicians, so that they will be qualified to monitor the 
performance of other doctors and ensure a fair but thorough peer review 
process is in place.
  Finally, our legislation includes provisions to encourage talented 
doctors to practice in the VA system. We would direct each VA hospital 
to seek to affiliate with a nearby medical school so that our hospitals 
will have the benefit of the fresh, young minds of medical students and 
the more experienced judgments Of medical school faculty. These 
affiliations would introduce young doctors to the work of the VA, which 
might lead them to consider a career there. We also would create loan 
forgiveness and tuition reimbursement programs to encourage doctors to 
commit to practice in VA hospitals.
  We also recognize that many experienced doctors might be willing to 
practice part-time in a VA hospital but would be unwilling to totally 
leave private practice. Our bill would instruct the VA to develop 
programs to increase the recruitment of experienced, quality doctors 
who might be willing to practice part-time in the VA health care 
system. It would also offer access to the federal employees health 
insurance program to doctors who are willing to practice at least five 
days per month in a VA medical facility.
  This bill addresses very real issues that directly affect the health 
of our veterans. The VA's investigation of what went wrong at Marion 
may lead us to additional legislative initiatives, but the steps we 
have outlined in this bill are steps that need to be taken now to 
protect veterans in VA hospitals throughout the country.
  This legislation has been endorsed by Veterans for America. I urge my 
colleagues to join in moving forward with this legislation to ensure 
that our veterans receive the quality of care they deserve.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 2377

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Veterans Health Care Quality 
     Improvement Act''.

     SEC. 2. STANDARDS FOR APPOINTMENT AND PRACTICE OF PHYSICIANS 
                   IN DEPARTMENT OF VETERANS AFFAIRS MEDICAL 
                   FACILITIES.

       (a) Standards.--
       (1) In general.--Subchapter I of chapter 74 of title 38, 
     United States Code, is amended by inserting after section 
     7402 the following new section:

     ``Sec. 7402A. Appointment and practice of physicians: 
       standards

       ``(a) In General.--The Secretary shall, acting 
     through the Under Secretary for Health, prescribe standards 
     to be met by individuals in order to qualify for appointment 
     in the Administration in the position of physician and to 
     practice as a physician in medical facilities of the 
     Administration. The standards shall incorporate the 
     requirements of this section.
       ``(b) Disclosure of Certain Information Before 
     Appointment.--Each individual seeking appointment in the 
     Administration in the position of physician shall do the 
     following:
       ``(1) Provide the Secretary a full and complete explanation 
     of the following:
       ``(A) Each lawsuit, civil action, or other claim (whether 
     open or closed) brought against the individual for medical 
     malpractice or negligence (other than a lawsuit, action, or 
     claim closed without any judgment against or payment by or on 
     behalf of the individual).
       ``(B) Each payment made by or on behalf of the individual 
     to settle any lawsuit, action, or claim covered by 
     subparagraph (A).
       ``(C) Each investigation or disciplinary action taken 
     against the individual relating to the individual's 
     performance as a physician.
       ``(2) Submit a written request and authorization to the 
     State licensing board of each State in which the individual 
     holds or has held a license to practice medicine to disclose 
     to the Secretary any information in the records of such State 
     on the following:
       ``(A) Each lawsuit, civil action, or other claim brought 
     against the individual for medical malpractice or negligence 
     covered by paragraph (1)(A) that occurred in such State.
       ``(B) Each payment made by or on behalf of the individual 
     to settle any lawsuit, action, or claim covered by 
     subparagraph (A).
       ``(C) Each medical malpractice judgment against the 
     individual by the courts or administrative agencies or bodies 
     of such State.
       ``(D) Each disciplinary action taken or under consideration 
     against the individual by an administrative agency or body of 
     such State.
       ``(E) Any change in the status of the license to practice 
     medicine issued the individual by such State, including any 
     voluntary or nondisciplinary surrendering of such license by 
     the individual.
       ``(F) Any open investigation of the individual by an 
     administrative agency or body of such State, or any 
     outstanding allegation against the individual before such an 
     administrative agency or body.
       ``(c) Disclosure of Certain Information Following 
     Appointment.--(1) Each individual appointed in the 
     Administration in the position of physician after the date of 
     the enactment of the Veterans Health Care Quality Improvement 
     Act shall, as a condition of service under the appointment, 
     disclose to the Secretary, not later than 30 days after the 
     occurrence of such event, the following:
       ``(A) A judgment against the individual for medical 
     malpractice or negligence.
       ``(B) A payment made by or on behalf of the individual to 
     settle any lawsuit, action, or claim disclosed under 
     paragraph (1) or (2) of subsection (b).
       ``(C) Any disposition of or material change in a matter 
     disclosed under paragraph (1) or (2) of subsection (b).
       ``(2) Each individual appointed in the Administration in 
     the position of physician as of the date of the enactment of 
     the Veterans Health Care Quality Improvement Act shall do the 
     following:
       ``(A) Not later than the end of the 60-day period beginning 
     on the date of the enactment of that Act and as a condition 
     of service under the appointment after the end of that 
     period, submit the request and authorization described in 
     subsection (b)(2).
       ``(B) Agree, as a condition of service under the 
     appointment, to disclose to the Secretary, not later than 30 
     days after the occurrence of such event, the following:
       ``(i) A judgment against the individual for medical 
     malpractice or negligence.
       ``(ii) A payment made by or on behalf of the individual to 
     settle any lawsuit, action, or claim disclosed pursuant to 
     subparagraph (A) or under this subparagraph.
       ``(iii) Any disposition of or material change in a matter 
     disclosed pursuant to subparagraph (A) or under this 
     subparagraph.
       ``(3) Each individual appointed in the Administration in 
     the position of physician shall, as part of the biennial 
     review of the performance of the physician under the 
     appointment, submit the request and authorization described 
     in subsection (b)(2). The requirement of this paragraph is in 
     addition to the requirements of paragraph (1) or (2), as 
     applicable.
       ``(d) Investigation of Disclosed Matters.--(1) The Regional 
     Director of the Veterans Integrated Services Network (VISN) 
     in which an individual is seeking appointment in the 
     Administration in the position of physician shall perform a 
     comprehensive investigation (in such manner as the standards 
     required by this section shall specify) of each matter 
     disclosed under subsection (b) with respect to the 
     individual.
       ``(2) The Regional Director of the Veterans Integrated 
     Services Network in which an individual is appointed in the 
     Administration in the position of physician shall perform a 
     comprehensive investigation (in a manner so specified) of 
     each matter disclosed under subsection (c) with respect to 
     the individual.
       ``(3) The results of each investigation performed under 
     this subsection shall be fully documented.
       ``(e) Approval of Appointments by Regional Directors of 
     VISNs.--(1) An individual may not be appointed in the 
     Administration in the position of physician without the 
     approval of the Regional Director of the Veterans Integrated 
     Services Network in which the individual will first serve 
     under the appointment.
       ``(2) In approving the appointment under this subsection of 
     an individual for whom

