[House Report 110-786]
[From the U.S. Government Publishing Office]



110th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     110-786

======================================================================



 
          VETERANS' HEALTH CARE POLICY ENHANCEMENT ACT OF 2008

                                _______
                                

 July 29, 2008.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Filner, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 6445]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 6445) to amend title 38, United States Code, to 
prohibit the Secretary of Veterans Affairs from collecting 
certain copayments from veterans who are catastrophically 
disabled, having considered the same, report favorably thereon 
with amendments and recommend that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     3
Background and Need for Legislation..............................     4
Hearings.........................................................     9
Subcommittee Consideration.......................................     9
Committee Consideration..........................................     9
Committee Votes..................................................     9
Committee Oversight Findings.....................................    10
Statement of General Performance Goals and Objectives............    10
New Budget Authority, Entitlement Authority, and Tax Expenditures    10
Earmarks and Tax and Tariff Benefits.............................    10
Committee Cost Estimate..........................................    10
Congressional Budget Office Estimate.............................    10
Federal Mandates Statement.......................................    15
Advisory Committee Statement.....................................    15
Constitutional Authority Statement...............................    15
Applicability to Legislative Branch..............................    15
Section-by-Section Analysis of the Legislation...................    15
Changes in Existing Law Made by the Bill as Reported.............    16

                               Amendment

  The amendments are as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Veterans' Health Care Policy 
Enhancement Act of 2008''.

SEC. 2. PROHIBITION ON COLLECTION OF CERTAIN COPAYMENTS FROM VETERANS 
                    WHO ARE CATASTROPHICALLY DISABLED.

  (a) Prohibition on Collection of Copayments and Other Fees for 
Hospital or Nursing Home Care.--Section 1710 of title 38, United States 
Code, is amended--
          (1) by redesignating subsection (h) as subsection (i); and
          (2) by inserting after subsection (g) the following new 
        subsection (h):
  ``(h) Notwithstanding any other provision of this section, a veteran 
who is catastrophically disabled shall not be required to make any 
payment otherwise required under subsection (f) or (g) for the receipt 
of hospital care or nursing home care under this section.''.
  (b) Effective Date.--Subsection (h) of section 1710 of title 38, 
United States Code, as added by subsection (a), shall apply with 
respect to hospital care or nursing home care provided after the date 
of the enactment of this Act.

SEC. 3. EXPANSION OF AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO 
                    PROVIDE COUNSELING FOR FAMILY MEMBERS OF VETERANS 
                    RECEIVING NONSERVICE-CONNECTED TREATMENT.

  Section 1782(b) of title 38, United States Code, is amended by 
striking ``if--'' and all that follows and inserting a period.

SEC. 4. COMPREHENSIVE POLICY ON PAIN MANAGEMENT.

  (a) Comprehensive Policy Required.--Not later than October 1, 2008, 
the Secretary of Veterans Affairs shall develop and implement a 
comprehensive policy on the management of pain experienced by veterans 
enrolled for health care services provided by the Department of 
Veterans Affairs.
  (b) Scope of Policy.--The policy required by subsection (a) shall 
cover each of the following:
          (1) The systemwide management of acute and chronic pain 
        experienced by veterans.
          (2) The standard of care for pain management to be used 
        throughout the Department.
          (3) The consistent application of pain assessments to be used 
        throughout the Department.
          (4) The assurance of prompt and appropriate pain care 
        treatment and management by the Department, systemwide, when 
        medically necessary.
          (5) The Department's program of research related to acute and 
        chronic pain suffered by veterans, including pain attributable 
        to central and peripheral nervous system damage characteristic 
        of injuries incurred in modern warfare.
          (6) The Department's program of pain care education and 
        training for health care personnel of the Department.
          (7) The Department's program of patient education for 
        veterans suffering from acute or chronic pain and their 
        families.
  (c) Updates.--The Secretary shall revise the policy developed under 
subsection (a) on a periodic basis in accordance with experience and 
evolving best practice guidelines.
  (d) Consultation.--The Secretary shall develop the policy developed 
under subsection (a), and revise such policy under subsection (c), in 
consultation with veterans service organizations and organizations with 
expertise in the assessment, diagnosis, treatment, and management of 
pain.
  (e) Annual Report.--
          (1) In general.--Not later than 180 days after the date of 
        the completion and initial implementation of the policy under 
        subsection (a) and on October 1 of every fiscal year thereafter 
        through fiscal year 2018, the Secretary shall submit to the 
        Committee on Veterans' Affairs of the Senate and the Committee 
        on Veterans' Affairs of the House of Representatives a report 
        on the implementation of the policy developed under subsection 
        (a).
          (2) Contents.--The report required by paragraph (1) shall 
        include the following:
                  (A) A description of the policy developed and 
                implemented under subsection (a) and any revisions to 
                such policy under subsection (c).
                  (B) A description of the performance measures used to 
                determine the effectiveness of such policy in improving 
                pain care for veterans systemwide.
                  (C) An assessment of the adequacy of the Department's 
                pain management services based on a survey of patients 
                managed in Department clinics.
                  (D) An assessment of the Department's research 
                programs relevant to the treatment of the types of 
                acute and chronic pain suffered by veterans.
                  (E) An assessment of the training provided to 
                Department health care personnel with respect to the 
                diagnosis, treatment, and management of acute and 
                chronic pain.
                  (F) An assessment of the Department's pain care-
                related patient education programs.
  (f) Veterans Service Organization Defined.--In this section, the term 
``veterans service organization'' means any organization recognized by 
the Secretary for the representation of veterans under section 5902 of 
title 38, United States Code.

