[Congressional Record Volume 153, Number 178 (Friday, November 16, 2007)]
[Senate]
[Pages S14624-S14627]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      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.

                          ____________________