[[Page S14626]]

     any matters have been disclosed under subsection (b), a 
     Regional Director shall--
       ``(A) certify in writing the completion of the performance 
     of the investigation under subsection (d)(1) of each such 
     matter, including the results of such investigation; and
       ``(B) provide a written justification why any matters 
     raised in the course of such investigation do not disqualify 
     the individual from appointment.
       ``(f) Board Certification.--(1) Except as provided in 
     paragraph (2), an individual may not be appointed in the 
     Administration in the position of physician unless the 
     individual is board certified in the specialties in which the 
     individual will practice under the appointment.
       ``(2) A Regional Director may waive the limitation in 
     paragraph (1) with respect to any individual who has 
     completed a residency program within the two-year period 
     ending on the date of such waiver if the individual provides 
     satisfactory evidence (as determined in accordance with the 
     standards required by this section) of an intent to become 
     board certified. The period of any waiver under this 
     paragraph may not exceed one year.
       ``(g) State License Required for Practice in In-State VA 
     Medical Facilities.--Each physician practicing at a medical 
     facility of the Department in a State, whether under an 
     appointment in the Administration or through the extension of 
     privileges of practice, shall, as a condition of such 
     practice, hold a license to practice medicine in the State 
     within one year of appointment.
       ``(h) Enrollment of Physicians With Practice Privileges in 
     Proactive Disclosure Service.--Each medical facility of the 
     Department at which physicians are extended the privileges of 
     practice shall enroll each physician extended such privileges 
     in the Proactive Disclosure Service of the National 
     Practitioners Data Base.''.
       (2) Clerical amendment.--The table of sections at the 
     beginning of chapter 74 of such title is amended by inserting 
     after the item relating to section 7402 the following new 
     item:

``7402A. Appointment and practice of physicians: standards.''.

