[Senate Report 111-60]
[From the U.S. Government Publishing Office]
Calendar No. 128
111th Congress Report
SENATE
1st Session 111-60
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VETERANS' HEALTH CARE AUTHORIZATION ACT OF 2009
_______
July 24, 2009.--Ordered to be printed
_______
Mr. Akaka, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
[To accompany S.252]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (S.252), to amend
title 38, United States Code, to enhance the capacity of the
Department of Veterans Affairs to recruit and retain nurses and
other critical health-care professionals, to improve the
provision of health care to veterans, and for other purposes,
reports favorably thereon, with an amendment, and recommends
that the bill, as amended, do pass.
Introduction
On January 15, 2009, Chairman Akaka introduced S.252, the
proposed ``Veterans' Health Care Authorization Act of 2009.''
S.252 as introduced would enhance the capacity of the
Department of Veterans Affairs (hereinafter, ``VA'') to recruit
and retain nurses and other critical health care professionals.
This bill included a majority of provisions from S.2969,
legislation introduced on May 1, 2008 by Chairman Akaka in the
110th Congress. S.2969 was reported favorably by the Committee,
S. Rpt. 110-473, with an amendment in the nature of a
substitute, and was subsequently placed on the Senate
Legislative Calendar on September 18, 2008. It was not taken up
by the Senate prior to the adjournment of the 110th Congress.
S.2969 as reported and S.252 as introduced include
provisions derived from a number of other bills, described
below.
On October 31, 2007, Chairman Akaka introduced, by request,
S.2273, the proposed ``Enhanced Opportunities for Formerly
Homeless Veterans Residing in Permanent Housing Act of 2007.''
S.2273 would enhance services for previously homeless veterans
and for veterans at risk of becoming homeless. S.2969 as
reported included similar provisions as did S.252 as
introduced.
On April 2, 2008, Senator Murray introduced S.2799, the
proposed ``Women Veterans Health Care Improvement Act of
2008.'' S.2799 would require studies of the health care needs
of women veterans and of the services available to them from
VA, and would require expansion of the services available to
women veterans. S.2969 as reported contained similar provisions
as did S.252 as introduced. Senator Murray introduced S.597 on
March 16, 2009, which contained provisions similar to those in
S.2799.
On April 2, 2008, Chairman Akaka introduced S.2796. S.2796
would require VA to conduct a pilot program on the use of
community-based organizations to ensure that transitioning
veterans and their families receive the care and benefits to
which they are entitled. S.2969 as reported contained this
program as did S.252 as introduced.
On April 22, 2008, Senator Harkin introduced S.2899, the
proposed ``Veterans Suicide Study Act.'' S.2899 would direct VA
to conduct a study on suicides among veterans. S.2969 as
reported included similar provisions as did S.252 as
introduced.
On April 28, 2008, Chairman Akaka introduced S.2926, the
proposed ``Veterans Nonprofit Research and Education
Corporations Enhancement Act of 2008.'' S.2926 would authorize
multi-medical center nonprofit research corporations
(hereinafter, ``NPCs''), clarify existing authorities, and
strengthen VA oversight of NPCs. S.2969 as reported included
similar provisions as did S.252 as introduced.
On April 29, 2008, Senator Tester introduced S.2937. S.2937
would provide VA with permanent authority to provide health
care for participants in certain Department of Defense chemical
and biological tests, and would expand the study of the impact
of Project Shipboard Hazard and Defense (hereinafter, ``SHAD'')
on veterans' health. S.2969 as reported included similar
provisions as did S.252 as introduced.
On May 1, 2008, Senator Bond introduced S.2963. S.2963
would, among other things, enhance the mental health care
services available to members of the Armed Forces and veterans,
and enhance counseling and other benefits available to
survivors of members of the Armed Forces and veterans. S.2969
as reported included similar provisions as did S.252 as
introduced. S.772, introduced April 1, 2009, by Senator Bond,
includes provisions similar to S.2963.
On May 6, 2008, Chairman Akaka introduced, by request,
S.2984, the proposed ``Veterans' Benefits Enhancement Act of
2008.'' S.2984 contained a number of provisions since enacted
into law, but also included modifications to a number of
reporting requirements, authorizations to disclose certain
personal information in limited circumstances, and authorities
for the operation and upkeep of the VA police force. S.2969 as
reported included similar provisions as did S.252 as
introduced.
On May 8, 2008, Chairman Akaka introduced S.3000, the
proposed ``Native American Veterans Access Act of 2008.''
S.3000 would include federally recognized tribal organizations
in certain programs for State veterans homes. S.2969 as
reported included similar provisions as did S.252 as
introduced.
On June 23, 2008, Ranking Member Burr introduced S.3178.
S.3178 would authorize a dental insurance program for veterans
and survivors and dependents of veterans. S.2969 as reported
included provisions derived from this legislation as did S.252
as introduced. On February 26, 2009, Senator Burr again
introduced S.498, a bill similar to S.3178.
On April 22, 2009, the Committee held a hearing on pending
health care legislation. Testimony was offered by: Gerald M.
Cross, M.D., FAPP, Principal Deputy Under Secretary for Health,
Department of Veterans Affairs; Walter A. Hall, Assistant
General Counsel, Department of Veterans Affairs; Joleen Clark,
Chief Officer for Workforce Management and Consulting, Veterans
Health Administration; Adrian Atizado, Assistant National
Legislative Director, Disabled American Veterans; Ammie
Hilsabeck, R.N., Oscar G. Johnson VA Medical Center (Iron
Mountain, MI), on behalf of American Federation of Government
Employees; Ralph Ibson, Health Policy Senior Fellow, Wounded
Warrior Project; and Blake Ortner, Senior Legislative Director,
Paralyzed Veterans of America.
Committee Meeting
The Committee met in open session on May 21, 2009, to
consider, among other legislation, S.252, consisting of S.252
as introduced with a number of modifications following
testimony provided at the foregoing hearing. The Committee
voted by roll call to report favorably S.252 without dissent.
Summary of S.252 as Reported
S.252, as reported, (hereinafter, ``the Committee bill'')
would amend the title of the original bill, and would make
numerous enhancements and expansions to VA health care and
services. This legislation is similar to S.2969, which was
reported by the Committee on September 18, 2008, but not taken
up by the Senate. Changes from S.2969 include: refinements to
the personnel sections; deletions to reflect provisions that
were enacted as Pub. L. 110-387; and deletions of provisions
that were introduced in S.801.
TITLE I--DEPARTMENT PERSONNEL MATTERS
Section 101 would authorize VA to extend title 38, United
States Code (U.S.C.), employment status to certain employees
under limited circumstances; amend salary authorities for
certain VA positions; amend the statute governing certain work
schedules; amend the statute governing transparency and conduct
of locality pay surveys; and enhance other authorities to
improve recruitment and retention of medical professionals.
Section 102 would impose limitations on overtime duty and
would amend the statutes governing weekend duty and alternative
work schedules for nurses.
Section 103 would reauthorize and expand certain
educational assistance programs to improve recruitment and
retention.
Section 104 would establish standards for the appointment
and practice of physicians in VA medical facilities.
TITLE II--HEALTH CARE MATTERS
Section 201 would repeal the annual reporting requirements
on nurse pay and long-term planning.
Section 202 would amend the annual Gulf War research report
by changing the report due date.
Section 203 would mandate that payment by VA on behalf of a
covered beneficiary for the Civilian Health and Medical Program
of VA (hereinafter, ``CHAMPVA'') medical care shall constitute
payment and eliminate any liability on the part of the
beneficiary for that care.
Section 204 would authorize VA to make disclosures from
certain medical records under limited circumstances.
Section 205 would require the disclosure to the Secretary
of health plan contract information and social security numbers
of certain veterans receiving care from VA.
Section 206 would require the designation of a National
Quality Management Officer, and a Quality Management Officer
for each VA facility, would describe the responsibilities of
such Officers, and would require VA to establish mechanisms for
employees to submit confidential reports on matters related to
quality of care in VA facilities. Further, this provision
requires certain reports regarding VA quality programs and
implementation of this section.
Section 207 would require a report on Department health
care quality management.
Section 208 would require VA to establish a pilot program
on the use of community-based organizations to ensure that
transitioning veterans and their families receive the care and
benefits they need.
Section 209 would authorize VA to contract with appropriate
entities for specialized residential care and rehabilitation
for certain Operation Iraqi Freedom or Operation Enduring
Freedom (hereinafter, ``OIF/OEF'') veterans with TBI.
Section 210 would require VA to establish an expanded study
on the health impact of Project SHAD.
Section 211 would require VA to provide care and services
to certain individuals in non-Department facilities under
limited circumstances.
Section 212 would authorize tribal organizations to access
the construction grants and per diem payments provided under
the State Veterans Home Program in the same manner as other
eligible entities.
Section 213 would require VA to establish a pilot program
on the provision of dental insurance plans to veterans,
survivors, and dependents of veterans.
TITLE III--WOMEN VETERANS HEALTH CARE
Section 301 would require VA to report on the barriers to
women veterans' access to VA health care.
Section 302 would require VA to develop a plan to improve
the provision of health care services to women veterans.
Section 303 would require an independent study on the
health consequences of service in OIF/OEF for women veterans.
Section 304 would require VA to implement a program of
training and certification for VA mental health care providers
on care for veterans suffering from military sexual trauma.
Section 305 would require VA to establish a pilot program
on counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
Section 306 would require a report on full-time women
veterans' program managers at VA medical centers.
Section 307 would require the Advisory Committees on Women
Veterans and Minority Veterans to include women veterans
recently separated from service in the Armed Forces.
Section 308 would require VA to establish a pilot program
on child care for certain veterans receiving health care from
VA.
Section 309 would authorize VA to provide health care
services to the newborn children of woman veterans under
certain circumstances.
TITLE IV--MENTAL HEALTH CARE
Section 401 would establish eligibility for members of the
Armed Forces who served in OIF/OEF for readjustment counseling
and related mental health services through the Readjustment
Counseling Service of the Veterans Health Administration.
Section 402 would restore the authority of the Readjustment
Counseling Service to provide referral and other assistance to
former members of the Armed Forces, not otherwise authorized
for counseling.
Section 403 would require VA to conduct a study on suicides
among veterans since January 1, 1999, and report to Congress on
their findings.
Section 404 would require VA to transfer $5,000,000 to the
Secretary of Health and Human Services for the Graduate
Psychology Education program.
TITLE V--HOMELESS VETERANS
Section 501 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
coordinate the provision of supportive services to formerly
homeless veterans residing on certain military property.
Section 502 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
coordinate the provision of supportive services to formerly
homeless veterans residing in permanent housing.
Section 503 would authorize VA to establish a pilot program
to make grants to public and nonprofit organizations that
provide outreach to inform low-income and elderly veterans who
reside in rural areas about pension benefits.
Section 504 would require assessments of the pilot programs
described in Sections 501-503.
TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS
Section 601 would authorize multi-medical center nonprofit
research and education corporations (``NPCs''), expand existing
corporations to multi-medical center research corporations,
amend authorities on the applicability of state law, clarify
the status of corporations, and reinstate the requirement of
501(c)(3) status of corporations.
Section 602 would clarify the purpose of NPCs.
Section 603 would amend the requirements for VA and non-VA
Board members.
Section 604 would amend and clarify the provision on
general powers of NPCs.
Section 605 would redesignate section 7364A of title 38,
U.S.C., as section 7365.
Section 606 would amend the provision on reporting by
adding additional information to be reported on; amend the
provision related to the confirmation of application of
conflict of interest regulations to include appropriate
corporation positions; and authorize the establishment of an
appropriate payee reporting threshold.
TITLE VII--OTHER MATTERS
Section 701 would expand the authority for VA police
officers.
Section 702 would provide a uniform allowance for VA police
officers.
Background and Discussion
TITLE I--DEPARTMENT PERSONNEL MATTERS
Title I of the Committee bill contains a number of
provisions that would amend specific personnel authorities in
title 38, United States Code (U.S.C), so as to give the
Secretary of Veterans Affairs additional tools to retain health
care personnel, expand scholarship programs for the purposes of
recruitment and retention; and authorize additional pay for
executive positions within VHA, and for certain nursing
positions.
Section 101. Enhancement of authorities for retention of medical
professionals.
Section 101 of the Committee bill contains provisions that
would amend title 38 to remove salary restrictions at nurse and
executive grades to improve recruitment and retention;
improving the methodology and transparency of the computation
of the locality pay scale; and establishing guidelines on the
use of mandatory overtime for nurses in emergency situations.
Subsection 101(a)--Secretarial authority to extend title 38
status to additional positions.
Background. The unique features of the title 5, title 38,
and title 38 hybrid personnel systems have resulted in uneven
conditions of employment for some employees working in the same
occupational series and occupational groups. For example,
corrective therapy assistants, hired under title 5, provide
services under the same occupational series as occupational
therapy assistants and physical therapy assistants, hired as
title 38 hybrids. All three work in the same organizational
units providing rehabilitation therapy, but are hired and
employed under different conditions.
Committee Bill. Subsection (a)(1) of section 101 of the
Committee bill would amend section 7401(3) of title 38, so as
to give the Secretary of VA the authority to apply the title 38
hybrid employment system to additional health care occupations
when such action is deemed necessary to meet recruitment or
retention needs. The Committee bill limits the application of
title 38 hybrid status to those providing direct patient care
services or services incident to direct patient-care services,
not otherwise available to provide medical care and treatment
for veterans.
The Secretary would be required to notify the House and
Senate Committees on Veterans' Affairs and the Office of
Management and Budget (OMB) 45 days prior to implementing a
decision to convert an occupation to the hybrid system. Prior
to Congressional and OMB notification, VA would be required to
notify labor organizations representing VHA employees in
occupations being considered for inclusion, in order to seek
their comments.
In testimony submitted for the record of the Committee's
April 22, 2009, hearing, VA supported the provisions of this
subsection as this change would give the Secretary the ability
to react quickly, through the title 38 hiring process, to bring
on additional employees.
Subsection (a)(2) of section 101 of the Committee bill
would further amend section 7401(3) by adding nurse assistants
to the list of occupations eligible for appointment under title
38. By bringing this position under the title 38 hiring
process, the Department will have the ability to expedite
hiring to fill nurse assistant positions.
In accordance with the original purpose for a separate
title 38 hiring system, it is the Committee's intent that VA
continue to have the ability to expedite the hiring of certain
health care personnel. The Committee is aware that, as
presently implemented, the hiring process under title 38 has
not proven as expeditious as intended and that concerns have
been raised that adding additional professions to the list of
hybrid positions could overburden the title 38 hybrid
employment system. It is the Committee's belief, however, that
the Department has the capacity, resources, and responsibility
to resolve the obstacles to expedited hiring under title 38.
In addition, testimony submitted by VA for the record of
the April 22, 2009, Committee hearing, stated that nurse
assistants, in particular, are high priority positions that
have proven difficult to fill. VA supported the provisions of
subsection (a)(2) of this section in its testimony, citing
turnover rates of 11.1 percent for 2007 and 10.96 percent for
2008, which illustrate the great difficulty VA experiences in
retaining nurse assistants.
Professional organizations have also recognized VA's need
for better tools to enhance recruitment of allied health
professionals. On May 26, 2009, the Committee received a letter
from the Joint Commission on Allied Health Personnel in
Ophthalmology (JCAHPO) supporting Section 101(a) because it
would increase VA's ability to recruit and retain qualified eye
care technicians. According to JCAHPO, a qualified eye care
technician can improve the workload of an ophthalmologist by an
average of 36%.
Subsection 101(b) and (c)--Probationary periods for
registered nurses, and prohibition on temporary
part-time registered nurse appointments in excess
of two years.
Subsections (b) and (c) of section 101 of the Committee
bill are addressed below together, as they are dependent upon
each other, and address similar issues.
Subsection (b) would modify the terms of the probationary
period that registered nurses must serve upon employment by the
Department, and subsection (c) would limit the extent of a
temporary appointment of part-time registered nurses.
Background. Subsection 7403(b) of title 38, provides that
appointments of health care providers under that section shall
be for a probationary period of two years. The probationary
period serves to ensure an appropriate time of observation and
vetting before an employee becomes permanent.
Currently, part-time registered nurses (``RNs'') are
employed by the Department on a temporary basis under section
7405 of title 38. As temporary employees, they are not eligible
for the same job protection and grievance rights as employees
appointed under section 7403 who have completed the
probationary periods. Further, when employees transition from
full to part-time, they are considered employees under 7405,
with commensurate loss of rights and protections. Valerie
O'Meara, R.N., representing the American Federation of
Government Employees, testified before the Committee on April
9, 2008, about her experience switching from full to part-time
status to raise a family. She explained that she lost her
grievance and arbitration rights, and was not permitted to
contest Reductions-In-Force decisions. Further, she described
the cases of older nurses who have worked a decade or more for
the VA who switch to part-time because of the stress of their
job or to care for their aging parents. The Committee believes
VA would benefit from retaining the expertise of these
registered nurses, even on a part-time basis.
VA has been challenged to fill RN positions due to rising
demand for these professionals. A March 2009 Memorandum from
the Congressional Research Service indicated that VA had 1700
vacancies for registered nurses, with a projected loss of
another 7600 VA Registered Nurses due to retirement by the year
2013.
Committee Bill. Subsections (b) and (c) of section 101 of
the Committee bill would clarify the terms of a probationary
period under section 7403 of title 38, and address the inequity
faced by part-time nurses under section 7405 of title 38.
Subsection (b) would amend section 7403(b) by adding two
new paragraphs. New paragraph (2) would mandate that an
appointment of a registered nurse under the section, whether on
a full- or part-time basis, shall be for a probationary period
of two years. The intent of this provision is to ensure
equitable treatment for full and part-time nurses, which is
vital to the Department's ability to recruit and retain part-
time nurses.
New paragraph (3) would mandate that an appointment under
section 7403 on a part-time basis of a health care professional
who has previously served on a full-time basis shall be without
a probationary period. This provision would clarify that no RN
who has already served a probationary period would be required
to serve a probationary period upon switching from a full-time
to a part-time appointment. The Committee sees no utility in
requiring an RN who has served a probationary period on a full-
time basis to serve an additional probationary period.
Subsection (c) of section 101 would amend section 7405 of
title 38, to add a new subsection (g). The proposed new
subsection would specify that the appointment of an RN on a
temporary part-time basis under section 7405 would be for a
probationary period, as defined under section 7403(b), as would
be amended by subsection (b) of section 101 of the Committee
bill. Upon completion of the probationary period, the
appointment would no longer be considered temporary, and would
instead be considered an appointment under 7403(a), unless the
part-time appointment resulted from an academic affiliation, a
research proposal or grant, or was used for non-citizens in
accordance with 38 U.S.C. 7407(a). Subject to these exceptions,
and the completion of the probationary period, all temporary
part-time appointments of RNs would be considered permanent.