SEC. 5. ESTABLISHMENT OF CONSOLIDATED PATIENT ACCOUNTING CENTERS.

  (a) Establishment of Centers.--Chapter 17 of title 38, United States 
Code, is amended by inserting after section 1729A the following:

``Sec. 1729B. Consolidated patient accounting centers

  ``(a) In General.--Not later than 5 years after the date of enactment 
of this section, the Secretary of Veterans Affairs shall establish not 
more than seven consolidated patient accounting centers for conducting 
industry-modeled regionalized billing and collection activities of the 
Department.
  ``(b) Functions.--The centers shall carry out the following 
functions:
          ``(1) Reengineer and integrate all business processes of the 
        revenue cycle of the Department.
          ``(2) Standardize and coordinate all activities of the 
        Department related to the revenue cycle for all health care 
        services furnished to veterans for nonservice-connected medical 
        conditions.
          ``(3) Apply commercial industry standards for measures of 
        access, timeliness, and performance metrics with respect to 
        revenue enhancement of the Department.
          ``(4) Apply other requirements with respect to such revenue 
        cycle improvement as the Secretary may specify.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is amended by inserting after the item relating to section 
1729A the following:

``1729B. Consolidated patient accounting centers.''.

SEC. 6. SIMPLIFYING AND UPDATING NATIONAL STANDARDS TO ENCOURAGE 
                    TESTING OF THE HUMAN IMMUNODEFICIENCY VIRUS.

  Section 124 of the Veterans' Benefits and Services Act of 1988 (38 
U.S.C. 7333 note; 102 Stat. 505) and the item relating to such section 
in the table of contents of such Act (102 Stat. 487) are repealed.

  Amend the title so as to read:

      A bill to amend title 38, United States Code, to prohibit 
the Secretary of Veterans Affairs from collecting certain 
copayments from veterans who are catastrophically disabled, and 
for other purposes.

                          Purpose and Summary

    H.R. 6445 was introduced by Representative Donald J. 
Cazayoux, Jr. of Louisiana on July 9, 2008. H.R. 6445, as 
amended, contains provisions from H.R. 6439, introduced by 
Representative Phil Hare of Illinois; H.R. 6122, introduced by 
Representative Tim Walz of Minnesota; H.R. 6366, introduced by 
Representative Steve Buyer of Indiana, the Ranking Member of 
the Committee on Veterans' Affairs; and H.R. 6114, introduced 
by Representative Mike Doyle of Pennsylvania.
    H.R. 6445 would modernize the Department of Veterans 
Affairs (VA) policies regarding copayments for non-service-
connected Priority Group 4 veterans who are catastrophically 
disabled, pain care management programs, eligibility for 
counseling services for family members, and requirements for 
informed consent for HIV testing. Additionally, this 
legislation would enhance the VA's ability to collect third-
party payments by requiring the VA establish not more than 
seven consolidated patient accounting centers (CPACs).
    The bill would prohibit the VA from collecting copayments 
from veterans who are catastrophically disabled (Priority Group 
4) for hospital or nursing home care and would direct the VA to 
establish not more than seven CPACs for conducting industry-
modeled regionalized billing and collection activities.
    The bill would repeal the specification that in order for 
family members of non-service-connected veterans to be eligible 
for counseling services the counseling must be essential to 
permit the discharge of the veteran from the hospital. It would 
direct the VA to develop and implement a comprehensive policy 
on the management of pain experienced by veterans enrolled for 
health care services provided by the VA and revise the policy 
on a periodic basis in accordance with experience and evolving 
best practice guidelines. The bill would also require VA to 
develop and revise the policy in consultation with veterans' 
service organizations and organizations with expertise in the 
assessment, diagnosis, treatment, and management of pain.
    The bill would remove the requirement for written informed 
consent for HIV testing among veterans, thereby reducing 
existing barriers to the early diagnosis of HIV infection.

                  Background and Need for Legislation


  PROHIBITING COLLECTION OF COPAYMENTS FROM CATASTROPHICALLY DISABLED 
                                VETERANS

    The Veterans' Health Care Eligibility Reform Act of 1996 
(Public Law 104-262) directed the VA to establish a patient 
enrollment system to manage the provision of care and services 
provided to veterans, established seven priority groups, and 
directed the VA to enroll veterans in accordance with the 
priorities listed in the law. The Department of Veterans 
Affairs Health Care Programs Enhancement Act of 2001 (Public 
Law 107-135) subsequently added a new Priority Group 8 to 
reflect veterans with the lowest priority to VA health care to 
the existing seven priority groups.
    Veterans enrolled in Priority Groups 5 through 8, who are 
verified by the VA to be non-service connected catastrophically 
disabled and who have incomes above means-tested levels, may 
apply for enrollment into Priority Group 4. Those veterans who 
were previously subject to copayments are required to agree to 
pay those copayments after moving to Priority Group 4.
    Catastrophically disabled veterans are defined as having a 
permanent, severely disabling injury, disorder, or disease that 
compromises the ability to carry out the activities of daily 
living to such a degree that the individual requires personal 
or mechanical assistance to leave home or bed or requires 
constant supervision to avoid physical harm to self or others. 
According to the VA, approximately 25,000 catastrophically 
disabled veterans are enrolled in Priority Group 4.
    H.R. 6445 would prohibit the VA from collecting copayments 
from non-service connected veterans who are catastrophically 
disabled in Priority Group 4 for hospital or nursing home care. 
The very nature and severity of the disabilities experienced by 
these veterans often precludes them from being employed and 
may, therefore, deprive them of a steady form of income. The 
Committee believes requiring catastrophically disabled veterans 
to pay copayments may cause these veterans undue financial 
hardship.