       (b) Effective Date and Applicability.--
       (1) Effective date.--Except as provided in paragraph (2), 
     the amendments made by subsection (a) shall take effect on 
     the date of the enactment of this Act.
       (2) Applicability of certain requirements to physicians 
     practicing on effective date.--In the case of an individual 
     appointed to the Veterans Health Administration in the 
     position of physician as of the date of the enactment of this 
     Act--
       (A) the requirements of subsections (f) and (g) of section 
     7402A, United States Code, as added by subsection (a) of this 
     section, shall take effect on the date that is one year after 
     the date of the enactment of this Act; and
       (B) the requirements of subsection (h) of such section 
     7402A, as so added, shall take effect on the date that is 60 
     days after the date of the enactment of this Act.

     SEC. 3. ENHANCEMENT OF QUALITY ASSURANCE BY THE VETERANS 
                   HEALTH ADMINISTRATION.

       (a) Enhancement of Quality Assurance Through Quality 
     Assurance Officers.--
       (1) In general.--Subchapter II of chapter 73 of title 38, 
     United States Code, is amended by inserting after section 
     7311 the following new section:

     ``Sec. 7311A. Quality assurance officers

       ``(a) National Quality Assurance Officer.--(1) The Under 
     Secretary of Health shall designate an official of the 
     Administration to act as the principal quality assurance 
     officer for the quality-assurance program required by section 
     7311 of this title. The official so designated may be known 
     as the `National Quality Assurance Officer of the Veterans 
     Health Administration' (in this section referred to as the 
     `National Quality Assurance Officer').
       ``(2) The National Quality Assurance Officer shall report 
     directly to the Under Secretary for Health in the discharge 
     of responsibilities and duties of the Officer under this 
     section.
       ``(3) The National Quality Assurance Officer shall be the 
     official within the Administration who is principally 
     responsible for the quality-assurance program referred to in 
     paragraph (1). In carrying out that responsibility, the 
     Officer shall be responsible for--
       ``(A) establishing and enforcing the requirements of that 
     program; and
       ``(B) carrying out such other responsibilities and duties 
     relating to quality assurance in the Administration as the 
     Under Secretary for Health shall specify.
       ``(4) The requirements under paragraph (3) shall include 
     requirements regarding the following:
       ``(A) A confidential system for the submittal of reports by 
     Administration personnel regarding quality assurance at 
     Administration facilities.
       ``(B) Mechanisms for the peer review of the actions of 
     individuals appointed in the Administration in the position 
     of physician.
       ``(C) Mechanisms for the accountability of the facility 
     director and chief medical officer of each Administration 
     medical facility for the actions of physicians in such 
     facility.
       ``(b) Quality Assurance Officers for VISNs.--(1) The 
     Regional Director of each Veterans Integrated Services 
     Network (VISN) shall appoint an official of the Network to 
     act as the quality assurance officer of the Network.
       ``(2) Each official appointed as a quality assurance 
     officer under this subsection shall be a board-certified 
     physician.
       ``(3) The quality assurance officer for a Veterans 
     Integrated Services Network shall report to the Regional 
     Director of the Veterans Integrated Services Network, and to 
     the National Quality Assurance Officer, regarding the 
     discharge of the responsibilities and duties of the officer 
     under this section.
       ``(4) The quality assurance officer for a Veterans 
     Integrated Services Network shall--
       ``(A) direct the quality assurance office in the Network; 
     and
       ``(B) coordinate, monitor, and oversee the quality 
     assurance programs and activities of the Administration 
     medical facilities in the Network in order to ensure the 
     thorough and uniform discharge of quality assurance 
     requirements under such programs and activities throughout 
     such facilities.
       ``(c) Quality Assurance Officers for Medical Facilities.--
     (1) The director of each Administration medical facility 
     shall appoint a quality assurance officer for that facility.
       ``(2) Each official appointed as a quality assurance 
     officer under this subsection shall be a board-certified 
     physician.
       ``(3) The official appointed as a quality assurance officer 
     for a facility under this subsection shall be a practicing 
     physician at the facility. If the official appointed as 
     quality assurance officer for a facility has other clinical 
     or administrative duties, the director of the facility shall 
     ensure that those duties are sufficiently limited in scope so 
     as to ensure that those duties do not prevent the officer 
     from effectively discharging the responsibilities and duties 
     of quality assurance officer at the facility.
       ``(4) The quality assurance officer for a facility shall 
     report directly to the director of the facility, and to the 
     quality assurance officer of the Veterans Integrated Services 
     Network in which the facility is located, regarding the 
     discharge of the responsibilities and duties of the quality 
     assurance officer under this section.
       ``(5) The quality assurance officer for a facility shall be 
     responsible for designing, disseminating, and implementing 
     quality assurance programs and activities for the facility 
     that meet the requirements established by the National 
     Quality Assurance Officer under subsection (a).''.
       (2) Clerical amendment.--The table of sections at the 
     beginning of chapter 73 of such title is amended by inserting 
     after the item relating to section 7311 the following new 
     item:

``7311A. Quality assurance officers.''.