It is the Committee's intent that the amendments to
sections 7403 and 7405 will eliminate disincentives to part-
time employment of RNs in VA. Many RNs, after serving a full
career in VA, or in response to family concerns, are faced with
the decision to either retire from VA or transition to part-
time service. Informed by the testimony presented at the
Committee hearings on April 9 and May 21, 2008, the Committee
believes VA would benefit from the service that these
registered nurses would provide on a part-time basis. Further,
increased use of part-time registered nurses will help VA fully
staff facilities, and better meet the rising demand for health
care services.
It is not the intent of the Committee bill to prevent or
limit the hiring of part-time nurses beyond the probationary
period. Rather, the Committee intends that upon completion of
such period, the appointment be considered permanent, with all
accompanying benefits and privileges.
In written testimony provided to the Committee for its
April 22, 2009 legislative hearing, the American Federation of
Government Employees testified in support of transitioning
part-time temporary employees to an appointment under 7403(a)
following completion of a probationary period. Carl Blake,
National Legislative Director, Paralyzed Veterans of America,
in testimony before the Committee on May 21, 2008, also voiced
support for the provision to eliminate the probationary period
for RNs who transition from full-time to part-time.
Subsection 101(d)--Waiver of offset from pay for certain
reemployed annuitants.
Subsection (d) of section 101 of the Committee bill would
authorize VA to waive salary offsets for retirees who are
reemployed in the Veterans Health Administration.
Background. Under current law, the salary of a VHA employee
rehired after retirement from the Federal Government is reduced
according to the amount of their annuity under a government
retirement system. The reduction is required by sections 8344
and 8468 of title 5, U.S.C., which deal with annuity payments
upon reemployment.
VHA faces a growing wave of retirements at all levels of
administration and health care providers. According to the
Department, at the end of 2006, 56 percent of Medical Center
Directors were eligible for retirement, and by 2013 over 90
percent of these key personnel will be eligible for retirement.
Many of the likely successors for the director positions,
current Associate Directors, are also retirement eligible. VA
projects that by 2013, 95,019 VHA employees will be eligible to
retire, including 97 percent of current senior executives, 81
percent of facility Chiefs of Staff, and 91 percent of nurse
executives. This rate of retirement eligibility is
unprecedented, and the sudden loss of the experience and
expertise of these employees would seriously limit VA's ability
to deliver care.
Because reemployed annuitants receive only that portion of
their salary that is above their annuity payment, there is
little incentive under the current employment system to return
to VA employment. Annuitants who wish to continue working are
able to receive full pay from a non-government employer, in
addition to their annuity, something they cannot do at VA.
In testimony before the Committee on May 21, 2008, Cecilia
McVey, MHA, RN, former President of the Nurses Organization of
Veterans Affairs, said that ``During this time of a critical
nursing shortage, it is more important than ever to keep these
valuable resources to provide the best care to veterans.''
Rehiring annuitants addresses issues arising from the high
number of retirements facing VA. Increased employment of
annuitants would potentially limit costs by reducing the use of
expensive contract agreements. Retaining experienced
professionals while younger employees develop their
capabilities would also ensure the transfer of valuable
institutional knowledge from one generation of leaders to
another within VA.
A program which allows the Government Accountability Office
to temporarily hire retirees, without a salary offset, for the
purposes of training, education, and mentoring, has proven
successful.
Committee Bill. Subsection (d) of section 101 of the
Committee bill would amend section 7405 of title 38 so as to
add a new subsection (g) which would authorize the Secretary to
waive sections 8344 and 8468 of title 5, U.S.C., on a case-by-
case basis when reemploying an annuitant on a temporary basis.
This section would further require that an annuitant to whom a
waiver under the proposed new section (g) is granted be subject
to the provisions of chapter 71 of title 5, relating to the
protection of government employees from discrimination and
retaliation.
By authorizing the Secretary to waive these two sections of
title 5, the Committee intends to encourage retirees to return
to work at VHA. At present, many VA employees go on to work
outside of the Department after retiring from VA, with some
even returning to work at VA on a contract basis. By
eliminating the salary offset, it is the Committee's hope that
there will be a significant pay incentive that will encourage
annuitants to return to VA, rather than seeking employment
elsewhere.
Subsection 101(e)--Rate of basic pay for appointees to the
office of the under secretary for health set to
rate of basic pay for senior executive service
positions.
Subsection (e) of section 101 of the Committee bill would
amend section 7404(a) of title 38, to set the rate of basic pay
for appointees to the Office of the Under Secretary of Health.
Background. Under current law, non-physician and non-
dentist appointees under section 7306 of title 38, which
relates to the composition of the Office of VA's Under
Secretary for Health, including the Director of Pharmacy
Benefits Management Strategic Health Group, the Director of
Dietetics, the Director of Podiatry, and the Director of
Optometry, among others, serve in executive level positions
that are equivalent in scope and responsibility to positions in
the Senior Executive Service (SES), which includes senior
managers and administrators in the VA Central Office, among
others. The pay level for section 7306 appointees is adjusted
each year by Executive Order, as authorized by chapter 53 of
title 5, and is capped, by subsection 7404(d) of title 38, at
the pay rate for Level V of the Executive Schedule, currently
at $143,500 including locality pay. VA employees in the SES, on
the other hand, can receive pay up to Level II of the Executive
Schedule, currently $177,000.
According to VA, the disparity between pay levels for SES
and non-SES employees serving in similar capacities has led to
difficulties in recruiting and retaining non-SES executive
level managers. Executives in these positions provide valuable
input to the Under Secretary for Health, and manage significant
elements of the Veterans Health Administration.
Committee Bill. Subsection (e) of section 101 of the
Committee bill would amend section 7404(a) of title 38 so as to
add a paragraph that would mandate that pay for certain
appointees to the Office of the Under Secretary for Health be
set according to the SES. This change would be effective on the
first day of the first pay period beginning the day after 180
days after the date of enactment of this legislation.
This change would effectively establish that, for the
purposes of basic pay, all senior executives in the Office of
the Under Secretary for Health would receive pay based on Level
II or Level III of the Executive Schedule. The Secretary would
be required to meet the same OPM certification criteria as is
currently utilized for SES pay scales. By implementing a
uniform pay scale for all senior executives in that office, the
Committee believes VA will be better able to recruit and retain
highly qualified individuals.
This provision was developed in close cooperation with the
Department, and the Department indicated its support for this
subsection in testimony submitted for the Committee's April 22,
2009, hearing.
In testimony before the Committee on May 21, 2008, Thomas
Berger, PhD, Chair of the National PTSD and Substance Abuse
Committee, Vietnam Veterans of America (VVA), expressed VVA's
support for additional pay ``to enhance recruitment and
retention of top professionals to run the VA health care
system.''
Subsection 101(f)--Special incentive pay for department
pharmacist executives.
Background. VA is challenged to match the compensation
offered by non-Federal employers to senior executives,
including National Pharmacist Executives (NPEs). NPEs include
managers of the VA National Formulary, Directors of the
Consolidated Mail Outpatient Pharmacies, consultants to the
Secretary for pharmacy issues, Network Pharmacy Benefits
Managers, and the Director of Emergency Pharmacy Services.
Under current law, basic salaries for NPEs are set according to
the General Schedule, which caps salaries for these positions
at $153,200. According to surveys conducted by VA, salary
ranges for national and regional pharmacy executives are
between $180,000 and $225,000. Further inducements commonly
available in the private sector include profit sharing or stock
options, yearly bonuses more generous than those currently
available from VA, recruitment and retention bonuses, and
corporate vehicles for individuals in regional positions.
VA has been challenged to fill NPE positions in recent
years, due largely to the pay disparity between VA and the
private sector, and the lack of financial incentives to take on
responsibilities at the national and regional level. In
addition, applications for Chief of Pharmacy positions at VA
facilities, the primary source of future NPEs, have fallen off
dramatically. The Workforce Succession Strategic Plan for VHA
FY 2006-2010 (October, 2005), listed pharmacists second only to
RNs as national priorities for recruitment and retention.
Committee Bill. Subsection 101(f) of the Committee bill
would amend section 7410 of title 38, relating to additional
pay authorities, to authorize recruitment and retention special
incentive pay for pharmacist executives of up to $40,000. The
determination of whether to provide such pay, and its amount,
would be based on: grade, step, scope and complexity of the
position, personal qualifications, characteristics of the labor
market concerned, and such other factors as the Secretary
considers appropriate. This provision would provide that such
pay would be in addition to other pay, awards, and bonuses. In
testimony submitted for the Committee's April 22, 2009,
hearing, VA supported this provision.
Subsection 101(g)--Pay for physicians and dentists.
Subsection 101(g) of section 101 of the Committee bill
would make three separate amendments to section 7431 of title
38, relating to pay for physicians and dentists.
Committee Bill. Paragraph (1) of subsection (g) would
clarify the determination of the non-foreign cost of living
adjustment (COLA), authorized by section 7431(b). The COLA is
provided to employees in locations with substantially higher
costs of living than those of Washington, DC, and or
environmental conditions that differ substantially from those
in the continental United States. Similar provisions, which are
applicable to other government employees, are in section 5941
of title 5, U.S.C.
Paragraph (1) of subsection 101(g) of the Committee bill
would amend section 7431(b) so as to add a new paragraph that
would provide that the non-foreign cost of living adjustment
allowance authorized under section 5941 of title 5, U.S.C.,
shall, in the case of VA physicians and dentists, be determined
as a percentage of base pay only. Section 7431(b) currently
does not specify the basis for the determination of the
allowance, which has led to inconsistent determinations.
Paragraph (2) of subsection (g) would amend section
7431(c)(4)(B)(i) to exempt physicians and dentists in executive
leadership provisions from the panel process in determining the
amount of market pay and tiers for such physicians and
dentists. Market pay is ``pay intended to reflect the
recruitment and retention needs for the specialty or assignment
* * * of a particular physician or dentist'' in a VA facility.
Under current law, the Secretary is to take into account the
views of ``an appropriate panel or board'' in determining the
amount of market pay for an individual physician or dentist. In
cases where such physicians or dentists occupy executive
leadership positions such as chief officers, network directors,
and medical center directors, the consultation of a panel has
some limitations. The small number of providers who would
qualify as peers for the executive leaders results in their
serving on each other's compensation panels. This amendment
will provide the Secretary with discretion to identify
executive physician/dentist positions that do not require a
panel process.
Paragraph (3) of subsection (g) would amend section
7431(c)(7) so as to allow an exception to the prohibition in
current law on a reduction in market pay when a physician or
dentist remains in the same position or assignment. The
exception would allow for a reduction in market pay when there
has been a change in board certification or a reduction of
privileges, even when the individual remains in a position or
assignment. By allowing such reduction in market pay, the
Committee bill would prevent a physician or dentist from
receiving additional market compensation for credentials and or
privileges he or she may no longer possess.
In testimony submitted for the Committee hearing on April
22, 2009, VA indicated support for the provisions in subsection
101(g) of the Committee bill.
Subsection 101(h)--Adjustment of pay cap for nurses.
Subsection (h) of section 101 of the Committee bill relates
to pay for RNs.
Background. Under current law, section 7451 of title 38
governs basic pay levels for VA RNs, and certain other VA
employees. Section 7451(c)(2) mandates that the maximum rate of
basic pay for any grade for a covered position, including RNs,
may not exceed the maximum rate of basic pay established for
positions in level V of the Executive Schedule under section
5316 of title 5, U.S.C. Level V is currently set at $143,500.
In testimony submitted for the Committee's April 9, 2008,
hearing, Ms. Converso of United American Nurses cited a
``crisis in our country regarding the shortage of registered
nurses.'' At the same hearing, Marisa W. Palkuti, MEd,
Director, Healthcare Retention and Recruitment Office, Veterans
Health Administration, cited a growing inadequacy in the number
of health care workers, including RNs nationwide, and suggested
that ``[t]his shortfall will grow exponentially over the next
20 years.''
During that hearing, Sheila M. Cullen, the then-Director of
the San Francisco VA Medical Center, testified about her
efforts to retain nurses. To compete with other health care
employers in the region, and to address the high cost of
living, Ms. Cullen instituted salary increases for RNs between
5 and 8 percent annually in recent years.
The current level V cap often prevents VA registered nurses
from receiving locality pay. Locality pay, which is in addition
to basic pay, is based on compensation levels in a local labor
market. When a nurse's basic pay is equal to the level V cap,
no additional locality pay can be awarded, regardless of
conditions in local labor market, a result that has a
detrimental effect on recruitment and retention.
Committee Bill. Subsection (h) of section 101 of the
Committee bill would amend section 7451(c)(2) of title 38, so
as to adjust the pay cap for registered nurses and others in
covered positions from Level V to Level IV. Level IV is
currently set at $153,200. By raising the cap on nurse basic
pay, the Committee intends to provide VA with additional
flexibility to compete in local labor markets. Based on
testimony presented at Committee hearings, and on oversight
activities, the Committee believes that additional pay would
improve VA's ability to recruit and retain qualified nurses.
This provision was supported by VA in testimony submitted
to the Committee for its April 22, 2009, hearing. Also, in
testimony before the Committee on May 21, 2008, Cecilia McVey,
MHA, RN, Former President of the Nurses Organization of
Veterans Affairs, called for the increase in the cap on RN pay
proposed by the Committee bill.
Subsection 101(i)--Exemption for certified registered nurse
anesthetists from limitation on authorized
competitive pay.
Subsection (i) of section 101 of the Committee bill would
allow pay for certified registered nurse anesthetists (CRNAs)
to exceed the pay caps established for RNs employed by the
Department.
Background. As discussed above, under subsection 101(h),
current law limits pay for CRNAs at level V of the Executive
Schedule, currently $143,500. Additional compensation may be
provided to CRNAs in the form of recruitment and/or retention
bonuses. As is currently the case with RNs, the level V cap
often prevents CRNAs from receiving locality pay.
In December 2007, the Government Accountability Office
(``GAO'') released a report on CRNA retention, titled
``Department of Veterans Affairs (VA) medical facilities have
challenges in recruiting and retaining VA CRNAs for their
workforce'' (GAO-08-56). GAO found that about three-fourths of
all VA medical facility chief anesthesiologists responding to
the survey reported that they had difficulty recruiting CRNAs.
Overall, 54 percent of VA medical facility chief
anesthesiologists reported temporarily closing some operating
rooms and 72 percent reported delaying some elective surgeries
due to difficulty fully staffing CRNAs. GAO projected that 26
percent of VA's CRNAs will either retire from or leave VA by
2012. VA medical facility officials reported that the
recruitment and retention challenges are caused primarily by
the low level of VA CRNA salaries when compared with CRNA
salaries in local market areas.
In testimony before the Committee on April 9, 2008, Ms.
Cullen and Steven P. Kleinglass, Director of the Minneapolis VA
Medical Center, both discussed the challenges created by the
current limit on CRNA pay. Mr. Kleinglass noted that at the
Minneapolis VAMC, the VA pay scale falls behind the local
medical community as a whole, and that ``therefore, in theory,
we should have most of our employees on a retention bonus.''
Ms. Cullen, in San Francisco, is prevented from offering
locality pay due to the statutory limit, even though the local
median salary for CRNAs is $171,334. As a result, she has had
to implement the 25 percent retention incentive extensively. At
the same hearing, Ms. O'Meara echoed these concerns.
``Facilities around the country are finding it increasingly
difficult to recruit CRNAs.''
Committee Bill. Subsection (i) of section 101 of the
Committee bill would further amend section 7451(c)(2) of title
38, as amended by subsection 101(h) of the Committee bill, to
allow pay for CRNAs to exceed the pay caps established for RNs
employed by the Department.
This proposed exemption would provide VA with greater
flexibility to offer additional pay to CRNAs, a necessary tool
when CRNA positions prove difficult to fill due to insufficient
compensation.
This proposed amendment was endorsed in testimony before
the Committee on May 21, 2008, by Carl Blake, National
Legislative Director, Paralyzed Veterans of America and J.
David Cox, RN, National Secretary-Treasurer, American
Federation of Government Employees. In addition, VA supported
this provision in testimony submitted for the Committee's April
22, 2009, hearing.
Subsection 101(j)--Increased limitation on special pay for
nurse executives.
This provision would amend section 7452(g)(2) to increase
the limitation on special pay for nurse executives from $25,000
to $100,000.
Background. Under current law, the Secretary may provide
between $10,000 and $25,000 in special pay to nurse executives
at each Department health care facility and at the VA Central
Office. The amount is determined based on the grade of the
nurse executive position, the scope and complexity of the nurse
executive position, the personal qualifications of the nurse
executive, the characteristics of the health care facility
concerned, the nature and number of specialty care units at the
health care facility concerned, demonstrated difficulties in
recruitment and retention of nurse executives at the health
care facility concerned, and such other factors as the
Secretary considers appropriate.
Given the limits on nurse pay, most nurse executives are
already paid at or near the top of their grade. As such, VA
lacks the ability to provide additional financial incentive to
individuals who take on the increased responsibility of
executive positions. Given the systemic shortage of nurses as
described previously, the Committee believes that an additional
financial incentive is warranted to attract highly qualified
nurses to executive positions.
Committee Bill. Subsection (j) of section 101 of the
Committee bill would amend section 7452(g)(2) of title 38 so as
to increase the authorized limit on special pay for nurse
executives from $25,000 to $100,000. In testimony before the
Committee on May 21, 2008, Mr. Blake expressed PVA's support
for this provision of the Committee bill.
Subsection 101(k)--Locality pay scale computation.
Subsection 101(k) of the Committee bill would amend section
7451 of title 38 so as to improve implementation and
transparency of VA's locality pay system for nurses and others
in covered positions.
Background. Section 7451(d) of title 38 currently
authorizes a locality pay system (LPS) to address
geographically-related pay issues, and to strengthen
recruitment and retention of nurses and others in covered
positions. That section mandates that pay for personnel in
covered positions at each facility be adjusted periodically to
reflect changing pay rates in local labor markets. The director
of each facility is charged with using data from the Bureau of
Labor Statistics (BLS) to determine prevalent pay rates, and to
make necessary adjustments to the pay of nurses and others in
covered positions employed by the facility in question. When
BLS data are not available, the director is required to use
data provided by a third party. If no third party data are
available, the director is required to conduct a locality pay
survey to determine prevalent pay rates. Each locality pay
schedule, of which there are nearly 800, is required to be
reviewed and approved by the Under Secretary for Health.
In the report titled ``Many Medical Facilities Have
Challenges Recruiting and Retaining Nurse Anesthetists'' (GAO-
08-56, December 2007), GAO found that, in 2005 and in 2006,
over half of VA medical facilities used the LPS to determine
whether to adjust VA CRNA salaries. However, in the eight VA
medical facilities visited, GAO found that the majority of the
facilities did not correctly follow VA's LPS policy. Officials
at these facilities did not always know or were not aware of
certain aspects of the LPS policy, and VA has not provided
training on the LPS to VA medical facility officials since the
policy was changed in 2001. As a result, GAO found that VA
medical facility officials cannot ensure that VA CRNA salaries
have been adjusted as needed to be competitive. While the
report dealt only with CRNAs, the conclusions regarding faulty
implementation of the LPS are likely applicable to others in
covered positions, based on Committee oversight activities.
