[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.]
* * * * * * *