  EXPANSION OF AUTHORITY OF SECRETARY OF VETERANS AFFAIRS TO PROVIDE 
    COUNSELING FOR FAMILY MEMBERS OF VETERANS RECEIVING NON-SERVICE-
                          CONNECTED TREATMENT

    The Department of Veterans Affairs Health Care Programs 
Enhancement Act of 2001 (Public Law 107-135) consolidated and 
reorganized the authority for the VA to provide services to 
non-veterans. This Act created section 1782 to title 38, United 
States Code, that outlines the conditions by which the VA may 
provide counseling, training and mental health services to 
immediate family members.
    Under current law, all enrolled veterans receiving care for 
service-connected treatment are eligible for family support 
services to the extent they are necessary to the veterans' 
treatment. Veterans being treated for non-service-connected 
disabilities are only eligible for these family support 
services if they are necessary in connection with the veteran's 
treatment, initiated during the veteran's hospitalization, and 
their continued provision on an outpatient basis is deemed 
essential to permit the discharge of the veteran from the 
hospital.
    Over the past decade, VA has transformed its delivery of 
health care services from an inpatient-based model to an 
outpatient-based model. According to VA, this transformation 
has significantly increased its efficiencies, increased 
veterans' access to care, and aligned the VA with the health 
care industry at large. As a result, some families have become 
ineligible for counseling, training, and other family support 
services that are essential to the veterans' treatment simply 
because their loved ones' care was for a non-service-connected 
disability that was provided on an outpatient basis.
    H.R. 6445 would eliminate the requirement that family 
support services be initiated during the veteran's 
hospitalization and deemed essential to permit the veteran's 
discharge, thus making the eligibility criteria the same for 
all veterans. An enrolled veteran is eligible for any needed 
medical treatment, regardless of whether or not the condition 
is service-connected. The Committee believes it is incongruent 
to base eligibility for needed family support services on the 
service-connected nature of a veteran's disability. If family 
support services are necessary in connection with the veteran's 
treatment, it should be irrelevant whether the disability under 
treatment is service-connected or non-service-connected and 
whether the treatment is provided in a hospital setting or on 
an outpatient basis.
    H.R. 6445 would enable the VA to provide needed counseling, 
training and mental health services to immediate family members 
of these veterans. As the mental health needs of veterans 
continue to grow and the VA is authorized to provide treatment 
and support to more veterans and their families, it is likely 
that it will need to increase its mental health workforce to 
accommodate the increased demand. The Committee strongly 
encourages the VA to fully implement the Veterans Benefits, 
Health Care, and Information Technology Act of 2006 (Public Law 
109-461). This Act authorized the VA to recognize and hire 
Licensed Professional Counselors and Marriage and Family 
Therapists as mental health professionals in the VA. However, 
the VA has yet to adopt regulations and policies to credential 
and employ mental health counselors in the VA system. These 
qualified and licensed mental health professionals are willing 
and able to care for our nation's veterans and their families 
and will help the VA meet the additional mental health workload 
now and into the future.

                COMPREHENSIVE POLICY ON PAIN MANAGEMENT

    According to the National Center for Health Statistics, 
pain affects an estimated 76 million Americans, more than 
cancer, diabetes and heart disease combined. Uncontrolled pain 
is a leading cause of disability and reduced quality of life. 
It adversely affects every aspect of daily living. Pain 
patients consume health care resources at a higher rate than 
other groups of patients. Under-treated pain is a leading 
contributor to health care costs, accounting for more than $100 
billion a year in health care expenses and lost productivity.
    The VA recognized that early assessment and pain management 
treatment is fundamental to the delivery of patient-centered 
medicine. In November 1996, VA appointed a Multidisciplinary 
Pain Committee to assess the appropriateness of VA pain 
management policies. This Committee found that the VA lacked a 
systematic pain management process. To address this 
shortcoming, VA developed a National Pain Management Strategy 
in November of 1998 and in March of 1999 VA issued a guide 
``Pain Assessment, the 5th Vital Sign,'' establishing 
procedures for pain assessment, treatment, and outcomes of 
treatments in all clinical settings to ensure consistent 
assessment of pain.
    In 2002, the VA Office of Inspector General (IG) conducted 
a review of VA's Pain Management Initiative to determine 
whether the initiative had been implemented in medical and 
surgical settings, pain interventions were timely and adequate, 
and reflected documented follow-up pain measurements. On June 
10, 2002, the IG issued a report (01-00026-101) that found that 
VA had made significant improvements over the previous five 
years since the initiative was established, but also found that 
the extent of implementation varied and more work needed to be 
done. Subsequently, VA issued VHA Directive 2003-021, 
establishing a Pain Management Strategy to make pain management 
a national priority. The Directive outlined the VA's strategy 
as providing a system-wide VHA standard of care for pain 
management; ensuring that pain assessment is performed in a 
consistent manner; ensuring that pain assessment is prompt and 
appropriate to include patients and families as active 
participants in pain management; providing for an 
interdisciplinary, multi-modal approach to pain management; 
and, ensuring that clinicians practicing in the VA health care 
system are adequately prepared to assess and manage pain 
effectively. This Directive expired on May 31, 2008.
    H.R. 6445 would require VA to develop and implement a 
comprehensive policy on the management of pain experienced by 
veterans. It would require the VA to develop the policy in 
consultation with veterans service organizations and 
organizations with expertise in the assessment, diagnosis, 
treatment, and management of pain.