The failure to properly implement the LPS runs the risk of
negatively affecting recruitment and retention, and
inappropriately limits the pay of nurses and others who
continue their employment at VA. Further, due to a lack of
transparency of the LPS process, employees do not have
reasonable access to the surveys that determine locality pay.
Committee Bill. Subsection (k)(1) of section 101 of the
Committee bill would add a new subparagraph (F) to section
7451(d)(3) of title 38. Proposed new subsection (F) would
require the Under Secretary for Health to provide appropriate
education, training, and support to directors of Department
health care facilities in the conduct and use of LPS surveys.
The Committee intends for this change to address the inadequate
training found by GAO.
In testimony before the Committee on April 9, 2008, Ms.
O'Meara emphasized the need for adequate training in the use
and implementation of the LPS. At the Committee hearing on May
21, 2008, Mr. Cox stated that ``management training on the
nurse locality pay process will increase compliance with the
2000 nurse locality pay law (The Veterans Benefits and Health
Care Improvement Act of 2000, Pub. L. 106-419) that Congress
enacted to address recruitment and retention.''
In testimony submitted for the Committee hearing on April
9, 2008, the Department stated that development of web-based
training to assist in the conduct of surveys was expected to be
available by late summer 2008, and that additional training
events are planned. The Committee believes these are important
improvements in education on the LPS, but believes that
additional measures may be required.
Subsection (k)(2) of section 101 of the Committee bill
would add a new subparagraph (D) to section 7451(e)(4) of title
38. Under this proposed new subparagraph (D), a facility
director would be required to publicize information on the
methodology used in making an adjustment to rates of pay based
on the LPS. This is intended to improve transparency in the
LPS.
Subsection (k)(3) of section 101 of the Committee bill
would further amend section 7451(e) by adding a new paragraph
(6). Under current law, each facility director is required to
report to the Secretary on wage-related staffing issues.
Proposed new paragraph (6) would require such reports to be
made available to any individual in a position included in such
report, or, upon the authorization of such individual, to the
representative of the labor organization representing that
individual. Taken together, the Committee believes that the
changes proposed by subsections (k)(2) and (3) of section 101
of the Committee bill will improve transparency of the LPS.
These amendments address concerns raised in testimony
before the Committee on May 21, 2008, by Mr. Cox, and on April
9, 2008, by Ms. O'Meara. According to Mr. Cox, ``greater
employee access to pay survey data will add accountability to
the locality pay process to ensure that surveys are done
properly and that needed pay adjustments are made.''
The Committee is aware that in some facilities, access to
LPS survey data is unnecessarily challenging for many
employees. As Ms. O'Meara said in her testimony on April 9,
2008, ``[l]ocality pay should be provided based on local labor
market conditions, and be paid according to consistent rules,
not on how hard employees fight for it or whether a particular
manager decides to pay it.''
Concerns have been raised that the Committee bill places
inordinate emphasis on the conduct of LPS surveys, rather than
the use of BLS or third party data, which the Department
prefers. The Committee recognizes the value of BLS and third
party data and does not intend that facility directors conduct
their own surveys when such information is available. The
Committee believes that, implemented effectively and according
to statute, the LPS can effectively address geographically-
related pay issues, and can strengthen recruitment and
retention.
Subsection 101(l)--Eligibility of part-time nurses for
additional nurse pay.
Subsection (l) of section 101 of the Committee bill would
expand eligibility for additional premium pay to part-time
nurses.
Background. Additional pay for nurses is authorized by
section 7453 of title 38. In general, nurses are eligible for
overtime pay when they work over forty hours in a week or 8
hours in a day. Further additional pay is mandated for nurses
who work on weekends, at night, and on holidays. Other than
overtime pay, eligibility for additional pay is limited to
nurses working on specified tours of duty that meet the
requirements of each type of additional pay. Those nurses not
assigned to a specific tour are not eligible for the additional
pay associated with such tour, even if their period of service
includes hours which fall within the eligible time periods.
This limit affects the pay of both full- and part-time nurses,
as well as nurses who are on call and not assigned to tours of
duty.
Based on testimony presented at Committee hearings, and
information gathered during Committee oversight activity, the
Committee concludes that in many facilities VA is challenged to
fill nurse staff positions and some nursing tours are difficult
to cover. The Committee believes that the current eligibility
criteria for additional pay are too restrictive to create
effective financial incentives to encourage nurses to work
those tours.
Further, the current additional pay statute creates
unacceptable inequities between part-time and full-time nurses.
In testimony before the Committee on April 9, 2008, Ms. O'Meara
cited chronic problems with implementation of additional pay
requirements. She urged ``the Committee to take steps to ensure
that premium pay is available to all RNs who perform services
on weekends or off shifts, work overtime on a voluntary or
mandatory basis, or work during on call duty.'' By not
providing part-time nurses additional pay on the same basis as
full-time nurses, there is a disincentive for part-time and on-
call nurses to serve during times of the day and week that are
harder to staff. This is contrary to the intent of the
additional pay authorities.
In addition, excluding part-time and on-call nurses from
eligibility for additional pay, and denying additional pay for
nurses not assigned to a specific eligible tour, creates
further disparity between VA and non-VA compensation, and
contributes to recruitment and retention challenges.
Committee Bill. Subsection (l) of section 101 of the
Committee bill would amend section 7453 of title 38 so as to
expand eligibility for additional premium pay to part-time
nurses.
An amendment to subsection (a) of section 7453 would
provide that part-time nurses would be generally eligible for
additional pay when they meet the criteria in other subsections
of section 7453. Amendments to subsections (b) (concerning
evening pay), (c) (concerning weekend pay), and (d) (concerning
overtime pay), would replace ``tour of duty'' with ``period of
service.'' These changes would make any service performed
during evenings or weekends, or as overtime, eligible for
additional pay.
It is the Committee's intent to change the basis for
additional pay from the tour to the nurse's period of service
and the timing of such service. This reflects original
Congressional intent that additional pay is intended to create
incentives for nurses to work at times that would otherwise be
difficult to staff. The changes proposed by the Committee bill
would not eliminate the utility of established tours nor would
they reduce additional pay for such tours. Rather, the changes
would encourage a greater number of nurses to work during such
times, and would equitably reward all nurses who do so. In
testimony before the Committee on May 21, 2008, Mr. Blake
expressed the support of Paralyzed Veterans of America for
eligibility of part-time nurses for additional pay.
Subsection (l)(1)(D)(i) of section 101 of the Committee
bill would address an inequity in eligibility for additional
pay for overtime under section 7453(e) of title 38. Under
current law, nurses who perform continuous service in excess of
8 hours but on two different calendar days are not eligible for
additional pay for overtime service. This section of the
Committee bill would amend section 7453(e) to add service
performed in excess of eight consecutive hours to the list of
service eligible for additional overtime pay. In testimony
before the Committee on April 9, 2008, Ms. O'Meara emphasized
the urgency of this legislative change.
Subsection 101(m)--Exemption of additional nurse positions
from limitation on increase in rates of basic pay.
Subsection (m) of section 101 of the Committee bill would
make additional health care occupations exempt from limitations
on increases in rates of basic pay.
Background. Under current law, rates of basic pay for
nurses and other health care providers may be increased under
section 7455 of title 38. Under that section, the Secretary may
determine that salary increases are necessary for the purposes
of recruitment and retention, and to compete with pay for
similar positions in non-Federal facilities in the same labor
market.
Under subsection (c)(1) of section 7455, the amount of
increase in the maximum pay rate generally is limited to two
times the amount by which the original maximum exceeds the
minimum, and the maximum rate as so increased may not exceed
the pay rate of the Assistant Under Secretary for Health. Nurse
anesthetists, pharmacists, and licensed physical therapists are
exempted from this limit, based on the challenges VA faces in
recruiting and retaining employees in these occupations, as
discussed earlier in this report.
Committee Bill. Subsection (m) of section 101 of the
Committee bill would amend section 7455(c)(1) so as to make
additional occupations exempt from limitations on increases in
rates of basic pay. Specifically, this provision would add
licensed practical nurses, licensed vocational nurses, and
nursing positions otherwise covered by title 5 to the list of
positions exempted from the limits imposed by section
7455(c)(1). Also, this subsection would amend the current law
limitation on the permissible increase by utilizing the same
formula that is applied to the cap on title 5 special rates.
This change would give VA the greatest flexibility in
establishing maximum rates for title 38 employees. This
provision, combined with subsection (h) of section 101 of the
Committee bill, should ensure that VA has the pay flexibility
to compete with other employers for qualified health care
providers. In testimony before the Committee on April 9 and May
21, 2008, respectively, Ms. O'Meara and Mr. Cox emphasized the
need for additional pay flexibility to strengthen VA's ability
to compete with other employers.
Section 102. Limitations on overtime duty, weekend duty, and
alternative work schedules for nurses.
Section 102 of the Committee bill, which is derived from
S.252 as introduced, would amend various provisions of title 38
so as to establish special rules for nurse staff overtime
service, modify rules relating to leave during weekend duty,
and change the underlying authority for alternative work
schedules for nurses.
Subsection 102(a)--Overtime duty.
Background. Under current law, the Secretary may require
nurses to perform mandatory overtime in emergency situations.
The Committee recognizes that this authority is essential to
ensuring adequate staffing to provide patient care. However,
based on oversight activities, and as discussed at the
Committee hearing on April 9, 2008, it appears that, at some
facilities, the use of emergency mandatory overtime is
excessive and even abusive.
At the Committee hearing on April 9, 2008, Ms. O'Meara
testified that ``facility directors continue to invoke the
emergency exception when staffing shortages are the result of
easily anticipated scheduling and hiring problems.'' At that
same hearing, testimony on this issue was received from two VA
medical center directors, Steven P. Kleinglass, of the
Minneapolis VA Medical Center, and Sheila M. Cullen, of the San
Francisco VA Medical Center. These two facilities illustrate
two different approaches to the use of the emergency mandatory
overtime authority. According to Mr. Kleinglass, in Minneapolis
mandatory overtime is used to respond to a number of
situations, including unplanned leave, sick leave, emergency
annual leave, absenteeism, and tardiness for duty by nursing
staff. At the San Francisco medical center, on the other hand,
mandatory overtime has been used only once in the past three
years, an event implemented in cooperation with local
bargaining union.
The Committee is concerned that VA lacks a clear definition
of ``emergency'' for the purposes of implementing mandatory
overtime and that VA facility directors appear to have
unbridled discretion on the interpretation and implementation
of this authority. Without a clear definition of what
constitutes allowable situations, the use of emergency
authority can lead to inconsistent implementation and abuse.
Research has highlighted the danger of excessive overtime
service by nurses, as well as other health care providers. In
the report Keeping Patients Safe: Transforming the Work
Environment of Nurses (2004), the Institute of Medicine
recommended that ``to reduce error-producing fatigue, state
regulatory bodies should prohibit nursing staff from providing
patient care in any combination of scheduled shifts, mandatory
overtime, or voluntary overtime in excess of 12 hours in any
given 24-hour period and in excess of 60 hours per 7-day
period.''
At least nine states have enacted legislation restricting
the use of emergency mandatory overtime. In the interest of
patient and employee safety and appropriate labor standards,
these states limit the number of hours a nurse can be required
to work, except in certain defined emergency situations.
Committee Bill. Subsection (a) of section 102 of the
Committee bill would add a new section 7459 to subchapter IV of
chapter 74 of title 38. This new section would limit nursing
staff--including RNs, licensed practical or vocational nurses,
nurse assistants appointed under title 38 or title 5 of United
States Code, or any other nurse position designated by the
Secretary--to no more than 40 hours of work per administrative
work week (or 24 hours if such staff is covered by section 7456
of title 38), and not more than eight consecutive hours (or 12
hours if such staff is covered by sections 7456 or 7456A of
title 38). Nursing staff may exceed these limits voluntarily or
in emergency situations, as defined by the Committee bill.
The definition of ``emergency circumstances'' would be set
out in subsection (c) of the proposed new section 7459. Under
this subsection, the Secretary would be authorized to require
mandatory overtime otherwise prohibited if the following
conditions were met: (1) the work is a consequence of an
emergency that could not have been reasonably anticipated; (2)
the emergency is non-recurring and is not caused by or
aggravated by the inattention of the Secretary or lack of
reasonable contingency planning by the Secretary; (3) the
Secretary has exhausted all good faith, reasonable attempts to
obtain voluntary workers; (4) the nurse staff have critical
skills and expertise that are required for the work; and (5)
the work involves work for which the standard of care for a
patient assignment requires continuity of care through
completion of a case, treatment, or procedure. Nursing staff
would not be required to work hours after the requirement for a
direct role by the staff in responding to medical needs
resulting from the emergency ends.
The Committee is concerned that undue reliance on mandatory
overtime is not desirable and believes that, with reasonable
contingency planning, including consultation with nurse staff,
all VA facilities have the capacity to eliminate unnecessary
use of emergency mandatory overtime. It is clear that many VA
facilities already avoid unnecessary use of emergency mandatory
overtime through effective planning for adequate nurse
staffing.
Subsection (b)(2) of the proposed new section 7459 would
prohibit discrimination or adverse personnel action against
nursing staff if such staff were to refuse to work hours
prohibited by such section. This protection has proven
necessary in the many of the states which have legislatively
limited mandatory overtime, including Connecticut, Maryland,
Minnesota, New Jersey, and Washington. In written testimony
before the Committee on April 22, 2009, Ammie Hilsabeck
expressed AFGE's support for this provision of the Committee
bill.
Subsection 102(b)--Weekend duty.
Subsection (b) of section 102 of the Committee bill would
amend section 7456 of title 38, which authorizes VA to pay
nurses who perform two regularly schedule 12 hour tours on the
weekend for 40 hours. According to VA, this plan is typically
used only when a facility has significant difficulties in
securing adequate nurse staffing for the weekends.
Committee Bill. The Committee bill would repeal subsection
(c) of section 7456 which charges nurses 5 hours of leave for 3
hours of absence during a 12 hour tour of duty. In written
testimony before the Committee on April 22, 2009, AFGE
indicated its support for this provision.
Subsection 102(c)--Alternative work schedules.
Subsection (c) of section 102 of the Committee bill would
modify an existing alternative work schedule available to VA
nurses.
Background. Section 7456A of title 38 authorizes the
Secretary to provide alternative work schedules to RNs working
for the Department. These schedules, known as ``36/40''
schedules, allow VA nurses to work three regularly scheduled
12-hour tours of duty within a work week and to have that
service considered for all purposes as a full 40-hour basic
work week. These alternative work schedules are authorized ``in
order to obtain or retain the services of registered nurses.''
Alternative work schedules were authorized in December 2004
by the Department of Veterans Affairs Health Care Personnel
Enhancement Act of 2004, Public Law 108-445. According to the
Senate report accompanying the legislation that resulted in the
new law, S. Rpt. 108-375, this new authority was a response to
an
August 2003 request by the Department so as to ``enhance its
ability to recruit and retain high quality nurses.'' In that
report, the Committee noted that, based on a survey conducted
in 2000 by the American Organization of Nurse Executives,
inflexible scheduling was a major cause of nurse
dissatisfaction. The original intent of Congress in authorizing
alternative work schedules was that such schedules be widely
available so as to enhance the Department's ability to improve
employee satisfaction and therefore be better able to recruit
and retain nurses in competition with other employers.
Since the passage of Public Law 108-445, the implementation
of 36/40 alternative work schedules has varied throughout the
VA health care system. In testimony for the Committee hearing
on April 9, 2008, VA indicated that it ``encourages facility
managers to use alternate work schedules for all eligible
employees whenever feasible,'' and noted that the use of these
schedules ``increases VA's visibility as the employer of
choice.''
Some facilities, such as the San Francisco VA Medical
Center, have made effective use of alternative schedules to
reduce vacancy rates in nursing positions, and to improve nurse
satisfaction. In testimony before the Committee on April 9,
2008, the San Francisco VAMC Director, Ms. Cullen, stated that
``most new hires are highly interested in an alternative work
schedule. We believe that offering an alternative work schedule
improves recruitment, retention and employee satisfaction.''
Mr. Kleinglass, the Director of the Minneapolis VAMC, in
testimony before the Committee on April 9, 2008, noted that the
use of alternative schedules at the Minneapolis VA Medical
Center allows staff to ``find balance between their work and
home lives as they feel best suits their individual needs.''
Unfortunately, based on Committee oversight work, many VA
facilities have failed to make 36/40 alternative work schedules
widely available. While facility directors have discretion on
the implementation of these schedules, Congress intended that
their use be throughout the VA health care system. In testimony
before the Committee on April 9, 2008, Ms. O'Meara stated:
As a result of delay and resistance by the VA at the
national and local levels, [alternative work schedules]
have failed to meet their potential for addressing VA
nurse recruitment and retention problems. It seems as
if the law was never passed.
Committee Bill. Subsection (c) of section 102 of the
Committee bill would amend section 7456A of title 38 so as to
modify the 36/40 alternative work schedule authorized by that
section. Specifically, this section of the Committee bill would
amend section 7456A(b)(1)(A) to modify the scheduling
requirement for the 36/40 alternative work schedule. Currently,
the 36/40 alternative work schedule is defined as ``three
regularly scheduled 12-hour tours of duty within a work week.''
The Committee bill would redefine the schedule as six regularly
scheduled 12-hour periods of service within an 80-hour pay
period.
The intent of this provision is to facilitate easier
implementation of the alternative work schedule. In testimony
for the Committee hearing on May 21, 2008, the Department noted
that because a work week is defined as Sunday through Saturday,
it is often difficult schedule three 12-hour tours in their
entirety within one work week. The Department expressed support
for these provisions of the Committee bill, as they would
provide greater flexibility to scheduling.
By providing greater flexibility in the scheduling of the
alternative work schedule, the Committee intends to facilitate
and encourage wider use of such schedules. Based on hearing
testimony and oversight activities, the Committee believes that
by unnecessarily limiting the use of the current 36/40
alternative work schedules, VA facilities forego a valuable
recruitment and retention tool, and fail to keep pace with the
health care industry.
Section 103. Improvements to Certain Educational Assistance
Programs.
Section 103 of the Committee bill would amend two existing
VA Education Assistance Programs and provide the Secretary of
Veterans Affairs with new authority to make repayment of
educational loans for certain health professionals.
Background. Chapter 76 of title 38 contains numerous
authorities that are designed to enhance VA's ability to
attract and retain health professions. Among these authorities
are the Health Professional Scholarship Program (hereinafter
``HPSP''), in Subchapter II, and the Education Debt Reduction
Program, in Subchapter VII.
The authorization for the programs needs to be extended in
order to continue to give VA this authority, as the private
sector has made recruiting health care professionals
increasingly competitive. Title VII of Public Law 105-368 and
Public Law 107-135 made amendments to these programs. VA
currently awards Employee Incentive Scholarship Program
scholarships to qualifying and current employees to help VHA
meet the health care staffing requirements set forth in Section
7401 of title 38, U.S.C., in which the difficulties surrounding
recruitment and retention of VA health care employees is
specifically addressed.