       (b) Board-Certified Physician Requirement for Individuals 
     Appointed as Under Secretary for Health.--Section 305(a)(2) 
     of title 38, United States Code, is amended by inserting 
     ``shall be a board-certified physician and'' before ``shall 
     be''.
       (c) Reports on Quality Concerns Under Quality-Assurance 
     Program.--Section 7311(b) of such title is amended by adding 
     at the end the following new paragraph:
       ``(4) As part of the quality-assurance program, the Under 
     Secretary for Health shall establish mechanisms through which 
     employees of Administration facilities may submit reports, on 
     a confidential basis, on matters relating to quality of care 
     in Administration facilities to the quality assurance 
     officers of such facilities under section 7311A(c) of this 
     title and to the quality assurance officers of the Veterans 
     Integrated Services Networks (VISNs) in which such facilities 
     are located under section 7311A(b) of this title. The 
     mechanisms shall provide for the prompt and thorough review 
     of any reports so submitted by the receiving officials.''.
       (d) Review of Current Health Care Quality Safeguards.--
       (1) In general.--The Secretary of Veterans Affairs shall 
     conduct a comprehensive review of all current policies and 
     protocols of the Department of Veterans Affairs for 
     maintaining health care quality and patient safety at 
     Department of Veterans Affairs medical facilities. The review 
     shall include a review and assessment of the National 
     Surgical Quality Improvement Program (NSQIP), including an 
     assessment of--
       (A) the efficacy of the quality indicators under the 
     program;
       (B) the efficacy of the data collection methods under the 
     program;
       (C) the efficacy of the frequency with which regular data 
     analyses are performed under the program; and
       (D) the extent to which the resources allocated to the 
     program are adequate to fulfill the stated function of the 
     program.
       (2) Report.--Not later than 60 days after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report on the review conducted under paragraph (1), 
     including the findings of the Secretary as a result of the 
     review and such recommendations as the Secretary considers 
     appropriate in light of the review.

     SEC. 4. INCENTIVES TO ENCOURAGE HIGH-QUALITY PHYSICIANS TO 
                   SERVE IN THE VETERANS HEALTH ADMINISTRATION.

       (a) Incentives Required.--
       (1) In general.--Subchapter III of chapter 74 of title 38, 
     United States Code, is amended by inserting after section 
     7431 the following new section:

     ``Sec. 7431A. Physicians: additional incentives for service 
       in hard-to-fill positions

       ``(a) Loan Repayment for Physicians Who Serve in Hard-to-
     Fill Positions.--(1) In

[[Page S14627]]