                CONSOLIDATED PATIENT ACCOUNTING CENTERS

    Current law authorizes the VA to bill veterans' insurance 
companies (third-party collections) for non-service-connected 
care provided to veterans enrolled in the VA health care 
system. Public Law 105-33 gave VA the authority to retain these 
funds in the Medical Care Collections Fund (MCCF). VA can use 
the MCCF for providing medical services to veterans. In 2005, 
VA created the Mid-Atlantic CPAC in Asheville, North Carolina 
to help maximize its collections by using a private-sector 
model that is tailored to VA's billing and collection needs.
    Conference Report 109-305, accompanying Public Law 109-114, 
directed VA to establish a Revenue Improvement Demonstration to 
advance revenue performance and develop a model that could be 
leveraged systemwide. Due to their complementary missions, VA 
established the Revenue Improvement Demonstration Project at 
the Mid-Atlantic CPAC. Approximately $12 million for fiscal 
year 2007 in additional collections was generated as a result 
of this Revenue Improvement Demonstration Project in 
coordination with the CPAC initiatives.
    A June 2008 report from the Government Accountability 
Office (GAO) estimated that $1.2 to $1.4 billion dollars are 
going uncollected by VA. GAO reiterated its previous findings 
from 2001 and 2004 that VA has challenges in collecting from 
third-party payers, to include improper coding, delays in 
billing, and collections follow-up. These challenges prevent VA 
from maximizing its potential revenue from third-party 
insurance companies. However, in its 2008 report, GAO noted 
that the Mid-Atlantic CPAC achieved better billing performance 
and has been able to reduce billing times. GAO concluded that 
VA needs to establish standardized processes and procedures to 
improve timely and accurate billing and enhance collections. 
Effective management oversight and implementation will be key 
to the success of these initiatives.
    The Committee believes using the best practices from the 
CPAC and Revenue Improvement Demonstration Project would 
provide systemwide improvement for VA's collection processes. 
H.R. 6445 would require the VA to establish, within five years, 
no more than seven CPACs modeled after the existing CPAC and 
Revenue Improvement Demonstration Project in Asheville, North 
Carolina. The Committee expects VA to move quickly to implement 
these provisions in order to have the facilities operational in 
a timely manner.

SIMPLIFYING AND UPDATING NATIONAL STANDARDS TO ENCOURAGE TESTING OF THE 
                      HUMAN IMMUNODEFICIENCY VIRUS

    According to the Center for Disease Control (CDC), human 
immunodeficiency virus (HIV) is the virus that causes acquired 
immunodeficiency syndrome (AIDS). HIV attacks the immune system 
and destroys its ability to fight disease. As HIV progresses to 
AIDS, the body becomes increasingly susceptible to life-
threatening opportunistic infections. CDC estimates 1,039,000 
to 1,185,000 persons in the United States were living with HIV/
AIDS at the end of 2003 and approximately 40,000 persons become 
infected with HIV annually. Approximately 16 to 22 million 
persons in the United States are tested for HIV every year. 
Although 38 percent to 44 percent of all adults had been tested 
for HIV by 2002, CDC estimates that approximately 252,000 to 
320,000 persons are unaware of their HIV infection.
    The VA is the largest single provider of HIV/AIDS care in 
the United States. As of fiscal year 2005, there were 22,800 
patients with HIV/AIDS in the VA. According to the VA's Public 
Health Strategic Working Group, 50 percent of HIV positive 
veterans had already suffered significant damage to their 
immune system by the time they were diagnosed as HIV positive. 
These patients had, on average, 3.7 years of VA care before 
diagnosis, indicating that there were missed opportunities to 
make a diagnosis at a stage when HIV treatment could have 
prevented many of the complications experienced by these 
patients.
    The Veterans' Benefits and Services Act of 1988 (Public Law 
100-322), requires the VA to obtain a patient's written consent 
before being tested for HIV. Since the enactment of Public Law 
100-322, HIV testing has entered a new era. Lawmakers and 
public health officials are making changes to ensure that more 
people know their HIV status--an important consideration for 
maintaining their health and reducing the spread of the virus.
    In September 2006, CDC released the Revised Recommendations 
for HIV Testing of Adults, Adolescents, and Pregnant Women in 
Health-Care Settings which recommends that diagnostic HIV 
testing be a part of routine clinical care in all health care 
settings in the United States and recommends that separate 
written consent for HIV screening should no longer be required. 
The revised recommendations contend that people who are 
infected with HIV but not aware of it are not able to take 
advantage of the therapies that can keep them healthy and 
extend their lives, nor do they have the knowledge to protect 
their sex or drug-use partners from becoming infected.
    Knowing whether one is positive or negative for HIV may 
influence healthy decision making. Cohort studies have 
demonstrated that many infected persons decrease high risk 
behaviors once they become aware of their positive HIV status. 
HIV-infected persons who are unaware of their infection do not 
reduce risk behaviors. Because of medical treatment that lowers 
HIV viral load might also reduce risk for transmission to 
others, early referral to medical care could prevent HIV 
transmission in communities while reducing a person's risk for 
HIV-related illness and death.
    H.R. 6445 would remove the statutory requirements that a 
patient's written consent be obtained before testing for HIV, 
and accompanied by pre-and post-test documented counseling. 
This will enable the VA to update its procedures to conform to 
current standard of care and afford VA the flexibility to 
update their screening standards.
    This provision is identical to VA's legislative request in 
its fiscal year 2009 budget submission to update VA's HIV 
Testing Policy in accordance with CDC Testing Recommendations. 
The American Medical Association, the HIV Medicine Association, 
the American Academy of HIV Medicine, the American Academy of 
Pediatrics, the National Medical Association, and the National 
Association of Community Health Centers have endorsed the CDC 
recommendations. The Committee believes that these 
recommendations are appropriate for VA to implement. However, 
we recognize that these recommendations might change over time.
    The Committee recognizes that VA is a leader in responding 
to the challenges of the HIV/AIDS epidemic. The Committee urges 
VA to continue to ensure that veterans with HIV infection 
receive the highest quality clinical care and preventative 
services and that those veterans at risk also receive 
appropriate counseling, assistance and preventive services to 
lower their risk of acquiring the infection.