Committee Bill. Subsection (a) of section 103 of the
Committee bill would amend section 7618 of title 38 so as to
reinstate HPSP through the end of 2013. The Committee believes
that renewing HPSP, which expired in 1998, will help reduce the
nursing shortage in VA by enabling VA to provide scholarships
to nursing personnel who, on completion of their education,
will be obligated to work a year for every year of education,
with a minimum obligation of two years, at a VA health care
facility. This subsection would also expand eligibility for the
scholarship program to all VA health personnel appointed to
positions described under paragraphs (1) and (3) of section
7401 of title 38, which includes all title 38 health care
employees as well as all hybrid occupations. It also expands
the use of the program to any eligible employee, not just to
those recently appointed. The Committee expects that this
expansion of those eligible for the scholarship program will be
helpful in VA's efforts to recruit and retain employees in a
number of difficult-to-fill health care occupations.
Subsection (b) of section 103 would amend two provisions in
subchapter VII of chapter 76, relating to VA's Education Debt
Reduction Program.
Paragraph (1) of subsection (b) would amend section
7681(a)(2) so as to add retention, along with recruitment, as a
purpose of the debt reduction program.
Paragraph (2) would amend subsection (a)(1) of section 7682
and would strike subsection (c) of that section so as to make
the debt reduction program available to ``an'' employee, not
just to a ``recently appointed'' employee as in current law.
The Committee's intent is that this program should be available
beginning from the first date of a qualified applicant's
employment. In addition, the Department had interpreted
``recently appointed'' to exclude any employee who had worked
for VA for longer than 6 months. The new language makes it
clear that eligibility for the program will not be subject to
this 6 month time limit.
Subsection (c) of section 103 would authorize the Secretary
of VA, in consultation with the Secretary of Health and Human
Services, to use the authorities in section 487E of the Public
Health Service Loan Repayment Program for the repayment of
educational loans of health professionals from disadvantaged
backgrounds in order to secure clinical research expertise in
VA from such individuals. This loan repayment program is
currently not available to Federal employees other than those
working for the National Institutes of Health. By extending
this authority to VA, clinicians with medical specialization
and research interests may be more likely to join VHA. Funding
for the repayment of educational loans under this program would
have to come from VA medical care funding.
Section 104. Standards for Appointment and Practice of
Physicians in Department of Veterans Affairs Medical
Facilities.
Section 104, which was originally derived from S.2377 in
the 110th Congress prior to being incorporated in S.2969, would
establish a new section in title 38 setting out procedures for
appointing new physicians in VA, and the requisite
qualifications of such physicians.
Background. Current section 7402 of title 38 sets forth the
requirements that must be met in order for a person to be
appointed as a physician with VA. Included in these
requirements are that the applicant holds the degree of doctor
of medicine, or doctor of osteopathy, from a university
approved by the Secretary; that the applicant has completed an
internship approved by the Secretary; and that the applicant is
licensed to practice medicine, surgery, or osteopathy in a
State.
Under subsection (f) of section 7402, any applicant who has
or has had multiple licenses or certifications and has had one
or more of them suspended, revoked, or surrendered for cause,
is subject to employment restrictions.
VA also requires extensive disclosures from applicants,
including the status of their credentials, and is permitted to
deny appointment or terminate employment if that information is
not disclosed. This information must be resubmitted every two
years. A VA policy that took effect on November 14, 2008,
requires applicants to submit extensive information regarding
previous malpractice claims, and authorizations to their State
licensing boards to permit those boards to release records to
VA.
Current law does not require physicians to be board
certified in the area in which they will practice in order to
be eligible for employment with VA. VA permits facility
directors and chiefs of staff to determine that an applicant is
qualified based on other factors. VA believes its current
requirements are in keeping with medical standards.
Physicians elsewhere in Federal service are not required to
be licensed in the State in which they practice, but simply to
be licensed in any State. VA makes use of telemedicine, and
exchanges physicians or allows physicians to collaborate with
others in the Federal system in different States. This also
occurs during certain emergency situations. Additionally, some
States have licensing procedures that take more than 1 year to
complete.
Committee Bill. Section 104 of the Committee bill would
establish a new section in title 38--section 7402A Appointment
and practice of physicians: standards--which would set forth
the procedures for appointing new physicians in VA, and the
requisite or desired qualifications to practice as a VA
physician. This provision would take effect immediately upon
enactment, except for subsection (f) as that section pertains
to physicians already employed by VA, which would go into
effect 60 days after enactment, and subsection (g), relating to
performance contracts with VISN directors, which would go into
effect upon the start of the first cycle, beginning after the
date of enactment, of performance contracts for VISN directors.
Subsection (a) of the proposed new section would require
the Secretary, through the Under Secretary for Health, to
develop and promulgate minimum standards a physician must meet
in order to be appointed to that position in the VHA, or to be
permitted to practice in the VA medical facilities. The
standards developed would be required to include the
requirements outlined in the new section 7402A.
Subsection (b) of the proposed new section would require
any individual seeking to be appointed as a physician within
the VHA to provide the following information: a full and
complete explanation of any lawsuit for medical malpractice or
negligence that is pending or was brought against the
applicant; any settlements agreed to as a result of a lawsuit
for malpractice or negligence; and any investigation or
disciplinary action against the applicant that relates to the
applicant's work as a physician. The applicant must also
provide authorization to the licensing board of any state where
the applicant holds or has ever held a license to practice
medicine, to disclose to the Secretary any records pertaining
to: any lawsuit for malpractice or negligence brought against
the applicant, and the details any settlements agreed to as a
result; any court or administrative agency's judgment against
the applicant; any disciplinary action brought against the
applicant by any State body or administrative agency; any
change in the status of the applicant's license to practice
medicine, whether voluntary or involuntary; any open
investigation of, or outstanding allegation against, the
applicant; and any written notification from the State to the
applicant pertaining to the potential termination of the
applicant's license.
Subsection (c) of the proposed new section would require
any physician appointed to practice in the VHA, after the
enactment of the Committee bill, to disclose to the Secretary,
within 30 days of occurrence: a judgment against the physician
for medical malpractice or negligence; a payment made as part
of a settlement for a lawsuit or action, previously disclosed
prior to appointment, or any disposition or change in status of
any issue disclosed prior to appointment. Additionally, this
subsection would require any physician practicing in VHA at the
time of the enactment of the Committee bill to provide, within
60 days after the date of enactment, to the Secretary with an
authorization for state medical boards to release any
information regarding pending or completed disciplinary actions
or claims against a license to practice medicine. A physician
currently practicing in VHA would be required, as a condition
of employment, to agree to disclose, within 30 days of
occurrence, any future claim or judgment against the physician
or payment as part of a settlement arising from a lawsuit
alleging malpractice or negligence, or the disposition or
change in status of any matter disclosed pursuant to the
authorization for disclosure the physician would be required to
give to a State licensing board.
Subsection (d) of the proposed new section would require
the director of the VISN in which an applicant seeks employment
as a VA physician to conduct an investigation into the
information disclosed by the applicant as required by new
subsection (b). The appropriate VISN director also would be
required to perform a similar investigation of any material
disclosed by a VA physician employed as of the date of
enactment of the Committee bill, or a physician appointed after
that date who discloses information while employed by VA, as
required by new subsection (c). The results of all such
investigations would be required to be fully documented.
Subsection (e) of the proposed new section would require an
applicant seeking to be employed as a VA physician to receive
the approval of the appropriate VISN director, unless a full
investigation by the medical center director failed to disclose
any actions described in new subsections (b),(c), and (d). In
this event, the VISN Director's approval would not be required.
If an applicant has disclosed information as required by
new subsection (b), the VISN director, if the director chooses
to approve the applicant, would be required to certify in
writing that the investigation of each issue required by new
subsection (d) was completed, and the director would be
required to provide a written explanation as to why any
identified issue did not disqualify the applicant.
Subsection (f) of the proposed new section would require
each VA medical facility that employs physicians who are
extended the privileges of practice at that facility to enroll
each physician in the Proactive Disclosure Service of the
National Practitioners Data base.
Subsection (g) of the proposed new section would require
the Secretary to include in each performance contract with a
VISN director, a provision that encourages the director to hire
physicians who are board certified or eligible for such
certification in the field in which they will be practicing
when employed by VA. The Secretary would be authorized to
determine the nature of this provision in the performance
contracts.
The Committee believes that the requirements that would be
put in place by the proposed new section 7402A are necessary to
strengthen qualification standards for hiring physicians at VA
and for monitoring their performance once they are working for
VA. Despite the measures VA has in place regarding review of
qualifications, history, and credentials, there have been
incidents of physicians practicing in VA with suspended
licenses and other problems with their qualifications. One of
the more recent incidents of such a situation occurred at the
Marion, Illinois, VA Medical Center, and that lack of
appropriate review resulted in several patient deaths. The fact
that VA's existing policy failed to prevent this result
illustrates that additional measures to prevent under-qualified
physicians from practicing medicine are needed and that it is
justified to give VA's hiring practices the force of law.
TITLE II--HEALTH CARE MATTERS
Section 201. Repeal of certain annual reporting requirements.
Section 201, which was initially derived from S.2984, by
request legislation introduced in the 110th Congress, would
repeal the requirement for VA to submit to Congress two annual
reports, one relating to pay adjustments for registered nurses,
and one relating to VA's long-range health planning.
Background. Public Law 101-366, The Department of Veterans
Affairs Nurse Pay Act of 1990, established a reporting
requirement relating to pay adjustments for registered nurses
because, at that time, annual General Schedule (GS)
comparability increases were extended to VA nurses at the
discretion of the facility Director. However, with the
subsequent enactment of Public Law 106-419, the Veterans
Benefits and Health Care Improvement Act of 2000, GS
comparability increases must be given to VA nurses and other
health care personnel described in section 7451.
With respect to VA's long-range health care planning, VA's
annual budget documents contain information on the Veterans
Health Administration's tactical and strategic goals,
performance measures, and supporting activities; current and
anticipated methods for serving VA's special populations; and
other priorities, resource requirements and distribution
methodologies. With the advent of VA's 5-Year Strategic Plan in
2004, VA's budget submission also includes the top 20
priorities for medical construction projects.
Committee Bill. Subsection (a) of section 201 of the
Committee bill would repeal the requirement to report annually
on any pay adjustments made to the basic pay of VA nurses and
other health care personnel described in section 7451 of title
38. In light of the fact that covered staff receive, at a
minimum, the annual increases in pay provided under the GS
schedule, the Committee views this annual report as
unnecessary.
Subsection (b) of this section of the Committee bill would
repeal the requirement for the Secretary to annually report on
the Department's long-range health planning, including
operation and construction plans for medical facilities. The
Committee is satisfied that this report contains information
that is already submitted in other reports and plans,
particularly those prepared annually in connection with the
Department's budget request.
Section 202. Modifications to annual Gulf War research report.
Section 202, which is also derived from S.2984 from the
110th Congress, would make changes to VA's annual report on
Gulf War research.
Background. Under current law, section 707 of the Persian
Gulf War Veterans' Health Status Act, Public Law 102-585, the
executive branch, through a designated head of an appropriate
department or agency, is required to report to the Committees
on Veterans' Affairs of the Senate and the House of
Representatives on the status and results of all research
undertaken in the area of Gulf War Illnesses and the research
priorities identified during the previous year. Since the
requirement was enacted in 1992, the Secretary of Veterans
Affairs has been the official responsible for compiling and
submitting this report. This report is due by March 1 of each
year. Under current law, this report is a continuing
obligation.
Committee Bill. Section 202 of the Committee bill would
change the due date of this annual report to Congress on the
research on the health effects of service during the Persian
Gulf War from March 1 to July 1 of each year, and also
establish a sunset date for this reporting requirement of July
2013.
VA has testified that it is difficult if not impossible to
submit the report by the current March 1 statutory deadline and
it is the Committee's view that a July 1 deadline is more
attainable. Imposition of a sunset date is intended to afford
Congress sufficient opportunity to assess, in 5 year's time,
whether there exists a continued need for this formal reporting
requirement.
Section 203. Payment for care furnished to CHAMPVA beneficiaries.
Section 203, which is also derived from S.2984 as
introduced in the 110th Congress, would clarify the status of
payment made by VA to health care providers on behalf of
beneficiaries under the Civilian Health and Medical Program of
the Department of Veterans Affairs (hereinafter, ``CHAMPVA'')
program.
Background. CHAMPVA is a health care program under which VA
shares the cost of covered health care services and supplies
with eligible beneficiaries. The program is administered by the
Veterans Health Administration. To be eligible for CHAMPVA, a
person must be in one of these categories: (1) the spouse or
child of a veteran who has been rated permanently and totally
disabled for a service-connected disability by VA; (2) the
surviving spouse or child of a veteran who died from a VA-rated
service-connected disability; (3) the surviving spouse or child
of a veteran who was at the time death rated permanently and
totally disabled from a service-connected disability; or (4)
the surviving spouse or child of a servicemember who died in
the line of duty, of a cause other than willful misconduct.
Most of these cases, these family members are eligible for the
Department of Defense's health care program known as TRICARE.
While VA's regulations for the CHAMPVA program, in section
17.55 of title 38 CFR, provide for VA payments to providers
under the CHAMPVA program to constitute payment in full, VA's
enforcement of this regulation has been hampered by a lack of
statutory authority. VA has indicated that some providers still
attempt to bill beneficiaries for the difference between the
billed amount and the amount payable under the CHAMPVA program.
Committee Bill. Section 203 of the Committee bill would
amend section 1781 of title 38 to provide that payments made by
the Secretary to providers who furnish medical care to a
beneficiary covered under CHAMPVA shall constitute full
payment, removing any liability for the beneficiary to the
provider.
Section 204. Disclosures from certain medical records.
Section 204, which is also derived from S.2984 from the
110th Congress, would permit VA health care practitioners to
disclose the relevant portions of certain VA records to
surrogate decisionmakers who are authorized to make decisions
on behalf of patients who lack decisionmaking capacity.
Background. Section 7332 of title 38 authorizes VA to
disclose treatment information for drug abuse, alcoholism and
alcohol abuse, human immunodeficiency virus (HIV) infection,
and sickle cell anemia only for certain purposes which are set
out in the section. Disclosure to surrogate decisionmakers for
the purpose of making informed decisions regarding the
treatment of patients who lack decisionmaking capacity, but to
whom the patients had not specifically authorized release of
section 7332-protected information prior to losing
decisionmaking capacity, is not one of the specified purposes.
Committee Bill. Section 204 of the Committee bill would
amend section 7332 of title 38 to permit VA health care
practitioners to disclose the relevant portions of VA records
of the treatment of drug abuse, alcoholism and alcohol abuse,
HIV infection, and sickle cell anemia to surrogate
decisionmakers who are authorized to make decisions on behalf
of patients who lack decisionmaking capacity, but to whom the
patient has not specifically authorized release of section
7332-protected information prior to losing decisionmaking
capacity. This change would allow for such disclosure only
under the circumstances where the information is clinically
relevant to the decision that the surrogate is being asked to
make. The term ``representative'' means the individual,
organization, or other body authorized under section 7331 of
title 38 and the regulations implementing that provision, to
give informed consent on behalf of a patient who lacks
decisionmaking capacity.
Section 205. Disclosure to secretary of health-plan contract
information and social security number of certain veterans
receiving care.
Section 205, which is also derived from S.2984 of the 110th
Congress, would authorize VA to require that those seeking or
receiving VA health care provide certain information in
connection with such care.
Background. Although VA has authority under section 1729 of
title 38, U.S.C., to recover from health insurance carriers the
reasonable charges for treatment of a veteran's nonservice-
connected disability, there is no express statutory authority
that requires an applicant for, or a recipient of, VA medical
care to provide information concerning health insurance
coverage.
Under Section 7 of the Privacy Act, VA cannot deny to an
individual any right, benefit, or privilege provided by law
because of such individual's refusal to disclose his or her
social security number. However, this prohibition does not
apply with respect to any disclosure that is required by
Federal statute.
VHA must match veterans' income data with the Internal
Revenue Service and the Social Security Administration to carry
out its income verification responsibility under section 5317
of title 38. Such matching requires the use of verified social
security numbers. According to VHA, officials have obtained
verified social security numbers for approximately 97 percent
of its enrolled veterans and 86 percent of the spouses for whom
income is reported. While this suggests that the voluntary
reporting process is working, VHA estimates that they still
have more than 1 million veterans enrolled for whom no social
security number has been provided. Further, VHA notes that the
Department has been unable to match income for more than
675,000 spouses because the social security numbers have not
been provided.
Committee Bill. Section 205 would amend title 38 by adding
a new section--section 1709. Disclosure to Secretary of health-
plan contract information and social security number of certain
veterans receiving care--which would authorize the Secretary of
Veterans Affairs to require that applicants for, and recipients
of, VA medical care and services provide their health-plan
contact information and social security numbers to the
Secretary upon request.
Subsection (a) of the new section would require specific
information on any health-plan contract which provides
coverage. Information that may be required regarding health-
plan coverage would include the name of the health-plan
contract, the name of the veteran's spouse, if coverage is
under the spouse's health-plan contract, the plan number, and
the plan's group code. This authority will ensure that VA is
able to obtain contract information for a particular health
plan.
Subsection (b) of the new section would provide that the
Secretary may require applicants for, or recipients of, VA
medical care or services to provide their social security
numbers and those of dependents or VA beneficiaries upon whom
the applicant or the recipient's eligibility is based. This
subsection, in conjunction with subsection (c), discussed
below, affords the Secretary the statutory authority to require
applicants for and recipients of VA health care benefits to
disclose social security numbers.
Subsection (c) of the new section would provide that the
Secretary shall deny the application for, or terminate an
individual's enrollment in, VA's patient enrollment system of
individuals who fail to provide information requested pursuant
to subsection (b). The subsection further provides that the
Secretary may reconsider the application for or reinstate the
provision of care or services once the information requested
pursuant to subsection (b) has been provided.
Subsection (d) of the new section would provide that this
section may not be construed as authority to deny medical care
and treatment to an individual in a medical emergency.
VA strongly supported this provision in testimony provided
to the Committee for its April 22, 2009, hearing. Because
eligibility for medical care and services is conditioned on the
applicant or recipient's provision of health-plan contract
information or social security numbers, the Administration
believes that the applicant or recipient will have an incentive
to provide the requested information. The Committee expects VA
to provide a high degree of confidentiality for beneficiaries'
health plan information and social security numbers.
Section 206. Enhancement of quality management.
Section 206 of the Committee bill, which was originally
derived from S.2377 as introduced in the 110th Congress, would
require actions to enhance VA's quality management efforts.
Background. Under current law, section 7311 of title 38, VA
operates a quality management system to monitor and evaluate
the quality of VA health care. That system is headed by the
Chief Quality and Performance Management Officer of the
National Quality and Performance Office. While a number of
other entities have a role in VA quality management efforts,
including the Office of the Inspector General, the Office of
the Medical Inspector, the National Patient Safety Office, and
the Office of Compliance and Business Integrity, none has a
permanent oversight capacity at every VA medical center.