     order to recruit and retain physicians in the Administration 
     in hard-to-fill positions (as designated by the Secretary for 
     purposes of this subsection), the Secretary shall repay, for 
     each individual who agrees to serve as a physician for a 
     period of not less than three years in an Administration 
     facility in such a position, any loan of such individual as 
     follows:
       ``(A) Any loan of the individual described in paragraphs 
     (1) through (4) of section 16302(a) of title 10.
       ``(B) Any other loan of the individual designated by the 
     Secretary for purposes of this subsection the proceeds of 
     which were used by the individual to finance education 
     leading to the medical degree of the individual.
       ``(2) Each individual seeking repayment of loans under 
     paragraph (1) shall enter into an agreement with the 
     Secretary regarding the repayment of loans. Under the 
     agreement, the individual shall agree--
       ``(A) to perform satisfactory service in a physician 
     position specified in the agreement in an Administration 
     facility specified in the agreement for such period of years 
     as the agreement shall specify; and
       ``(B) to possess and retain for the period of the agreement 
     such professional qualifications as are necessary for the 
     service specified under subparagraph (A).
       ``(3) Repayment of loans under this subsection shall be 
     made on the basis of complete years of service under the 
     agreement under this subsection. The amount to be repayed 
     under an agreement under this subsection for a complete year 
     of service specified in the agreement shall be such amount, 
     not to exceed $30,000, for each complete year of service as 
     the agreement shall specify.
       ``(b) Tuition Reimbursement for Physician Students Who 
     Agree to Serve in Hard-to-Fill Positions.--(1) In order to 
     recruit and retain physicians in the Administration in hard-
     to-fill positions (as designated by the Secretary for 
     purposes of this subsection), the Secretary shall reimburse 
     individuals who are enrolled in a course of education leading 
     toward board certification as a physician for the tuition 
     charged for pursuit of such course of education if such 
     individuals agree to serve as a physician in an 
     Administration facility in such a position.
       ``(2) Each individual seeking tuition reimbursement under 
     paragraph (1) shall enter into an agreement with the 
     Secretary regarding such tuition reimbursement. Under the 
     agreement, the individuals shall agree--
       ``(A) to satisfactorily complete the course of education of 
     the individual described in paragraph (1); and
       ``(B) upon completion of the course of education, to become 
     board-certified as a physician; and
       ``(C) upon completion of the matters referred to in 
     subparagraphs (A) and (B)--
       ``(i) to perform satisfactory service in a physician 
     position specified in the agreement in an Administration 
     facility specified in the agreement for such period of years 
     as the agreement shall specify; and
       ``(ii) to possess and retain for the period of the 
     agreement such professional qualifications as are necessary 
     for the service specified under clause (i).
       ``(3) The amount of reimbursement payable to an individual 
     under paragraph (1) for a year may not exceed $30,000.
       ``(4) Any individual receiving tuition reimbursement under 
     paragraph (1) who does not satisfy the requirements of the 
     agreement under paragraph (2) shall be subject to such 
     repayment requirements as the Secretary shall specify in the 
     agreement.
       ``(5) An individual receiving tuition reimbursement under 
     paragraph (1) for pursuit of a course of education shall also 
     be paid a stipend in the amount of $5,000 for each academic 
     year of pursuit of such course of education after entry into 
     an agreement under paragraph (2).
       ``(c) Participation in FEHBP of Physicians Who Serve Part-
     Time in Hard-to-Fill Positions.--(1) In order to recruit and 
     retain physicians in the Administration in hard-to-fill 
     positions (as designated by the Secretary for purposes of 
     this subsection), an individual not otherwise eligible for 
     health insurance under chapter 89 of title 5 who agrees to 
     serve as a physician in an Administration facility in such a 
     position for not less than five days per month (of which two 
     days must occur in each 14-day period) shall be eligible for 
     enrollment in the health benefit plans under chapter 89 of 
     title 5 on a self only or self and family basis (as 
     applicable).
       ``(2) The Secretary shall administer this subsection in 
     consultation with the Director of the Office of Personnel 
     Management.
       ``(d) Additional Programs.--It is the sense of Congress 
     that the Secretary should undertake active and on-going 
     efforts to establish additional incentive programs to 
     encourage individuals to serve in the position of physician 
     in the Administration, or otherwise practice in the 
     Administration, in hard-to-fill positions, including, in 
     particular, incentive programs to encourage more experienced 
     physicians to serve or practice in such positions.
       ``(e) Construction.--The incentives required under this 
     section are in addition to any other special pays or benefits 
     to which the individuals covered by this section are eligible 
     or entitled under law.''.
       (2) Clerical amendment.--The table of sections at the 
     beginning of chapter 74 of such title is amended by inserting 
     after the item relating to section 731 the following new 
     item:

``7431A. Physicians: additional incentives for service in hard-to-fill 
              positions.''.

       (b) Affiliation of Department of Veterans Affairs Medical 
     Facilities With Medical Schools.--The Secretary of Veterans 
     Affairs shall, to the extent practicable, require each 
     medical facility of the Department of Veterans Affairs to 
     seek to establish an affiliation with a medical school within 
     reasonable proximity of such medical facility.

     SEC. 5. REPORTS TO CONGRESS.

       (a) Report.--Not later than December 15, 2009, and each 
     year thereafter through 2012, the Secretary of Veterans 
     Affairs shall submit to the congressional veterans affairs 
     committees a report on the implementation of this Act and the 
     amendments made by this Act during the preceding fiscal year. 
     Each report shall include, for the fiscal year covered by 
     such report, the following:
       (1) A comprehensive description of the implementation of 
     this Act and the amendments made by this Act.
       (2) Such recommendations as the Secretary considers 
     appropriate for legislative or administrative action to 
     improve the authorities and requirements in this Act and the 
     amendments made by this Act or to otherwise improve the 
     quality of health care and the quality of the physicians in 
     the Veterans Health Administration.
       (b) Congressional Veterans Affairs Committees Defined.--In 
     this section, the term ``congressional veterans affairs 
     committees'' means--
       (1) the Committees on Veterans' Affairs and Appropriations 
     of the Senate; and
       (2) the Committees on Veterans' Affairs and Appropriations 
     of the House of Representatives.

                          ____________________