                                Hearings

    On June 26, 2008, the Subcommittee on Health held a 
legislative hearing on a number of bills introduced in the 
110th Congress, including the discussion drafts of a number of 
provisions included in H.R. 6445, as amended. The following 
witnesses testified: Mr. Carl Blake, National Legislative 
Director, Paralyzed Veterans of America; Mr. Christopher 
Needham, Senior Legislative Associate, National Legislative 
Service, Veterans of Foreign Wars of the United States; Gerald 
M. Cross, M.D., FAAFP, Principal Deputy Under Secretary for 
Health, Veterans Health Administration, U.S. Department of 
Veterans Affairs, accompanied by Walter A. Hall, Assistant 
General Counsel, U.S. Department of Veterans Affairs and Gary 
M. Baker, Chief Business Officer, Veterans Health 
Administration, U.S. Department of Veterans Affairs. Those 
submitting statements for the record included: Mr. Joseph L. 
Wilson, Assistant Director, Veterans Affairs and Rehabilitation 
Commission, The American Legion; Mr. Raymond C. Kelley, 
National Legislative Director, American Veterans (AMVETS); Mr. 
Adrian M. Atizado, Assistant National Legislative Director, 
Disabled American Veterans; and, Ms. Barbara F. West, Executive 
Director, National Association of Veterans' Research and 
Education Foundation

                       Subcommittee Consideration

    On July 10, 2008, the Subcommittee on Health met in open 
markup session and ordered favorably forwarded to the full 
Committee H.R. 6445 by voice vote.

                        Committee Consideration

    On July 16, 2008, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 6445 as 
amended, favorably reported to the House of Representatives, by 
voice vote. During consideration of the bill the following 
amendment was considered:
An amendment in the nature of a substitute by Mr. Michaud of 
Maine that incorporated provisions of H.R. 6439, H.R. 6122, 
H.R. 6366, and H.R. 6114, was agreed to by voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report the legislation and amendments thereto. 
There were no record votes taken on amendments or in connection 
with ordering H.R. 6445 reported to the House. A motion by Mr. 
Buyer of Indiana to order H.R. 6445, as amended, reported 
favorably to the House of Representatives was agreed to by 
voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are reflected in the descriptive portions 
of this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 6445 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the 
House of Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
6445 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 6445 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                             U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 28, 2008.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 6445, the Veterans 
Health Care Policy Enhancements Act of 2008.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                         Robert A. Sunshine
                                   (For Peter R. Orszag, Director).
    Enclosure.

H.R. 6445--Veterans Health Care Policy Enhancements Act of 2008

    Summary: H.R. 6445 would:
     Allow the Department of Veterans Affairs (VA) to 
increase testing for human immunodeficiency virus (HIV) 
infection in the population of veterans who use VA health care 
facilities,
     Require VA to establish up to seven regional 
accounting centers to consolidate all VA billing and collection 
functions related to health care,
     Prohibit VA from collecting copayments and fees 
from certain catastrophically disabled veterans,
     Authorize VA to provide certain mental health 
services to the family members and housemates of veterans being 
treated for a nonservice-connected condition, and
     Require VA to develop and implement a 
comprehensive policy on pain care.
    In total, CBO estimates that implementing H.R. 6445 would 
cost $995 million over the 2009-2013 period, assuming 
appropriation of the estimated amounts. Enacting the bill would 
not affect direct spending or revenues.
    H.R. 6445 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would impose no costs on state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of H.R. 6445 is shown in the following table. 
The costs of this legislation fall within budget function 700 
(veterans benefits and services).

----------------------------------------------------------------------------------------------------------------
                                                                 By fiscal year, in millions of dollars--
                                                         -------------------------------------------------------
                                                            2009     2010     2011     2012     2013   2009-2013
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Testing for Human Immunodeficiency Virus:
    Estimated Authorization Level.......................       43      114      188      265      343       953
    Estimated Outlays...................................       38      107      181      257      335       918
Patient Accounting Centers:
    Estimated Authorization Level.......................        7       24        4        0        0        35
    Estimated Outlays...................................        6       22        6       -4       -6        24
Copayments for the Catastrophically Disabled:
    Estimated Authorization Level.......................        6        6        6        6        6        30
    Estimated Outlays...................................        6        6        6        6        6        30
Counseling for Family Members:
    Estimated Authorization Level.......................        4        5        5        5        5        24
    Estimated Outlays...................................        4        4        5        5        5        23
Total Changes:
    Estimated Authorization Level.......................       60      149      203      276      354     1,042
    Estimated Outlays...................................       54      139      198      264      340       995
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: CBO assumes that the legislation will be 
enacted near the end of fiscal year 2008, that the estimated 
amounts will be appropriated each year, and that outlays will 
follow historical spending patterns for similar programs.