VA's quality management program, including the National
Surgical Quality Improvement Program (NSQIP), has proven
effective in certain situations. However, in a report titled
``Quality of Care Issues, VA Medical Center, Marion, Illinois''
(January 2008), the VA Office of the Inspector General (OIG)
found that the quality management process was ineffective in
many respects. The peer review process, the tracking of
performance data on providers, and mortality assessments as
carried out at the Marion, Illinois VA Medical Center were all
found to be deficient. The OIG concluded that:
[T]he oversight reporting structure for quality
management reviews at the Marion VAMC was fragmented
and inconsistent, making it extremely difficult to
determine the extent of oversight of patient quality or
corrective actions taken to improve patient care. This
occurred partially because quality management
responsibilities were split between multiple groups at
the facility with little or no management oversight.
The OIG further concluded that the Marion VAMC Surgery
Service leadership was ineffective, and that communication
between the nurse responsible for NSQIP at the facility,
surgical providers, and the Chief of Surgery was highly
ineffective, allowing multiple quality management processes to
fail.
Based on information related to the Marion, IL experience
and other oversight activity, the Committee believes that the
Department's internal processes can ensure quality in some
circumstances, but that significant improvements are necessary.
Continuous and attentive monitoring is not fully in place, and
facility leadership across the VA system must prioritize
quality management.
Committee Bill. Section 206 of the Committee bill would add
a new section 7311A to chapter 73 of title 38. This new section
would require the Under Secretary for Health (``USH'') to
appoint a National Quality Management Officer, reporting
directly to the Under Secretary, who would develop requirements
and standards for a national quality management program, and
prescribe regulations for its implementation. The National
Quality Management Officer would be responsible for developing
ways of measuring quality at individual VA facilities, and
ensuring that those measures were routinely monitored and
analyzed.
The Committee believes that such a position would help
ensure the thorough and uniform discharge of quality management
requirements under such programs and activities throughout VA
facilities. The USH would also be required to designate quality
management officers for each VISN. Such officers would direct
the quality management effort of each network and coordinate,
monitor, and oversee the quality management programs and
activities of the medical facilities in the Network.
Additionally, section 206 of the Committee bill would
require each VA Medical Center Director to appoint a quality
management officer for that facility. The Director would be
required to ensure that other clinical or administrative duties
of the person appointed as the quality management officer are
reduced so as to not interfere with the person's quality
management duties. The quality management officer would report
to the Director of the facility and to the quality management
officer of the VISN of which that facility is a part.
Section 206 would also require the USH to put in place a
system through which VHA employees might submit reports, on a
confidential basis, on quality of care matters to the quality
management officer at the employee's facility. Such a system
would provide a safe channel through which employees might
report their concerns about care being furnished at the
facility. Such a system should make it possible for any such
reports to receive appropriate attention and review.
This section of the Committee bill also would require the
Secretary of Veterans Affairs to submit a report to Congress on
all policies and protocols of VA that pertain to maintenance of
health care quality and protection of patient safety at VA
medical facilities. This report would be required to include an
assessment of the NSQIP, with special emphasis on the
effectiveness of the design and structure of the program's data
collection, evaluation, and assessment structure, and the
sufficiency of resources allocated to that program.
In testimony before the Committee on May 21, 2008, Dr.
Gerald M. Cross, Principal Deputy Under Secretary for Health,
expressed VA's support for the provisions of this section of
the Committee bill that require a comprehensive review and
report on health care quality and patient safety policies
across the VA health care system. In written testimony
submitted for the Committee's April 22, 2009, VA stated that
the Department supported the intent of these provisions.
Section 207. Reports on improvements to Department health care quality
management.
Section 207, which is also derived from S.2377 from the
110th Congress, would require the Secretary to report on VA
efforts to implement the provisions of the Committee bill
concerning quality management.
Background. There are currently no regular requirements for
VA to report to Congress on VHA quality management efforts.
This lack of effective reporting mechanisms can contribute to
ineffective quality oversight. While the Inspector General
performs oversight of individual facilities and specific
events, the Committee believes a comprehensive annual reporting
requirement would more effectively ensure oversight and
accountability by the Committee and the Congress.
Committee Bill. Section 207 would require the Secretary to
submit a report to the Committees on Veterans' Affairs and
Appropriations of the Senate and the Committees on Veterans'
Affairs and Appropriations of the House of Representatives by
December 15, 2009, and annually thereafter, through 2012. This
report would detail VA efforts, over the preceding fiscal year,
to implement the provisions of sections 104 (relating to
standards for appointment and practice of VHA physicians) and
206 (relating to quality management officers) of the Committee
bill, along with any recommendations the Secretary may have to
improve the implementation of these sections or to otherwise
improve the quality of VA health care. The Committee expects
that this reporting requirement will lead to increased
oversight of the Department's efforts to improve quality
management efforts and activities.
Section 208. Pilot program on use of community-based organizations and
local and state government entities to ensure that veterans
receive care and benefits for which they are eligible.
Section 208 of the Committee bill, which is also derived
from S.2796 from the 110th Congress, would require VA to carry
out a pilot program to study the use of community-based
organizations, and local and State government entities, to help
ensure that veterans receive needed care and benefits.
Background. Dr. Stanley Luke, PhD, Vice President for
Programs of Helping Hands Hawaii, one of Hawaii's largest
social service nonprofits and a provider of direct services to
Hawaii veterans, testified before the Committee on May 21,
2008, expressing support for the pilot program contemplated by
this section of the Committee bill. According to Dr. Luke, as a
consequence of cultural or other factors in certain locations,
VA personnel may sometimes not be the most appropriate to reach
out to veterans and that, in such instances, local
organizations, with local cultural skills, may be better able
to relate to and interact with veterans and their families in
specific locations.
Helping Hands Hawaii has attempted to assist veterans
through outreach, explaining eligibility and available benefits
and services, and providing mental health care. The pilot
program provided for under this section of the Committee bill
would have VA focus more intently on this approach and study
whether these efforts can be effectively replicated.
Committee Bill. Section 208 of the Committee bill would
require the Secretary to establish and implement a pilot
program to study the use of community-based organizations, and
local and State government entities, in the provision of care
and benefits to veterans. This program would specifically seek
to improve coordination between community, State, and Federal
providers of health care and benefits to veterans who are
transitioning from military to civilian life; to make medical
care and mental health care more available to veterans who are
transitioning; to provide assistance to families of
transitioning veterans; and to provide greater outreach to
veterans and their families, and to inform them about their
eligibility for, and the availability of, benefits and care.
The pilot program would continue for a period of two years
after enactment of the Committee bill, and be carried out at
five locations that the Secretary would select. In selecting
the program locations, the Secretary would be required to place
special emphasis on rural areas, areas with high proportions of
minority groups, areas with high proportions of individuals who
have limited access to health care, and areas that are not in
close proximity to an active duty military station.
The Secretary would award grants to organizations and
entities for them to use in providing services under the pilot
program. Any organization or entity wishing to participate in
the program would be required to submit an application to the
Secretary containing a description of how the program was
developed in consultation with VA and a plan for the
organization to coordinate activities with local, State, and
Federal Government agencies that provide services so as to
avoid duplication of services.
The Secretary would be required to promulgate regulations
governing the appropriate use of grant funds by organizations.
The Secretary would also be required to submit a report on the
pilot program within 180 days after the program's end. The
report would include findings and conclusions, an assessment of
the benefits that were provided, and any recommendations from
the Secretary regarding whether to continue the pilot program.
Section 209. Specialized residential care and rehabilitation for
certain veterans.
Section 209, which was originally derived from S.2889, by
request legislation in the 110th Congress, would authorize VA
to contract for specialized residential care and rehabilitation
services for certain veterans of Operation Enduring Freedom and
Operation Iraqi Freedom (hereinafter (``OEF'' and ``OIF,''
respectively).
Background. Some veterans with TBI or other serious
disabilities and conditions have significant long-term care
needs. These veterans may not need nursing home care, but they
do not always have the resources needed to remain at home and
live independently. This presents a challenge both for the
veteran and the health care system.
Committee Bill. Section 209 of the Committee bill would
amend title 38 section 1720 of title 38 by adding a new
subsection (g) that would authorize the Secretary of Veterans
Affairs, in carrying out a community residential care program,
to contract for specialized residential care and rehabilitation
services for eligible veterans. Veterans covered by this
provision would be veterans of OIF/OEF who: (1) suffer from
TBI, (2) have an accumulation of deficits in activities of
daily living and instrumental activities of daily living that
affects their ability to care for themselves, and (3) would
otherwise receive their care and rehabilitation in a nursing
home, which would exceed their needs.
It is the intent of the Committee that VA should have
authority to provide veterans with significant long-term needs
with a much more appropriate treatment setting for long-term
rehabilitation services. VA supported this provision in its
testimony submitted for the April 22, 2009, hearing.
Section 210. Expanded study on the health impact of Project Shipboard
Hazard and Defense.
Section 210 of the Committee bill would require VA to
contract with the Institute of Medicine of the National
Academies (IOM) for an expanded study on the health impact of
Project Shipboard Hazard and Defense.
Background. During the period 1962-1974, the Department of
Defense conducted a series of tests of chemical and biological
materials in water-borne settings. The tests, known as Project
Shipboard Hazard and Defense (hereinafter ``Project SHAD'')
exposed hundreds of veterans to VX nerve gas, E. Coli, and
other substances.
The SHAD tests were intended to show the vulnerability of
Navy ships to chemical and biological warfare agents. By
learning how those agents would disperse, military planners
hoped to be able to improve procedures to protect crewmembers
and decontaminate ships.
Beginning in 2002, VA contracted with IoM to conduct a
study of the health effects on veterans who participated in
Project SHAD. While there are many known medical problems
associated with repeated chemical and biological weapons
exposure, the Committee is concerned that the study is
incomplete because it omits a number of Project SHAD veterans
who were known to the Department of Defense and to VA.
Committee Bill. Section 210 of the Committee bill would
require the Secretary to enter into a contract with IOM, within
90 days after the enactment of this Act, for the purposes of
IoM conducting a study of the health impacts of Project SHAD on
servicemembers participating in the tests. The Committee bill
would require that this study include all servicemembers
involved in the tests, insofar as is practicable and consistent
with the requirements of conducting sound research. The
Committee Bill would authorize the utilization of the results
from the study ``Long-Term Health Effects of Participation in
Project SHAD'' conducted by IoM.
Congress has previously approved unrestricted, VA-provided
care for veterans who participated in Project SHAD. While the
Committee remains committed to these veterans receiving care,
the Committee also believes there is value in examining the
impact of the testing on participants in order to better
understand the potential effects of other such testing.
The Committee also notes that there is value in continued
research into the areas of chemical and biological weapons
exposure and that VA and DOD should make every effort to
identify and contact all former servicemembers who participated
in Project SHAD as well as testing that occurred during the
same time period at Edgewood Arsenal, Dugway Proving Grounds,
Ft. McClellan, and Ft. Detrick.
Section 211. Use of non-Department facilities for rehabilitation of
individuals with Traumatic Brain Injury.
Section 211 of the Committee bill would specify the
circumstances under which non-VA facilities would be utilized
as part of the rehabilitation and community reintegration plans
for veterans and members of the Armed Forces who are receiving
care from VA for TBI.
Background. VA has done much in recent years to develop its
capability to treat TBI. However, VA has limited experience in
treating younger veterans with debilitating injuries such as
TBI. In 2007, Congress passed a series of VA-related provisions
in the National Defense Authorization Act, the bulk of which
sought to expand and enhance TBI care at VA facilities. As part
of those provisions, Congress gave VA the ability to enter into
cooperative agreements with public or private entities to send
certain veterans suffering with TBI to non-Department
facilities for rehabilitative care. In some circumstances, VA
may find the service of a non-VA facility to be better suited
to providing the care required by some veterans with TBI. In
the Senate-passed version of the NDAA, specific criteria for
eligibility and standards of care were set out, but those
provisions were dropped in the final compromise.
Committee Bill. Section 211 of the Committee bill would
amend section 1710E of title 38 so as to add two new
subsections that were included in the Senate-passed version of
the NDAA 2007. Proposed new subsection (b) would specify that
non-VA facilities would be used when the Secretary cannot
provide treatment or services at the frequency or for the
duration required by the individual plan of veteran or
servicemember suffering from TBI or when the Secretary
determines that it is optimal for the veteran or
servicemember's recovery and rehabilitation. Proposed new
subsection (d) would establish standards for the selection of a
non-Department facility, requiring that the facility itself
maintains care standards that have been established by an
independent, peer-reviewed organization that accredits
specialized rehabilitation programs for adults with TBI.
The Committee notes that VA provides services for veterans
with TBI currently through a variety of different mechanisms
and that the authority in this section is limited to those
situations in which the Secretary determines that the treatment
or services offered are optimal for the recovery and
rehabilitation of the individual, and where the Secretary is
unable to otherwise provide such treatment or services at the
frequency or for the duration prescribed. The Brain Injury
Association of America supports this section, ``as it sets
forth a pivotal mechanism for enhancing cooperation between the
private sector and the VA health care system. Such cooperation
is vitally necessary in order to provide access to, and choice
within, the full continuum of care that returning
servicemembers with TBI need and deserve.''
Section 212. Inclusion of Federally-recognized tribal organizations in
certain programs for State veterans' homes.
Section 212 of the Committee bill would include tribal
organizations in certain authorities relating to State
veterans' homes. The health facilities of tribal organizations
would be eligible to be treated as veterans homes for funding
purposes, and tribal organizations would be eligible to apply
for veteran State home construction grants.
Background. State veterans homes are homes established by
the States for disabled veterans in need of long-term care.
They provide nursing home care, domiciliary care and adult day
care. VA partners with the States in two ways to assist in
funding the homes. Under Sections 1741-1743 of title 38, VA has
the authority to carry out a per diem payment program under
which it provides a portion of the daily cost of care for each
veteran residing in a home. Under Sections 8131-8137 of title
38, VA has the authority to conduct a construction grant
program, in which it can provide up to 65 percent of the total
cost of building a home, with the States required to contribute
35 percent. Under current law, tribal organizations are not
considered States for the purposes of eligibility for either of
these programs.
Based on the 2000 U.S. Census, the Department of Veterans
Affairs projected in a September 2006 report that during the
time period from 2005 to 2020, the number of older veterans
overall will decline by 10 percent. During that same time, VA
projected a nearly 60 percent increase in the number of older
American Indian and Alaska Native veterans. The expected
decline in the overall number of older veterans is attributed
largely to the World War II and Korean War-era veteran
populations, which are declining largely for age-related
reasons. In contrast, American Indian veterans are much less
likely to be World War II or Korean War-era, and more likely to
be Vietnam-era than the overall veteran population.
As early as the 1990s, Native Americans identified a
pressing need for improved long term care in Native
communities. In 1995, the National Indian Council on Aging
described long-term care as the most pressing issue facing
American Indian elders. According to a survey reported in the
2002 American Indian and Alaska Native Roundtable on Long-Term
Care, only 17 percent of tribes report having nursing homes
available on the reservation or in the tribal community.
Nineteen percent reported that their tribe was planning to
create or expand long-term care services. Despite recognition
of the need for long term care, as well as interest among
tribes in developing such care, Native American communities are
constrained by limited Federal funding and the abject poverty
that characterizes much of Indian Country.
Committee Bill. Subsection (a) of section 212 of the
Committee bill would amend section 8138 of title 38 so as to
allow for the treatment of health facilities of tribal
organizations, or beds within such facilities, as State
veterans' homes. As a result of this amendment, tribal
organization health facilities would be treated in the same
manner as other health facilities (or beds), except that newly
designated subsection (f) of section 8138, which sets September
30, 2009, as the expiration date for the treatment of new
health facilities as State homes, would not apply to the health
facilities of tribal organizations.
Subsection (b) of section 212 of the Committee bill would
amend title 38 in a number of ways so as to give the Secretary
the authority to award construction grants to tribal
organizations for the construction of State veterans' homes as
set forth in subchapter III of chapter 81 of title 38.
Subsection (b)(1)(A) would provide that, for the purposes
of the subchapter, `tribal organization' would have the meaning
given to the term in section 3765 of title 38.
Subsection (b)(1)(B) would amend section 8132 of title 38,
the declaration of purpose for the subchapter, to include
tribal organizations along with the ``several states'' as the
entities to be assisted in creating State veterans' homes.
Subsection (b)(1)(C) would amend title 38 by adding a new
section--Section 8133A. Tribal organizations--that would give
the Secretary express authority to award construction grants to
tribal organizations. This new section would provide that
grants to tribal organizations shall be awarded in the same
manner as States, with certain exceptions. One such exception
is that, for the purpose of assigning priority under subsection
(c)(2) of section 8135 of title 38, if a tribal organization is
located within a State that has previously applied for a
construction grant, the tribal organization shall be treated as
if it previously applied as well. Other exceptions may be
prescribed by the Secretary to take into account the unique
circumstances of tribal organizations. By recognizing the
limited long-term care options in Native American communities,
as well as the sovereign status of federally-recognized tribes,
section 212 would enable the Secretary to award State veterans
home grants directly to tribal organizations.
As reported by the Harvard Project on American Indian
Economic Development: ``Where tribes make their own decisions
about what approaches to take and what resources to develop,
they consistently out-perform outside decisionmakers.'' The
Committee expects that, by including tribal organizations among
those eligible to apply for State veteran homes grants, these
organizations will be able to provide more effective long-term
care for the veterans in their communities.
Section 213. Pilot program on provision of dental insurance plans to
veterans and survivors and dependents of veterans.
Section 213 of the Committee bill would direct the
Secretary of Veterans Affairs to carry out a pilot program to
assess the feasibility of providing a dental insurance plan to
eligible veterans, survivors, and dependents of veterans.
Background. The Department of Veterans Affairs provides a
full range of dental services at its facilities. However, under
section 1712 of title 38, dental services are only offered to
certain veterans or to veterans under special circumstances.
For example, veterans who have a service-connected compensable
dental condition, are former prisoners of war, or who have 100
percent service-connected disabilities are eligible for any
needed dental care. Other veterans are eligible only for dental
care necessary to resolve problems arising in certain narrowly
defined situations, such as a veteran whose dental condition is
aggravating a service-related condition or who requires dental
care to continue participation in a vocational rehabilitation
program. In addition, CHAMPVA does not provide dental coverage
for survivors and dependents of veterans receiving care under
that program except under very limited circumstances. CHAMPVA,
established by Public Law 93-82, is primarily a fee-for-service
program that provides reimbursement for most medical care for
certain eligible dependents and survivors of veterans rated
permanently and totally disabled from a service-connected
condition. The program reimburses providers and facilities a
fixed amount for treatment given, less any co-pay from
beneficiaries.
The Department of Defense administers a health care system
for active duty servicemembers, military retirees, certain
Reserve and National Guard members, and eligible family members
under the TRICARE program. Through TRICARE, dental benefits may
be provided to select beneficiaries at military treatment
facilities; for others, voluntary dental insurance coverage is
available through a Department of Defense contract with private
insurers. Section 703 of Public Law 104-201, the National
Defense Authorization Act for Fiscal Year 2007, established the
TRICARE Retiree Dental Program (TRDP) through which military
retirees and their eligible family members are given the option
to purchase dental coverage under a contract managed by the
Department of Defense. Over one million eligible participants
have some level of dental coverage under TRDP. TRDP enrollees
have access to a network of about 112,000 dental plan providers
across the Nation. Premiums currently range from $14 to $48 per
month for an individual policy, depending on the region and
type of dental plan selected.