                            TESTING FOR HIV

    Section 6 would eliminate a rule prohibiting VA from 
conducting widespread testing for HIV infection in the 
population of veterans who use VA health care facilities. It 
also would eliminate current requirements for separate written 
consent for HIV tests and pre- and post-test counseling.
    Based on data from VA, CBO estimates that under section 6, 
the number of HIV tests administered by VA would increase 
significantly, from the current annual level of about 125,000 
tests to 200,000 in 2009 and to 250,000 a year over the 2010-
2013 period. Based on studies of veterans enrolled in VA health 
care, CBO expects that increased testing would lead to an 
increase in the number of newly diagnosed veterans and that 
those veterans would be identified earlier in the course of the 
disease.\1\ We expect that people who are tested for HIV at, 
and receive general care in, VA health care facilities would 
prefer to maintain continuity of care with VA health care 
providers, and thus would be treated by VA for HIV disease. 
Based on data from VA and the Kaiser Family Foundation, CBO 
estimates that the average cost of treatment in 2009 would be 
$18,000 per patient in the early stages of HIV infection, and 
$35,000 per patient in the advanced stages of the disease.
---------------------------------------------------------------------------
    \1\Ronald O. Valdiserri, Fred Rodriguez, and Mark Holodniy, 
``Frequency of HIV Screening in the Veterans Health Administration: 
Implications for Early Diagnosis of HIV Infection,'' AIDS Education and 
Prevention, vol. 20, no. 3 (2008), pp. 258-264; and Douglas K. Owens 
and others, ``Prevalence of HIV Infection Among Inpatients and 
Outpatients in Department of Veterans Affairs Health Care Systems: 
Implications for Screening Programs for HIV,'' American Journal of 
Public Health, vol. 97, no. 12 (2007), pp. 2173-2178.
---------------------------------------------------------------------------
    CBO estimates that under the bill, VA would start providing 
comprehensive HIV treatment to an additional 1,600 newly 
diagnosed veterans in 2009 at an average cost of $27,000 per 
person. By 2013, CBO estimates that the number of additional 
veterans being treated for HIV would grow to about 12,000. 
Because an increasing proportion of those veterans would be 
diagnosed in the early stages of the disease when treatment is 
less expensive, the average cost of treatment, before 
considering the effects of inflation, would decrease over time. 
Adjusting for inflation, CBO estimates that implementing 
section 6 would cost about $920 million over the 2009-2013 
period, assuming appropriation of the necessary funds.

                       PATIENT ACCOUNTING CENTERS

    Section 5 would require VA to establish up to seven 
consolidated patient accounting centers (CPACs) within the next 
five years. CPACs would be required to apply commercial 
industry standards to coordinate and standardize billing and 
collections related to health care. In total, CBO estimates 
that implementing this section would cost $24 million over the 
2009-2013 period, assuming appropriation of the estimated 
amounts.
    In 2006, VA established a CPAC in North Carolina, and the 
agency plans to expand the area it serves in 2008 and 2009. 
Based on information from VA, CBO expects that VA would begin 
establishing three CPACs in 2009, one in 2010, and the 
remaining two in 2011, and that all CPACs would be fully 
operational by the end of 2013. CBO also expects that there 
would be no net change in the overall number of employees 
working in billing and collection activities; some existing 
employees would move to CPACs, other existing employees would 
transition to different functions at their current location, 
and some new employees would be hired.
    CBO estimates that VA would require additional 
appropriations to retain those current employees who would 
transition to other functions at the facilities where they are 
employed, and that this period of transition would take nine 
months. Based on information from VA and assuming appropriation 
of the estimated amounts, CBO estimates that the total salary 
costs for those employees would be $12 million in 2009 and 
would grow to $25 million in 2012, before declining to $13 
million in 2013, when most CPACs would be operational. CBO 
estimates that other one-time costs of implementing CPACs--such 
as training, leases and start-up costs for office space, and 
information technology--would have a similar trend; initial 
costs would be $18 million in 2009, grow to $43 million in 2011 
and 2012, and decline to $22 million in 2013, assuming 
appropriation of the estimated amounts.
    In addition to CPACs, CBO expects that VA would require a 
small office at the VA headquarters in Washington, D.C., to 
oversee the regional CPACs. Based on information from VA, CBO 
estimates that the office would require 10 additional staff in 
2009 at a cost of $1 million but that staff would grow as CPACs 
become operational to about 33 people by 2013 with recurring 
costs of $4 million a year, assuming appropriation of the 
estimated amounts.
    Based on VA data on the growth in medical care collections 
(collections from third parties, copayments, and other fees) 
from the existing CPAC, CBO estimates that under the bill VA 
would collect an additional $30 million in 2009, which would 
rise to about $175 million in 2013. Under current law, those 
collections may be retained by the department and used to 
provide medical care and to offset expenses related to billing 
and collections. Thus, CBO estimates that much of the five-year 
costs of implementing CPACs would be offset by the resulting 
increase in collections; in the initial years implementation 
costs would exceed the additional collections, but starting in 
2012 these collections would exceed the implementation costs. 
Assuming appropriation of the estimated amounts, CBO estimates 
that implementing CPACs would have net costs of $24 million 
over the 2009-2013 period.