Committee Bill. Section 213 of the Committee bill, in a
freestanding provision with subsection (a) through (k), would
require the Secretary to carry out a pilot program on the
provision of dental insurance plans to veterans and survivors
and dependents of veterans.
Subsection (a) would require the Secretary to carry out the
pilot program so as to assess the feasibility and advisability
of providing dental insurance.
Subsection (b) would define the participants in the pilot
program as veterans enrolled in VA's medical care system and
survivors and dependents of veterans eligible for medical care
under CHAMPVA.
Subsections (c) and (d) would specify that the pilot
program would be carried out for a period of three years in not
less than two and no more than four VISNs.
Subsection (e) would specify that the Secretary is to
contract with a dental insurer to administer the dental plan.
Subsection (f) would require the dental plan under the
pilot program to provide benefits considered appropriate by the
Secretary, including diagnostic, preventative, endodontic,
surgical, and emergency services.
Subsection (g) would provide that enrollment in the dental
insurance plan would be voluntary and would be for such minimum
period of enrollment as the Secretary prescribes.
Subsection (h) would require the Secretary to set premiums
for dental plan coverage on an annual basis and would specify
that the premiums would be paid entirely by plan enrollees.
Subsection (i) would permit the voluntary disenrollment
from a dental plan if the disenrollment occurs within 30 days
of the beginning of the enrollment period or, under certain
allowable circumstances, such as a relocation to a jurisdiction
outside a plan area or a serious medical condition preventing
use of plan benefits, if the disenrollment does not jeopardize
the fiscal integrity of the dental plan.
Subsection (j) would specify that nothing regarding the
pilot program will affect VA's responsibility to provide dental
care under section 1712 of title 38 nor would an individual's
participation in an insurance plan under the pilot program
affect the individual's entitlement to dental services under
that section.
Subsection (k) would specify that the dental insurance plan
under the pilot program is to be administered pursuant to
regulations prescribed by VA.
The Committee is interested in testing within the VA
healthcare system the TRDP concept of supplementing dental
benefits provided at government facilities with more
comprehensive, voluntary dental insurance coverage financed
through enrollee premiums. This concept is not meant to
minimize VA's obligation to provide high quality dental
services under existing requirements of law.
TITLE III--WOMEN VETERANS HEALTH CARE MATTERS
Section 301. Report on barriers to receipt of health care for women
veterans.
Section 301 of the Committee bill, which was originally
derived from S.2799 of the 110th Congress, would require the
Secretary to submit a report to Congress, no later than June 1,
2010, on the barriers to women veterans' access to VA health
care.
Background. Under current law, VA is authorized to provide
care to all veterans, including women veterans. While there has
been some specific legislative action on certain areas of care
for women veterans, such as for homeless reintegration
services, the Committee believes that much more can be done.
Although this approach has yielded some clear successes, there
are concerns that there may be insufficient attention to
ensuring uniform access to gender-specific services across the
VA health care system. According to DOD, women represent
approximately 17 percent of all deployed servicemembers, and
therefore are a growing portion of the veteran population.
Committee Bill. Section 301 of the Committee bill, in a
freestanding provision, would require VA to submit a report to
Congress, not later than June 1, 2010, that would be required
to include, among other elements, information on an
identification and assessment of any stigma associated with
women veterans seeking mental health care, access to care for
women veterans described in terms of distance to VA facilities,
availability of child care, the comfort and personal safety
perception of women veteran patients, the sensitivity of VA
health care providers to issues affecting women veterans, and
the effectiveness of outreach to women veterans.
The Committee seeks to ensure that appropriate attention
and resources are directed to the needs of women veterans. For
that to happen, those needs must be properly identified and
described. That is the goal of this mandated study.
VA testified at the Committee's May 21, 2008, hearing on
pending legislation that it was already in the process of
conducting an assessment of barriers to care for women
veterans. The results of that effort can either be provided to
the Committee as soon as the results are available or can be
made a part of the report mandated by this section of the
Committee bill.
Section 302. Plan to improve provision of health care services to women
veterans.
Section 302 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require VA to develop
a plan to improve the provision of health care services to
women veterans, and to submit this plan to Congress no later
than 18 months after enactment of the Committee bill.
Background. Public Law 102-585, enacted in 1992, authorized
new and expanded services for women veterans, including
counseling for sexual trauma on a priority basis, specific
health services for women, such as Pap smears, mammography, and
general reproductive health care (including birth control and
treatment of menopause) at many VA medical facilities.
Public Law 104-262, enacted in 1996, expanded services
further to include maternity and infertility benefits. In
fiscal year 1997, the Under Secretary for Health appointed the
first full-time Director for the Women Veterans Health Program.
The program oversees a system of medical and psychosocial
services for women.
As discussed above, in connection with section 301 of the
Committee bill, the Committee is concerned that these benefits
are not being furnished evenly across the VA system.
The 2008 Report of the Advisory Committee on Women Veterans
found that:
The new and complex needs of today's women veterans,
particularly those who served in Operations Enduring
and Iraqi Freedom, require that VA assess the
effectiveness of its existing gender specific programs
and initiate new ones that strategically address the
many needs of this cohort in a way that is inviting,
compassionate, and demonstrate a driven yield toward
the best outcomes.
The burgeoning demand for care from women veterans requires
that VA be fully prepared to deal with their health care needs.
The estimated population of women veterans as of 2001 was 1.6
million, or about 7.2 percent of the total veteran population.
Currently, women make up 14.8 percent of the active duty
military force and approximately 22.8 percent of the reserve
force. By 2010, they are expected to represent over 14 percent
of the total veteran population. Fifty-six percent of women
veterans who use VA are less than 45 years of age.
Committee Bill. Section 302 of the Committee bill, in a
freestanding provision, would require VA to develop a plan on
the provision of health care services to women veterans. The
plan would include how VA intends to improve current services
to women veterans, as well as how to appropriately provide for
the future needs of women currently serving in Operations Iraqi
and Enduring Freedom. As part of this plan, the Secretary would
be required to identify the types of health care services that
will be available to women veterans at each VA medical center,
as well as what personnel would be required to provide such
services. This plan would have to be submitted to the two
Veterans' Affairs Committees not later than 18 months after the
date of enactment of the Committee bill.
It is the Committee's view that requiring VA to develop a
plan is a first step toward ensuring that the needs of women
veterans are met, now and into the future.
Section 303. Independent study on health consequences of women veterans
of military service in Operation Iraqi Freedom and Operation
Enduring Freedom.
Section 303, which is also derived from S.2799 of the 110th
Congress, would require the Secretary to enter into an
agreement with a non-Department entity to conduct an
independent study on the health consequences of service for
women veterans of service on active duty in the Armed Forces in
deployment in OIF/OEF.
Background. Public Law 98-160, enacted in 1983, established
the Advisory Committee on Women Veterans (hereinafter,
``Advisory Committee''). In addition, Public Law 103-446,
enacted in 1994, created the Center for Women Veterans
(hereinafter, ``Center''). Both entities play invaluable roles
in helping to shape VA's responses to the needs and concerns of
women veterans.
The Advisory Committee evaluates existing VA programs and
makes recommendations for the enhancement of programs and
services for women veterans while the Center oversees all VA
programs for women veterans. However, neither entity is
specifically charged to focus on the possible health
consequences for women veterans who have served on activity
duty in the Armed Forces in deployment in OIF/OEF.
More than 160,000 female U.S. servicemembers have served in
Iraq, Afghanistan, and the Middle East since 2003. From March
19, 2003 through June 6, 2009, 624 women were wounded in action
in OIF or OEF. Statistics were not kept by gender for wars
prior to the Iraq and Afghanistan conflicts.
Another consequence of the increased number of women
serving in the U.S. military is an increase in the occurrence
of rape and sexual assault by male servicemembers. Connie Lee
Best, PhD, a Clinical Psychologist and Professor in the
Department of Psychiatry and Behavioral Sciences at the Medical
University of South Carolina testified before the Committee on
April 25, 2007, noting that:
Numerous research studies have documented rates of rape
ranging from lows of 6 percent for active duty to rates
that are significantly higher. One study found that 23%
of female users of VA health care reported experiencing
at least one sexual assault while in the military.
Given the extensive service of women in OIF/OEF, the
Committee is of the view that VA must fully assess the health
consequences of their service. Only then will VA know how best
to meet their specific needs.
Committee Bill. Section 303 of the Committee bill, in a
freestanding provision, would require the Secretary of Veterans
Affairs to enter into an agreement with a non-Department
entity, such as the IOM, to conduct an independent study on the
health consequences of service in OIF/OEF for women veterans.
The study would be required to include an examination of any
and all possible environmental and occupational exposures and
their effects on the general, mental, and reproductive health
of women veterans who served in OIF/OEF. It would also be
required to include an analysis of all published literature on
such exposures to women while serving in the Armed Forces,
including combat trauma and military sexual trauma. The entity
conducting the study would be required to complete and submit a
report of the study to Congress no later than 18 months after
entering into the agreement for the study, and the Secretary
would be required to submit a response to the report of the
study no later than 90 days following the receipt of the
report.
Section 304. Training and certification for mental health care
providers on care for veterans suffering from sexual trauma.
Section 304 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require VA to
implement a program for education, training, certification and
continuing medical education for VA mental health care
providers on care and counseling services for veterans
suffering from military sexual trauma.
Background. Public Law 102-585, enacted in 1999, authorized
VA to include outreach and counseling services for women
veterans who experienced incidents of sexual trauma while
serving on active duty in the military. The law was later
amended by Public Law 103-452 so as to authorize VA to provide
counseling related to sexual trauma to men, as well as to
women. Public Law 108-422, enacted in 2004, extended VA's
authority permanently to provide military sexual trauma
(``MST'') counseling and treatment to active duty
servicemembers or those serving on active duty for training.
VA has a number of strong programs geared toward mental
health needs generally. However, MST is a discrete phenomenon
and must be addressed as such. In addition, given the high
numbers of women subjected to MST, as discussed above in
connection with Section 303 of the Committee bill, the
Committee believes that a more targeted approach is necessary.
Dr. Connie Best testified before the Committee in 2007
that:
* * * the VA is staffed by some of the best mental
health providers and by some with exceptional expertise
in MST. However, I believe the one of the problems
facing the VA in their responsibility to meet the needs
of today's veterans who have experienced MST is one of
sheer numbers * * *. That means more qualified and
appropriately trained providers must be available.
Those providers must be able to provide specialized
sexual assault services and understand the interaction
of sexual trauma with combat-related trauma.
Dr. Best suggested that VA should add specialized training
programs for providers in the treatment of MST.
Committee Bill. Section 304 of the Committee bill would
amend section 1720D of title 38 so as to add two new
subsections.
Proposed new subsection (d) would require VA to implement a
program for education, training, certification and continuing
medical education for VA mental health care providers on care
and counseling services for veterans suffering from MST. The
new subsection would require that the training be carried out
in a consistent manner and that it include principles of
evidence-based treatment and care for sexual trauma. VA would
also be required to determine the minimum qualifications
necessary for mental health professionals certified under the
program to provide evidence-based care and therapy to veterans
for MST.
Proposed new subsection (e) would require VA to report to
Congress annually on the care, counseling and services provided
to veterans under section 1720D. Specifically, VA would be
required to provide information on the number of mental health
professionals and primary care providers who have been
certified under the program; the amount and nature of
continuing medical education provided under such program to
professionals and providers who have been so certified; the
number of women veterans who received counseling, care and
services from professionals and providers who have been trained
or certified under the program; the number of training,
certification, and continuing medical education programs
operating under subsection (d); and the number of trained full-
time equivalent employees required in each facility of the
Department to meet the needs of veterans requiring treatment
and care for sexual trauma.
Finally, subsection (b) of section 304 of the Committee
bill, in a freestanding provision, would require the Secretary
to establish education, training, certification and staffing
standards for VA health care facilities for full-time
equivalent employees who are trained to provide sexual trauma
treatment and care.
Section 305. Pilot program on counseling in retreat settings for women
veterans newly separated from service in the armed forces.
Section 305 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require VA to carry
out a pilot program to evaluate the feasibility and
advisability of providing reintegration and readjustment
services in group retreat settings to certain women veterans.
Background. VA operates a program of readjustment
counseling which is provided through community-based facilities
known as Vet Centers. Currently, there are 232 Vet Centers,
located in all fifty states, the District of Columbia, Guam,
Puerto Rico and the US Virgin Islands. Each provides assistance
to veterans in need to readjustment counseling. The Vet Centers
are managed by the Readjustment Counseling Service located in
the Veterans Health Administration.
VA appears to appreciate the value of retreats for its
employees, especially those involved in mental health issues.
Recent retreats include one on the implementation of the VA's
Mental Health Strategic Plan and another for those advocating
recovery models of care in VISN 3. The Committee believes that
there is merit to evaluating the impact of providing
reintegration assistance in retreat settings to woman veterans
returning from a prolonged deployment.
Committee Bill. Section 305 of the Committee bill, in a
freestanding provision, would require VA to establish, not
later than 180 days after the date of enactment of the
Committee bill, a pilot program designed to evaluate the
feasibility of providing reintegration and readjustment
services in group retreat settings to women veterans who are
recently separated from service in the Armed Forces after a
prolonged deployment. This pilot program would be required to
be carried out for two years, beginning on the date the program
begins, in no fewer than five locations selected by the
Secretary.
Participation in the pilot program would be strictly
voluntary. Services provided under the program would include
information and assistance on reintegration into family,
employment, and community; financial and occupational
counseling; information and counseling on stress reduction and
conflict resolution; and any other counseling the Secretary
considers appropriate to assist the participants in
reintegrating into their families and communities.
The Committee bill would authorize the appropriation of $2
million annually in fiscal years 2010 and 2011 to carry out the
pilot program. VA would be required to report to Congress on
the pilot program no later than 180 days after completion of
the program.
Section 306. Report on full-time women veterans program managers at
medical centers.
Section 306 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require the Secretary
to submit to Congress a report on the employment of program
managers solely for the management and oversight of women
veterans' health care needs. This report would include whether
or not each facility employs at least one such full-time
employee.
Background. Women Veterans Program Managers are generally
available at each VA facility, although not all are full-time
positions. These coordinators ensure that women veterans are
afforded equal access to all services. They work to ensure that
women veterans receive high quality comprehensive medical care
in an environment that is sensitive to the privacy needs of
women. Women Veterans Program Managers also advocate for
gender-specific issues and needs. The Committee recognizes the
valuable contributions of the Women Veterans Program Managers
and believes that it is essential that every VA Medical Center
have sufficient resources to ensure that these positions are
full-time.
Committee Bill. Section 306 of the Committee bill, in a
freestanding provision, would require the Secretary, acting
through the Under Secretary for Health, to submit a one-time
report on Women Veterans Program Managers, so as to determine
how many of these positions are filled on a full-time basis.
Section 307. Service on certain advisory committees of women recently
separated from service in the Armed Forces.
Section 307 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require the Secretary
to appoint women veterans who are recently separated from the
Armed Forces, to the Department's Advisory Committee on Women
Veterans and to the Advisory Committee on Minority Veterans.
Background. Public Law 98-160, enacted in 1983, established
the Advisory Committee on Women Veterans and set forth specific
criteria for membership on the Committee, including those with
service-connected disabilities, those who represent women
veterans, and others. There is no specific requirement that any
member of the Advisory Committee be a woman veteran who has
recently separated from service in the Armed Forces.
Public Law 103-446, enacted in 1994, established the
Advisory Committee on Minority Veterans and set forth specific
criteria for membership on the Committee including
representatives of veterans who are minority group members,
individuals who are recognized authorities in fields pertinent
to the needs of veterans who are minority group members,
veterans who are minority group members and who have experience
in a military theater of operations, and others. There is no
specific requirement that any member of this Advisory Committee
be a woman veteran, who is also a member of a minority group
and who is recently separated from service in the Armed Forces.
Committee Bill. Subsection (a) of section 307 of the
Committee bill would amend section 542(a)(2)(A) of title 38so
as to require the Secretary to appoint women veterans who are
recently separated from the Armed Forces, to the VA Advisory
Committee on Women Veterans.
Subsection (b) of section 307 of the Committee bill would
amend section 544(a)(2)(A) so as to require the Secretary to
appoint women veterans who are also members of a minority group
and recently separated from the Armed Forces to serve on the
Advisory Committee on Minority Veterans.
Subsection (c) of section 307 of the Committee bill would
provide that the amendments made by this section shall apply
with appointments made to the two advisory committees on or
after the date of enactment of the Committee bill.
Section 308. Pilot program on subsidies for child care for certain
veterans receiving health care.
Section 308 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would require the Secretary
to implement a pilot program to assess the feasibility and
advisability of providing subsidies to certain veterans in
order to allow them to purchase child care services to
facilitate better access to health care from VA.
Background. There is currently no authority for VA to
reimburse veterans for child care expenses incurred while
receiving VA medical care. The Committee recognizes that some
veterans face significant barriers to receiving health care
from VA and that the absence of adequate child care for those
veterans who are primary caretakers of children is one such
impediment. This problem can be even more daunting for veterans
in that situation who are in need of intensive health care
services, such as care for PTSD, mental health, and other
therapeutic programs.
In order to address the issue of the need for child care
for its own employees, VA created the VA Child Care Subsidy
Program, as authorized by Public Law 107-67, the Treasury and
General Government Appropriations Act for Fiscal Year 2002.
That law authorized the use of appropriated funds by executive
agencies in order to provide child care services for Federal
civilian employees. The VA program is needs based, with the
amount of reimbursement available to an employee depending on
total family income and the amount paid for child care. In
order to qualify for reimbursement, children must be placed in
a licensed day care, home care or before/after school program,
and beneficiaries must complete and submit an application form.
The Committee believes that this existing VA program
provides an excellent model for VA to emulate as it moves
forward with the child care subsidies for veterans, which would
be authorized by this section of the Committee bill.
Committee Bill. Section 308 of the Committee bill, in a
freestanding provision, would require VA to carry out a pilot
program to examine what effect subsidies for child care for
certain veterans receiving VA health care would have on
improving access to health care services. The pilot program
would be authorized for two years, beginning on the date the
program begins, and would be required to be carried out in no
fewer than three VISNs.
Subsidies for child care would only be available during the
time period that a veteran is actually receiving specified
health care services at a VA medical facility, and during the
time required by the veteran to travel to and from the site of
treatment. Veterans eligible for subsidies would be those who
are the primary caretaker of a child or children and who are
receiving regular or intensive mental health care, or other
intensive health care services determined by the Secretary as
ones for which access would be improved by payment of a subsidy
for child care.