              COPAYMENTS FOR THE CATASTROPHICALLY DISABLED

    Section 2 would prohibit the collection of copayments and 
other fees from catastrophically disabled veterans who receive 
medical or nursing home care from VA. Catastrophically disabled 
veterans are those who have a permanent, severely disabling 
condition that compromises their ability to carry out the 
activities of daily living to such a degree that they require 
assistance to leave their homes or require constant supervision 
to avoid physical harm to themselves or others.
    Data from VA show that, in 2006, the department collected 
about $6 million in medical care and nursing home fees from 
catastrophically disabled veterans who are priority category 4 
veterans because their disabilities are not related to military 
service. Because those copayments and fees are fixed and the 
population of those veterans has been relatively stable over 
the past several years, CBO estimates that implementing this 
provision would decrease collections by $6 million per year. 
Such collections are offsets to discretionary appropriations. 
As part of the annual appropriations process, the Congress 
gives VA authority to spend those collections. Therefore, 
maintaining the same level of health care services for veterans 
would necessitate additional funding each year to make up for 
the loss of copayments under this bill. Thus, CBO estimates 
that implementing this provision would cost $30 million over 
the 2009-2013 period.

                     COUNSELING FOR FAMILY MEMBERS

    Section 3 would expand VA's authority to provide 
consultations, professional counseling, training, and other 
necessary mental health services to the family members or 
housemates of certain veterans being treated for nonservice-
connected conditions. Under current law, such services are only 
authorized if they began during the veteran's hospitalization 
and are necessary on an outpatient basis to permit the 
veteran's discharge from the hospital. The bill would strike 
those restrictions and allow VA to provide such services on the 
same basis to all veterans, regardless of whether the condition 
being treated is service-connected or not.
    In 2007, the VA provided services to about 5,000 family 
members or housemates of roughly 2.15 million veterans (a rate 
of 0.23 percent) at a cost of about $3 million. Another 2.65 
million veterans were treated in 2007 for nonservice-connected 
conditions, but their family members or housemates were not 
eligible for mental health services. CBO expects that under the 
bill, the currently ineligible family members or housemates 
would require such services at the same rate they are being 
provided to those who are currently eligible.
    After adjusting for inflation and growth in the number of 
veterans requiring treatment, CBO estimates that under the bill 
VA would provide mental health services to an additional 6,700 
people a year at an annual cost of almost $5 million, on 
average, over the 2009-2013 period. CBO estimates that 
implementing this provision would cost $23 million over the 
2009-2013 period, assuming appropriation of the estimated 
amounts.

                COMPREHENSIVE POLICY ON PAIN MANAGEMENT

    Section 4 would require VA to develop and implement a 
comprehensive policy on pain care at all VA health care 
facilities, under which VA would assess and appropriately treat 
acute and chronic pain. The department also would be required 
to make annual reports on the policy to the Congress. VA 
reports that it has implemented appropriate pain assessment and 
management protocols at its medical facilities. Thus, CBO 
estimates that implementing the provision would cost less than 
$500,000 over the 2009-2013 period for the production of annual 
reports, assuming availability of appropriated amounts.
    Intergovernmental and private-sector impact: H.R. 6445 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would impose no costs on state, local, or 
tribal governments.
    Previous CBO estimate: On January 15, 2008, CBO transmitted 
a cost estimate for S. 2160 as ordered reported by the Senate 
Committee on Veterans' Affairs on November 14, 2007. Section 3 
of that bill is similar to section 4 of H.R. 6445 and CBO 
estimated it would have no costs, but the House bill would 
impose reporting requirements that CBO estimates would have 
small annual costs.
    On August 23, 2007, CBO transmitted a cost estimate for S. 
1233 as ordered reported by the Senate Committee on Veterans' 
Affairs on June 27, 2007. Section 303 of that bill is similar 
to section 2 of H.R. 6445. Their estimated costs over a five-
year period are identical, except that CBO assumes a later 
enactment date for H.R. 6445.
    Estimate prepared by: Federal Costs: Sunita D'Monte and 
Alexis Miller; Impact on State, Local, and Tribal Governments: 
Lisa Ramirez-Branum; Impact on the Private Sector: Daniel 
Frisk.
    Estimate approved by: Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 6445 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
6445.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for H.R. 6445 is provided by Article 
I, section 8 of the Constitution of the United States.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    This section would provide the short title of H.R. 6445 as 
the ``Veterans' Health Care Policy Enhancement Act of 2008.''

Section 2. Prohibition on collection of certain copayments from 
        veterans who are catastrophically disabled

    This section would add a new subsection to section 1710 of 
chapter 17 of title 38, United States Code, which would 
prohibit the VA from collecting copayments from veterans who 
are non-service connected catastrophically disabled (Priority 
Group 4) for hospital and nursing home care.

Section 3. Expansion of authority of Secretary of Veterans Affairs to 
        provide counseling for family members of veterans receiving 
        non-service-connected treatment

    This section would repeal the requirement currently in 
subsection (b) of section 1782, United States Code, that in 
order for family members of non-service-connected veterans to 
be eligible for counseling services, the counseling must be 
essential to permit the discharge of the veteran from the 
hospital.

Section 4. Comprehensive policy on pain management

    This section would direct the VA to develop and implement a 
comprehensive policy on the management of pain experienced by 
veterans enrolled for health care services provided by the VA. 
It further directs the VA to revise the policy on a periodic 
basis in accordance with experience and evolving best practice 
guidelines. The VA should develop and revise the policy in 
consultation with veterans service organizations and other 
organizations with expertise in the assessment, diagnosis, 
treatment, and management of pain. In addition, this section 
requires the VA to submit a report on the implementation of the 
policy to the Committee not later than 180 days after the date 
of the completion and initial implementation of the policy and 
on October 1 of every fiscal year thereafter through fiscal 
year 2018.