The pilot program would be required to be modeled, insofar
as practicable, on the VA Child Care Subsidy Program and would
use the same income eligibility and payment structure as used
in that program. The Secretary would be required to report on
the program to Congress within six months of the conclusion of
the program on the Secretary's findings and conclusions about
the program, along with any recommendations the Secretary
considers appropriate. The Committee bill would authorize the
appropriation of $1.5 million annually for fiscal year 2010 and
2011 for the purposes of the pilot program.
Section 309. Care for newborn children of women veterans receiving
maternity care.
Section 309 of the Committee bill, which is also derived
from S.2799 of the 110th Congress, would authorize the
Secretary to provide health care services, for not more than
seven days after birth, to a newborn child of a woman veteran
who is receiving maternity care from VA.
Background. Under current law, VA is authorized to provide
maternity and infertility benefits to women veterans who enroll
for VA care. Obstetrical care, excluding care for the newborn,
is provided under contract.
While a veteran's care extends to maternity, prenatal, and
postnatal care for female veterans, there is no authority for
the provision of, or payment for, any care for the newborn
child of a female veteran patient. This statutory scheme
results in a significant gap in care for the increasing number
of women veterans enrolled with VA.
The current women veteran population is predominantly of
child bearing age. Therefore, it is a disservice to the growing
female veteran population and an inequity to not provide some
newborn care.
According to various studies, the average hospital stay for
low-birth weight infants (a common reason for prolonged
neonatal hospital stays) ranges from 6.2 to 68.1 days, whereas
the average hospital stay for average-sized infants was 2.3
days. Seven days of coverage would assist the mothers of
newborns in need of simple, routine care, as well as many in
need of more complex hospitalization.
Committee Bill. Section 309 of the Committee bill would add
a new section--section 1786, entitled ``Care for newborn
children of women veterans receiving maternity care''--to
Subchapter VIII of chapter 17 of title 38. This new section
would authorize the Secretary to provide health care services,
for not more than seven days after birth, to a newborn child of
a woman veteran who is receiving maternity care from VA, if the
mother gave birth in a VA medical facility, or in an outside
facility pursuant to a contract between that facility and the
Department. These services would include all post-delivery
care, including routine care, required by a newborn.
It is the Committee's belief that this limited but
important step will help to ensure that the needs of women
veterans enrolling for VA care are met in a more complete
manner.
TITLE IV--MENTAL HEALTH CARE
Section 401. Eligibility of members of the Armed Forces who serve in
Operation Iraqi Freedom or Operation Enduring Freedom for
counseling and services through Readjustment Counseling
Service.
Section 401 would allow members of the Armed Forces,
including members of National Guard or Reserves, who serve in
OIF/OEF to receive services through VA's Readjustment
Counseling Service.
Background. Adrian Atizado representing the Disabled
American Veterans, testified before the Committee on April 22,
2009:
According to VA, as of August 2008, over 945,000 OEF/
OIF servicemembers have separated from military
service. Of those, over 400,000 OEF/OIF veterans have
sought VA health care since 2002, and over 178,483 have
received a diagnosis of a possible mental health
disorder. Within that group, 105,465 have been given a
probable diagnosis of Post Traumatic Stress Disorder
(PTSD).
While recently separated OIF/OIF veterans and members of
the National Guard or Reserves who were mobilized for service
in OIF/OEF who served their period of mobilization, are
eligible for readjustment counseling services from VA under
section 1712A of title 38, members of the Armed Forces still on
active duty are not eligible for these services.
Committee Bill. Section 401 of the Committee bill, in a
freestanding provision consisting of four subsections, would
establish eligibility for readjustment counseling services for
any member of the Armed Forces who serves on active duty in
OIF/OEF, including a member of the National Guard or Reserves.
Subsection (a) would set forth the basic eligibility for
this population of servicemembers for readjustment counseling
and related mental health services under section 1712A of title
38. These services would be provided through VA's Vet Centers.
Subsection (b) would specify that there is no requirement
that a servicemember be currently on active duty to be eligible
for these services.
Subsection (c) would condition the eligibility for these
services on regulations prescribed jointly by the Secretaries
of Defense and VA.
Subsection (d) would limit the availability of services
under this section to the availability of appropriations for
the provision of these services, to ensure that new veterans
entering the Vet Center system will not be a detriment to those
the Vet Centers are currently serving.
The Committee recognizes that among many in the active duty
and reserve Armed Forces, there is a stigma associated with
seeking assistance in connection with mental health concerns.
In light of the clear indication that many who serve in combat
may experience psychological impact from such service--as shown
by a 2008 Rand Corporation Study on mental health in OIF/OEF
veterans, (Tanielian and Jaycox (Eds.), ``Invisible Wounds of
War: Psychological and Congitive Injuries, Their Consequences,
and Services to Assist Recovery,'' Santa Monica, CA: RAND
Corporation, 2008.)--there appears to be significant value in
allowing servicemembers still on active duty to come to VA's
Vet Centers for help in dealing with such concerns.
At the same time, the Committee is concerned about placing
an undue burden upon the Vet Centers, given their current
responsibility to not only provide readjustment counseling to
currently eligible veterans, but also to provide outreach to
returning servicemembers and newly discharged veterans.
Section 402. Restoration of authority of Readjustment Counseling
Service to provide referral and other assistance upon request
to former members of the Armed Forces not authorized
counseling.
Section 402 of the Committee bill would restore the
authority of VA's Readjustment Counseling Service to provide
referral and other assistance, upon request, to former members
of the Armed Forces who have been discharged or released from
active duty but who are not otherwise eligible for such
counseling and services.
Background. VA was first authorized to furnish readjustment
counseling services to Vietnam-era veterans in 1979 in Public
Law 96-22. Included in that original authority was a provision
that required VA to provide referral services and other
assistance to veterans who sought readjustment counseling but
who were not eligible to receive those services because of the
nature of their discharge from the military or for other
reasons. This authority was repealed in 1996 in Public Law 104-
262, the Veterans Health Care Eligibility Reform Act of 1996.
Committee Bill. Section 402 of the Committee bill would
amend section 1712A of title 38 by adding a subsection (c)
which would restore the provisions which require VA to provide
referral services and other assistance to veterans who request
readjustment counseling but who are not eligible for such
services.
It is the Committee's intent that those who have been
discharged under conditions other than honorable still be
afforded assistance in acquiring mental health services and
also in gaining review of their discharges. The Committee
believes that VA should be available to provide some assistance
to those who have served and are in need of readjustment
assistance, even if they are not eligible for the full array of
VA benefits.
Section 403. Study on suicides among veterans.
Section 403 of the Committee bill would require VA to
conduct a study on suicides among veterans since January 1,
1999, and report to Congress on the findings.
Background. Numerous reports have illustrated that the rate
of suicide among veterans is steadily increasing. One such
report was the RAND study noted above which reported that 1 in
5 veterans of the wars in Iraq and Afghanistan are returning
and suffering with stress or mental health disorders, but that
only half of those veterans are actually receiving treatment
for these conditions.
VA's Office of Mental Health reported that the number of
suicides attempted at VA facilities increased from 492 in 2000
to 790 in 2007. The Army reported seven confirmed and 17
suspected suicides in January 2009. This number of suicides
would surpass the number of troops killed in combat for the
same month in Iraq and Afghanistan combined. Between 1995 and
2007, there have been over 2,200 suicides among active-duty
servicemembers. Despite these increases, there remains no
centralized database of veteran suicides and attempts.
Committee Bill. Section 403 of the Committee bill, in a
freestanding provision consisting of four subsections, would
require VA to conduct a study to determine the number of
veterans who died by suicide between January 1, 1999, and the
date of enactment of the Committee bill.
Subsection (a) would set forth the basic requirement for
the study.
Subsection (b) would require VA, in carrying out this
study, to coordinate with the DOD, Veterans Service
Organizations, the Centers for Disease Control and Prevention,
and state public health offices and veterans agencies.
Subsection (c) would require VA to submit a report to the
Committees on Veterans' Affairs of the Senate and the House of
Representatives on the findings of the study.
Subsection (d) would authorize the appropriation of such
sums as may be necessary to carry out the study.
Because the data shows that the incidence of suicide among
veterans is at record levels, the Committee believes a need
exists to have more comprehensive and accurate information so
this problem can be more successfully addressed.
Section 404. Transfer of funds to Secretary of Health and Human
Services for Graduate Psychology Education program.
Section 404 would mandate the transfer of $5 million from
VHA accounts to the Secretary of Health and Human Services
(HHS) for the Graduate Psychology Education program.
Background. The Graduate Psychology Education program was
established under section 755(b)(1)(J) of the Public Health
Services Act. This program is the only Federal program solely
dedicated to training post-doctoral psychologists.
Recent studies have projected continuing high demand for
psychological treatment of PTSD, TBI, and other combat-related
stress disorders. Reports issued by GAO, the DOD Mental Health
Task Force, the Presidential Task Force on Returning Global War
on Terror Heroes, the Institute of Medicine, and the
President's Commission on Care For America's Returning Wounded
Warriors, have identified shortages of trained mental health
providers, detailed problems in the training pipeline, and
provided recommendations concerning the workforce needed to
deal with what is projected to be an increased demand for
mental health care among servicemembers and veterans.
VA faces immediate challenges in recruiting mental health
professionals with focused specialty training in combat-related
stress disorders and post-deployment readjustment.
Committee Bill. Section 404 of the Committee bill would, in
a freestanding provision consisting of three subsections,
mandate the transfer of funds from VA to the Department of
Health and Human Services (HHS) for the Graduate Psychology
Education program and delineate the use of the funds and the
preferences for VA health care facilities.
Subsection (a) would require VA, no later than the
September 30, 2010, to transfer $5,000,000 from accounts of VHA
to HHS for the Graduate Psychology Education program.
Subsection (b) would specify that the funds transferred by
VA to HHS be used to make grants that would support the
training of psychologists in the treatment of PTSD, TBI, and
other combat-related disorders.
Subsection (c) would establish a preference in the awarding
of grants under this provision to VA health care facilities and
to graduate educational programs affiliated with VA facilities.
The Committee expects that establishing a collaborative VA-
HHS training pipeline should help ensure a steady flow of
specially-trained psychologists to serve the veteran
population. Graduates of these training programs will continue
to practice their specialty and will also be candidates for
hire by VA or civilian practices that serve veteran patient
populations. Many of the positions may be in rural communities
where veterans, especially those from National Guard and
Reserve units, often return to find VA facilities distant or
community-based outpatient clinics lacking mental health
professionals.
The Committee intends for the grantee training programs
receiving support through this effort to be involved with VA
clinicians and facilities as training sites, thus ensuring that
the substantial services provided in the course of training
will go to veterans. Ensuring an adequate supply of well-
trained psychologists--specializing in combat stress
disorders--is in the strong interest of the Nation, VA, and
individual veterans.
TITLE V--HOMELESS VETERANS
Veterans remain one of the more disproportionately
represented groups among the overall homeless population. It
has been estimated that one in every three homeless persons is
a veteran.
Dean Stoline, testifying for The American Legion before the
Committee on January 28, 2009, spoke of the substantial needs
of this population:
* * * there are approximately 154,000 homeless veterans
on the street each night. This number, compounded with
300,000 servicemembers entering the private sector each
year since 2001 with at least a third of them
potentially suffering from mental illness, requires
that intensive and numerous programs to prevent and
assist homeless veterans are available.
Many of these homeless veterans are returning from the
conflicts in Iraq and Afghanistan. VA reported that almost 3000
OIF/OEF homeless veterans were treated at VA medical centers
over that past four years.
VA administers a number of programs aimed at combating and
preventing homelessness among veterans. These programs include
the provision of residential domiciliary-based care (including
mental health care and substance abuse disorder treatment), a
grant and per diem program to assist community-based entities
that serve homeless veterans, employment and job training
assistance, and supported permanent housing.
The Committee has worked cooperatively with VA to expand
and enhance its authority to serve this particular population.
Title V of the Committee bill includes a number of provisions,
some proposed by VA, some suggested by advocates, some from
legislation, all of which are designed to enhance and improve
VA efforts to address the overall problem and to provide
assistance to homeless veterans
Section 501. Pilot program on financial support for entities that
coordinate the provision of supportive services to formerly
homeless veterans residing on certain military property.
Section 501 of the Committee bill would authorize the
Secretary to create and implement a pilot program to carry out,
and evaluate the impact of, providing grants to certain
organizations that will assist formerly homeless veterans
living on certain government property.
Background. The National Coalition for Homeless Veterans
(NCHV), in testimony before the Committee on May 21, 2008,
cited VA's 2006 Community Homelessness Assessment and Local
Education Networking Groups report, ``The lack of affordable
permanent housing is cited as the No. 1 unmet need of America's
veterans.'' This need is listed as the second highest unmet
need in the 2007 report.
Currently, veterans can utilize services from organizations
that are sponsored by the VA Grant and Per Diem program, but
organizations sponsored by this program can only provide
services to a veteran for up to two years. Domiciliary Care for
Homeless Veterans provides treatment and rehabilitation to
homeless veterans, but the average length of stay is only four
months. VA's Compensated Work Therapy/Transitional Residence
program provides both a residence and employment in conjunction
with work-skills training and other rehabilitation. The average
stay in this program is only 174 days. VA's Supported Housing
program allows VA staff to assist in locating permanent housing
for veterans, but does not provide any funding or vouchers to
allow VA to provide that housing.
A new VA pilot program provides loan guarantees for
transitional family housing, but not permanent long-term
housing. All of these programs are beneficial steps, but many
veterans are still not ready for transition to independent
living at the end of these programs. NCHV points out that
despite these programs, ``many formerly homeless veterans still
cannot afford fair market rents, nor will most of them qualify
for mortgages even with the VA home loan guarantee. They are,
essentially, still at risk of homelessness.'' Gerald M. Cross,
M.D., Principal Deputy Under Secretary for Health at VA,
testified at the Committee's May 21, 2008, hearing that
military facilities that have been recently closed or had a
major mission change could potentially be prime locations to
house already homeless veterans or those in danger of becoming
homeless.
Committee Bill. Section 501 of the Committee bill, in a
freestanding provision consisting of six subsections, would
authorize the Secretary, subject to the availability of
appropriations, to carry out, and evaluate the impact of, a
pilot program which would provide grants to entities that
coordinate the provision of supportive services for very low
income formerly homeless veterans.
Subsection (a) authorizes the Secretary to award grants to
public and nonprofit organizations to coordinate supportive
services to low-income formerly homeless veterans residing in
permanent housing that is located on qualifying properties as
part of a pilot program.
Subsection (b) defines qualifying property as property that
had been a military installation closed as part of the 2005
round of defense base closure and realignment under the Defense
Base Closure and Realignment Act of 1990, or under subchapter
III of chapter 5 of title 40, U.S.C. The Secretary of Defense
must determine, after reviewing any local authority's
redevelopment plans for the property, that the property can be
used to assist the homeless in accordance with any such
redevelopment plan.
Subsection (c) requires the Secretary to prescribe criteria
and requirements for grants under this section and to publish
such criteria and requirements in the Federal Register.
Subsection (d) limits the duration of the pilot program to
five years after the date of the commencement of the program.
Subsection (e) defines ``very low income'' to have the same
meaning as that used by the Department of Housing and Urban
Development.
Subsection (f) authorizes the appropriation of not more
than $3,000,000 in each fiscal year from 2010 through 2014 to
carry out the pilot program.
The Committee agrees with VA's position that military
facilities that have been recently closed or have had a major
mission change could serve as excellent locations to house
homeless veterans, or those in danger of becoming homeless. In
developing economic revitalization and community development
plans, local authorities could utilize grants under the program
that would be established by this provision so as to aid in
financing the conversion of such properties. The Committee
believes that veterans with certain applicable skills--
including but not limited to such occupations as carpentry,
plumbing, and landscaping--could be employed in the property
conversion process, or in other aspects of a community's
redevelopment plan, a process that could further aid very low-
income veterans. It is the Committee's belief that this
combination of available housing and employment under local
revitalization plans or in areas of the local economy could
enable participating veterans to become self supporting.
Section 502. Pilot program on financial support of entities that
coordinate the provision of supportive services to formerly
homeless veterans residing in permanent housing.
Section 502 of the Committee bill would authorize the
Secretary to implement a similar pilot program providing
supportive services to homeless veterans residing in permanent
housing on properties not qualifying under Section 501's pilot
program.
Background. Currently, there are a number of community-
based and/or non-profit organizations that can and do provide a
variety of services to assist formerly homeless veterans with
their reintegration into society. These groups, coupled with
VA's current efforts to provide supportive services, seek to
prevent homelessness from recurring, an approach consistent
with the overall direction that efforts against homelessness
are moving in. The focus among both VA providers and community
groups is shifting to prevention rather than reaction to
homelessness occurring. In VA's case, this is done largely
through intensive case management and collaboration with
veterans service organizations to find permanent housing for
formerly homeless veterans.
Committee Bill. Section 502 of the Committee bill
authorizes the Secretary to carry out a pilot program to make
grants to public and nonprofit organizations to coordinate
supportive services for veterans residing in permanent housing.
Subsection (a) would authorize the Secretary, subject to
the availability of appropriations, to award up to 10 grants to
public and nonprofit organizations to coordinate the provision
of supportive services to veterans residing in permanent
housing on qualifying properties.
Subsection (b) defines qualifying properties under this
subsection as properties in the United States on which
permanent housing is provided to formerly homeless veterans, as
determined by the Secretary.
Subsection (c) requires the Secretary to prescribe criteria
and requirements for grants under this section and to publish
such criteria and requirements in the Federal Register.
Subsection (d) limits the duration of the pilot program to
five years after the date of the commencement of the program.
Subsection (e) identifies the definition of ``very low
income'' to be that found in the Resident Characteristics
Report issued annually by the Department of Housing and Urban
Development.
Subsection (f) authorizes appropriations of not more than
$3,000,000 in each of the fiscal years 2010 through 2014 to
carry out the purposes of this section.
This effort, in ten communities across the Nation, would
further assist veterans in reintegrating into the community and
becoming self sufficient. The Committee expects that the ten
locations selected for the pilot program under section 502(a)
of the Committee bill will all be different from the locations
selected for the pilot program under section 501, described
above.
Joseph L. Wilson, Deputy Director of the Veterans Affairs
and Rehabilitation Commission of The American Legion, described
the need for the type of pilot program authorize in this
section of the Committee bill and in the prior section, in his
May 21, 2008, testimony before the Committee, saying ``[w]hile
permanent housing provides a stable base for veterans and their
families the need for resources to improve their way of life is
just as important * * *.These funded pilot programs will extend
more opportunities for formerly homeless veterans, which in
turn allow them to achieve and maintain a quality existence,
deserving of their service to our country.''
Section 503. Pilot program on financial support of entities that
provide outreach to inform certain veterans about pension
benefits.
Section 503 of the Committee bill would authorize the
Secretary to implement a pilot program to carry out, and
evaluate the impact of, providing grants to certain
organizations to inform certain veterans and their spouses
about VA pension benefits.