Section 5. Establishment of consolidated patient accounting centers

    This section would add a new section, 1729B to title 38, 
United States Code, which would require the VA to establish not 
more than seven consolidated patient accounting centers for 
conducting industry-modeled regionalized billing and collection 
activities not later than 5 years after the enactment of this 
act.

Section 6. Simplifying and updating national standards to encourage 
        testing of the Human Immunodeficiency Virus

    This section would repeal section 124 of the Veterans' 
Benefits and Services Act of 1988 (Public Law 100-322) to 
remove the requirement for written informed consent for HIV 
testing among veterans.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE




           *       *       *       *       *       *       *
PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *



   CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE


                          SUBCHAPTER I--GENERAL

Sec.
1701.  Definitions.
     * * * * * * *

   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
           NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

     * * * * * * *
1729B.  Consolidated patient accounting centers.

           *       *       *       *       *       *       *


SUBCHAPTER II--HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL 
                               TREATMENT

Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care

  (a) * * *

           *       *       *       *       *       *       *

  (h) Notwithstanding any other provision of this section, a 
veteran who is catastrophically disabled shall not be required 
to make any payment otherwise required under subsection (f) or 
(g) for the receipt of hospital care or nursing home care under 
this section.
  [(h)] (i) Nothing in this section requires the Secretary to 
furnish care to a veteran to whom another agency of Federal, 
State, or local government has a duty under law to provide care 
in an institution of such government.

           *       *       *       *       *       *       *


   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

           *       *       *       *       *       *       *


Sec. 1729B. Consolidated patient accounting centers

  (a) In General.--Not later than 5 years after the date of 
enactment of this section, the Secretary of Veterans Affairs 
shall establish not more than seven consolidated patient 
accounting centers for conducting industry-modeled regionalized 
billing and collection activities of the Department.
  (b) Functions.--The centers shall carry out the following 
functions:
          (1) Reengineer and integrate all business processes 
        of the revenue cycle of the Department.
          (2) Standardize and coordinate all activities of the 
        Department related to the revenue cycle for all health 
        care services furnished to veterans for nonservice-
        connected medical conditions.
          (3) Apply commercial industry standards for measures 
        of access, timeliness, and performance metrics with 
        respect to revenue enhancement of the Department.
          (4) Apply other requirements with respect to such 
        revenue cycle improvement as the Secretary may specify.

           *       *       *       *       *       *       *


SUBCHAPTER VIII--HEALTH CARE OF PERSONS OTHER THAN VETERANS

           *       *       *       *       *       *       *


Sec. 1782. Counseling, training, and mental health services for 
                    immediate family members

  (a) * * *
  (b) Counseling for Family Members of Veterans Receiving Non-
Service-Connected Treatment.--In the case of a veteran who is 
eligible to receive treatment for a non-service-connected 
disability under the conditions described in paragraph (1), 
(2), or (3) of section 1710(a) of this title, the Secretary 
may, in the discretion of the Secretary, provide to individuals 
described in subsection (c) such consultation, professional 
counseling, training, and mental health services as are 
necessary in connection with that treatment [if--
          [(1) those services were initiated during the 
        veteran's hospitalization; and
          [(2) the continued provision of those services on an 
        outpatient basis is essential to permit the discharge 
        of the veteran from the hospital].

           *       *       *       *       *       *       *

                              ----------                              


              VETERANS' BENEFITS AND SERVICES ACT OF 1988

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) * * *
  (b) Table of Contents.--The table of contents for this Act is 
as follows:

Sec. 1. Short title; table of contents.
     * * * * * * *
[Sec. 124. Restriction on testing for infection with the human 
          immunodeficiency virus.]

           *       *       *       *       *       *       *


TITLE I--HEALTH-CARE PROGRAMS

           *       *       *       *       *       *       *


Part C--Matters Relating to AIDS

           *       *       *       *       *       *       *


[SEC. 124. RESTRICTION ON TESTING FOR INFECTION WITH THE HUMAN 
                    IMMUNODEFICIENCY VIRUS.

  [(a) General Rule.--Except as provided in subsection (b), the 
Secretary of Veterans Affairs may not during any fiscal year 
conduct a widespread testing program to determine infection of 
humans with the human immunodeficiency virus unless funds have 
been appropriated to the Department of Veterans Affairs 
Department of Veterans Affairs specifically for such a program 
during that fiscal year.
  [(b) Voluntary Testing.--(1) The Secretary shall provide for 
a program under which the Department of Veterans Affairs offers 
each patient to whom the Department is furnishing health care 
or services and who is described in paragraph (2) the 
opportunity to be tested to determine whether such patient is 
infected with the human immunodeficiency virus.
  [(2) Patients referred to in paragraph (1) are--
          [(A) patients who are receiving treatment for 
        intravenous drug abuse,
          [(B) patients who are receiving treatment for a 
        disease associated with the human immunodeficiency 
        virus, and
          [(C) patients who are otherwise at high risk for 
        infection with such virus.
  [(3) Subject to the consent requirement in paragraph (4) and 
unless medically contraindicated, the test shall be 
administered to each patient requesting to be tested for 
infection with such virus.
  [(4) A test may not be conducted under this subsection 
without the prior informed and separate written consent of the 
patient tested. The Secretary shall provide pre- and post-test 
counseling regarding the acquired immune deficiency syndrome 
and the test to each patient who is administered the test.]

           *       *       *       *       *       *       *


                                  