Background. A recent study, (Greg Greenberg, Joyce H. Chen,
Robert A. Rosenheck, Wesley J. Kasprow. ``Receipt of Disability
through an Outreach Program for Homeless Veterans.'' Military
Medicine 172, no. 5 (May 1, 2007): 461-5.), concluded that
there is an acute need for outreach to low-income and elderly
veterans, and their spouses, to inform them of their potential
eligibility for need-based pension benefits from VA. Some of
these veterans and their spouses live in areas that are far
from VA facilities, and hence are underserved in outreach from
VA. Pension benefits are given by VA to wartime veterans who
have limited income, and are either 65 years of age, or older,
or who are permanently and totally disabled.
Committee Bill. Section 503 of the Committee bill would
authorize the Secretary to carry out and evaluate the impact of
a pilot program informing certain veterans and their spouses
about VA pension benefits.
Subsection (a) authorizes the Secretary to carry out a
pilot program which would provide grants to nonprofit or public
organizations, including faith-based organizations, to provide
outreach and information to low-income and elderly veterans and
their spouses who live in rural areas, of VA pension benefits
and services for which they may qualify for under chapter 15 of
title 38, U.S.C.
Subsection (b) requires the Secretary to prescribe criteria
and requirements for grants under this section and to publish
such criteria and requirements in the Federal Register.
Subsection (c) limits the duration of the pilot program to
five years after the date of the commencement of the program.
Subsection (d) authorizes appropriations of not more than
$1,275,000 in each of the fiscal years 2010 through 2014 to
carry out the purposes of this section.
The Committee believes that utilizing local organizations
and their existing networks would be an effective way of
disseminating key information to veterans and their spouses
about the VA pension program.
Section 504. Assessment of pilot programs.
Section 504 of the Committee bill would require the
Secretary to submit a report to Congress on each of the pilot
programs detailed in sections 501-503 of the Committee bill at
least 1 year before the end of each program's authorization.
Each report would be required to contain the lessons learned by
the Secretary which can be applied to other similar programs,
any recommendations from the Secretary as to whether to
continue the pilot program, the number of veterans and
dependents served by the pilot program, an assessment of the
quality of service provided by the program, the amount of funds
provided to grant recipients under the program, and the names
of all organizations that have received grants.
TITLE VI--NONPROFIT RESEARCH AND EDUCATION CORPORATIONS
Title VI of the Committee bill includes a number of
provisions that would amend subchapter IV of chapter 73
relating to NPCs.
NPCs were first authorized in 1988 in Public Law 100-322.
Prior to 1988, it was difficult for VA to accept private or
non-VA public funding for its research program. The methods in
place, such as the General Post Fund, were not well-suited to
this task. The General Post Fund was primarily designed to
accept and administer veterans' bequests, the regulations of
which made it difficult to flexibly disburse funds.
Additionally, university partners who could administer funds
for VA frequently had high overhead costs, reducing the amount
of funding available for actual research. NPCs were designed to
be a mechanism that could flexibly administer such funds, be
regulated and overseen by the Federal Government, and remain
affiliated with, but not part of, VA.
While NPCs were originally designed to support only VA
research, Congress has since expanded their role to include
support of education and training. Since that initial authority
was provided, the number of NPCs that have been established has
ranged from 96 to 84, with prior year revenues totaling more
than $240 million reported in June 2008. NPCs play a central
role in VA research, making up 18 percent of VA's total
research funding. Through NPCs, VA researchers access funding
from, and collaborate with, the Department of Defense and the
National Institutes of Health of the Department of Health and
Human Services. NPCs also give VA researchers access to
research support from foundations, corporations, and private
organizations.
NPCs were originally intended to support the research
programs of individual medical centers. This facility-specific
approach effectively supports individual programs, and NPCs are
essential components of many facilities' research efforts.
However, in the twenty years since the inception of NPCs, the
character of VA research has changed and the standards applied
to nonprofit corporation governance and management have become
more rigorous. Some facility research programs may simply be
too small to generate a revenue stream sufficient to support
the infrastructure and governance necessary to meet these
standards, but the facilities would nonetheless benefit from
having ready access to the benefits NPCs provide.
In general, the provisions of Title VI of the Committee
bill would alter the existing law to allow for multi-medical
center non-profit research corporations. Traditional NPCs are
chartered in the state in which they are physically located and
affiliated with one VA facility. In order to combine resources,
NPCs affiliated with nearby medical centers, possibly in
different states, need the ability to form higher-revenue
corporations, known as multi-medical center research
corporations, without unduly imposing on VA a requirement for
multiple personnel from multiple facilities to serve on an NPC
board of directors.
The Committee bill would grant authority to the Secretary
to establish multi-medical center research corporations, to
approve the conversion of single-facility NPCs to multi-medical
center research corporations. It also details the composition
of the board of directors for such corporations. The bill also
would make permanent the authority of the Secretary to
establish NPCs, clarify the powers of such corporations to
allow them to more flexibly disburse their funds, and clarify
the purposes of NPCs to remove ambiguity about their role in
supporting education and training. Finally, this title would
improve the oversight of NPCs, and make a clerical amendment.
Section 601. General authorities on establishment of corporations.
Section 601 of the Committee bill would expand
authorizations for the establishment of NPCs, and clarify the
definition and purpose of such corporations.
Background. Current law relating to the authority to
establish NPCs, section 7361 of title 38, allows NPCs to be
established at one VA medical center, and in one state. As
discussed above, NPCs were originally intended to support the
research programs of individual medical centers but that model
is no longer optimal. Current law requires that NPCs be tax
exempt organizations but does not specify the specific terms of
that status, which has led to some confusion about the tax and
regulatory status of NPCs in some states and among some
stakeholders.
Committee Bill. Section 601 of the Committee bill would
amend section 7361 of title 38 in a number of ways, with the
principal focus on authorizing the creation of multi-medical
center research corporations.
Subsection (a)(1) of section 601 would amend section 7361
so as to insert a new subsection (b) that would expressly
authorize the establishment of ``multi-medical center research
corporations.'' The board of directors of a multi-medical
center research corporation would have to include the director
of each VA medical center involved in the corporation. A multi-
medical center research corporation would be authorized to
manage finances relating to research or education or both
performed at the VA medical centers involved.
Additionally, single-facility NPCs and multi-medical center
research corporations would retain unchanged their current
ability to administer funds for research programs conducted at
multiple facilities, regardless of whether those facilities are
served by a multi-medical center research corporation. NPCs
could also serve as pass-through entities for programs
performed at multiple facilities.
Subsection (a)(2) of section 601 would add a new subsection
(f) to section 7361 that would authorize an existing NPC to
become a multi-medical center research corporation if its board
of directors approves such an expansion and it is also approved
by the Secretary. Ms. Donna McCartney, Chair of the National
Association of Veterans' Research and Education Foundations
(NAVREF) and Executive Director of the Palo Alto Institute for
Research and Education, testified before the Committee on May
21, 2008, that this provision is necessary because:
``* * * it will allow interested VA facilities with
small research programs to join with larger ones. Or
several smaller facilities may pool their resources to
support management of one NPC with funds and staffing
adequate to ensure an appropriate level of internal
controls, including segregation of financial duties.''
Subsection (b) of section 601 would further amend section
7361 by adding a new subsection (c) which would consist of the
provisions of current section 7365, relating to the
applicability of State law to NPCs, modified so as to specify
that multi-medical center corporations operating in different
states would be created under and subject to the laws of one of
the States in which the corporation operates.
Subsection (c) of section 601 would further amend section
7361 by recasting as a new subsection (d)(1) a provision in
subsection (a) of current section 7361 relating to the
obligation of NPCs to comply only with those Federal laws,
regulations, and executive orders and directives that apply to
private non-profit corporations generally and by adding a new
paragraph (2) to subsection (d) which would expressly provide
that NPCs are not owned or controlled by, or are not an agency
or instrumentality of, the United States.
Subsection (d) of section 601 would further amend section
7361 by restoring the requirement that all NPCs must operate as
501(c)(3) tax exempt organizations. This amendment is designed
to eliminate confusion in some states and among some
stakeholders over the tax status of NPCs.
In testimony, for the record of the Committee's April 22,
2009, hearing, VA expressed support for section 601 and
specifically for permitting the formation of multi-medical
center research corporations.
Section 602. Clarification of purposes of corporations.
Section 602 of the Committee bill, which is derived from
S.2926 in the 110th Congress, would clarify the purpose of NPCs
to include specific reference to their role as funding
mechanisms for approved research and education, in addition to
their role in facilitating research and education.
Background. Current law is not specific with respect to the
role of NPCs in supporting research and education, and does not
include multi-medical center corporations. Further, the statute
currently contains provisions that appear to allow NPCs to
offer residencies and similar programs, possibly in conflict
with the prohibition against nonprofit corporations conferring
personal benefits on individuals.
Committee Bill. Section 602 of the Committee bill would
amend section 7362 of title 38 in a number of ways, with the
principal focus on providing that, in addition to supporting
the conduct and administration of VA research projects and
education activities, NPCs may support functions more generally
related to VA research and education.
Subsection (a) of section 602 would amend subsection (a) of
section 7362 so as to clarify that NPCs are intended to provide
``a flexible funding mechanism'' for both the conduct of
approved research and education at one or more VA medical
centers and to fund ``functions'' relating to research and
education. These functions would include, but not be limited
to, travel to scientific conferences, recruitment of clinician
investigators, improvements in laboratories, procurement of
general use research equipment, and support for the
institutional review board, the animal laboratory and the
facility human protections program. Under current law, support
for such functions often cannot be tied to specific research
projects and, as such, may not be permitted.
Ms. McCartney's testimony noted that there have been
differences in interpretation regarding the permissibility of
NPC expenditures supporting VA research and education
generally, instead of being tied directly to an approved
project. This section of the Committee bill would clarify that
issue.
Subsection (b) of section 602 would amend subsection (b) of
section 7362 so as to make a technical modification to a
defined term relating to education and training.
Subsection (c) of section 602 would further amend
subsection (b) of section 7362 so as to strike a provision that
allows NPCs to include, under the education function of a
corporation, the employment of individuals as part of a
residency or similar program. By removing this language
relating to residencies and similar programs, it is not the
Committee's intent that this change diminish the authority of
NPCs to support elements of education and training activities
for VA trainees, such as VA residents, but simply to clarify
that NPCs cannot be chief sponsors of residencies, as they are
neither hospitals nor academic institutions and that function
may conflict with regulations governing 501(c)(3)
organizations. NPCs would still be able to support education
and training activities for VA trainees, and, for purposes of
this section, employees of the Veterans Health Administration
include VA trainees.
Subsection (d) of section 602 would further amend
subsection (b) of section 7362 so as to clarify that NPCs are
authorized to provide education and training to patients as
well as families of patients. The Committee recognizes that
patients' families often play a central role in the care and
recovery of veteran patients. As such, education for family
members directly supports the care and recovery of these
veterans. The return of wounded servicemembers from Iraq and
Afghanistan, many with severe TBI or debilitating multiple
traumas, is placing growing demands on family caregivers.
Clarifying that NPCs can provide such education would be an
important form of support for family caregivers.
Section 603. Modification of requirements for boards of directors of
corporations.
Section 603 of the Committee bill would address the
requirements for the composition of NPC boards of directors.
Background. Under current section 7363, certain non-VA
personnel who serve on the board of an NPC must be familiar
with issues involving medical and scientific research or
education. This limits the composition of boards of directors,
and prevents potential board members from serving who may have
valuable business, legal, or financial expertise.
In addition, subsection (c) of section 7363 requires that
members of NPC boards have no ``financial relationship'' with
any entity that is a source of funding for VA, with the
exception of governmental and non-profit entities. This phrase
has been interpreted by VA as an absolute prohibition on any
financial relationship on the part of a board member with a
precluded entity, either in the past or present. That
prohibition was included in the original NPC authorizing
legislation, Public Law 100-322, in 1988. Subsequently, the
Office of Government Ethics (hereinafter ``OGE'') promulgated
governmentwide conflict of interest regulations in 5 CFR Part
2635, and the waiver regulations required by section 208 of
title 18, U.S.C., in 5 CFR Part 2640 in August 1992, and
December 1996, respectively. In light of those actions by OGE,
the requirements placed on NPC board members have become more
onerous than those applied to many government and non-profit
employees.
Further, the financial conflict of interest requirements of
current subsection (c) of section 7363(c) go beyond the
requirements in paragraph (1) of subsection (c) of section
7366, which state that NPC board members ``shall be subject to
Federal laws and regulations applicable to Federal employees
with respect to conflicts of interest in the performance of
official functions.'' Under that paragraph, NPC board members
are governed by the statutory criminal code, section 208 of
title 18, U.S.C., and conflict of interest regulations, 5 CFR
Sec. Sec. 2635.401-2635.403. Those regulations, in addition to
guidance from the Internal Revenue Service and the Office of
Government Ethics, provide for the permissibility of de minimus
affiliations, and for the ability to recuse oneself when
necessary to avoid conflicts of interest.
Committee Bill. The Committee bill would amend section 7363
of title 38 in a number of ways so as to describe membership in
boards of multi-medical center research corporations, allow
non-VA individuals with diverse backgrounds to serve on NPC
boards, and to modify the provisions relating to conflicts of
interest.
Subsection (a) of section 603 would amend paragraph (1) of
subsection (a) of section 7363 so as to restructure the current
law without changing the intent or effect except to provide
that the directors of each medical center affiliated with a
multi-medical center research corporation are to be members of
that corporation's board of directors.
Subsection (b) of section 603 would amend paragraph (2) of
subsection (a) of section 7363 so as to require that not less
than two non-VA personnel be members of the board, and, in
addition to those with medical or scientific expertise, would
permit individuals to be on an NPC board who have backgrounds
or business, legal, or financial expertise that would benefit a
board.
Ms. McCartney testified that this provision of the
Committee bill would substantially aid NPCs in acquiring the
expertise needed to efficiently run research corporations,
including legal and financial management expertise.
Subsection (c) of section 603 would amend subsection (c) of
section 7363 so as to eliminate the requirement in current law
that members of NPC boards have no financial relationship with
any entity that is a source of funding for research or
education by VA, with the exception of governmental and non-
profit entities. By eliminating the restrictions in current
law, this section of the Committee bill would bring NPCs into
conformity with other 501(c)(3) entities and Federal conflict
of interest regulations.
Ms. McCartney emphasized the importance of this change and
the Committee concurs with her view that there is no reason to
hold board members of NPCs to a higher standard than what
applies to similar organizations or to government employees.
Section 604. Clarification of powers of corporations.
Section 604 of the Committee bill would restate NPCs'
authorities so as to clarify that they may accept, administer,
and transfer funds for various purposes.
Background. Section 7364 of title 38, entitled ``General
powers,'' sets forth the core authorities of NPCs. Over the
years, the incompleteness and imprecision of some of these
provisions have created obstacles to the conduct of NPC
business. In addition, current law is unclear and potentially
contradictory on some financial and personnel issues.
Current section 7364 does not fully address the financial
authorities necessary to NPCs. While the provision specifies
that NPCs may accept gifts and grants, it does not mention
other sources of funding common to NPCs, such as fees,
reimbursements, and bequests. In some situations, VA has
interpreted existing law to mean that NPCs may only accept the
types of income explicitly specified in current section 7364.
In addition, the authority of NPCs to utilize funds is poorly
defined, as it leaves out the administration, retention, and
spending of such funds.
Under current law, NPCs do not have the authority to charge
non-VA attendees fees for educational or training programs nor
do they have authority to retain such fees. While NPCs are
tasked with facilitating education and training, and to accept
funds in support of such activities, section 8154 of title 38
provides that only the Secretary has authority to conduct VA
educational programs, and to charge non-VA attendees fees for
such programs. That provision also specifies that the fees
collected be credited to the applicable VA medical
appropriation. As a result, even when non-VA attendees are
willing to pay fees to contribute to the costs of educational
or training events, NPCs do not have explicit authority to
charge or retain such funds, a result which presents a
significant obstacle to the conduct of such events.
Cooperative Research and Development Agreements (CRADAs)
are agreements mandated by VA to establish the terms and
conditions for certain industry-sponsored studies performed at
VA medical centers and administered by NPCs. Each CRADA must be
reviewed and approved by a VA attorney. Although NPCs generally
handle the preliminary negotiations relating to the development
of CRADAs, VA attorney review is often extensive, and can take
a number of hours, incurring significant costs. While NPCs
frequently have funds available to reimburse the Office of
General Counsel (OGC) for these costs, OGC does not have
authority to accept or retain reimbursement for its services.
Current section 7364 does not specifically address the
transfer of funds between VA and NPCs for costs associated with
personnel assignments under the Intergovernmental Personnel Act
(IPA), under subchapter VI of chapter 33 of title 5, U.S.C. IPA
assignments between VA medical centers and NPCs have been
common since the inception of NPCs. The assignment of NPC
employees to VA has proven to be of significant benefit to VA
research. In a May 2008 report titled ``Audit of Veterans
Health Administration's Oversight of Nonprofit Research and
Education Corporations,'' the VA Office of the Inspector
General (hereinafter, ``OIG'') found that under current law,
reimbursements from VA to NPCs, pursuant to the IPA, constitute
transfers of funds appropriated to VA prohibited by subsection
7362(a) of title 38. This finding jeopardizes an important
element of the partnership between VA and NPCs.
Current section 7364 authorizes NPCs to spend funds only on
research projects that have been approved by the VA facility
Research and Development Committee. Requiring approval prior to
any expenditure of funds unduly hinders operations and planning
necessary to the application or preparation for research
projects, such as the costs of hiring a grant writer or study
coordinator to prepare a grant proposal.
Committee Bill. Section 604 of the Committee bill would
amend section 7364 of title 38, by striking the current
sections (a) through (c) and inserting new subsections (a)
through (e) which, collectively, would set forth the general
powers of NPCs and clarify the relationship between VA and
NPCs.
Proposed paragraph (1)(A) of new subsection (a) of section
7364 would allow NPCs to accept, administer, retain, and spend
funds derived from gifts, contributions, grants, fees,
reimbursements, and bequests from individuals and public and
private entities. New paragraph (1)(B) would authorize NPCs to
enter into contracts and agreements with individuals and public
and private entities. These changes make explicit the financial
authorities of NPCs, which the Committee views as consistent
with the intent of the original authorizing legislation.
Proposed new paragraph (C) of new subsection (a)(1) would
authorize NPCs to charge registration fees for education and
training programs they administer, and to retain such funds.
Proposed paragraph (2) subsection (a) would prohibit the
use of funds appropriated to VA to pay fees charged by NPCs.
Taken together, these provisions would enable NPCs, and the
research programs served by NPCs, to gain financial support for
their educational and training programs.
Proposed paragraph (D) of new subsection (a)(1) would
authorize NPCs to reimburse OGC for certain expenses of
providing legal services attributable to NPC research and
education agreements. With financial assistance from NPCs, OGC
would be better able to staff Regional Counsel offices and the
VA Central Office so as to meet the demand to review the
growing number of CRADAs. Proposed new paragraph (3) of
subsection (a) would further mandate that funds reimbursed to
OGC by NPCs are to be used only for staff and training, and
related travel, for the provision of legal services related to
review of research agreements such as CRADAs.
Proposed paragraph (E) of new subsection (a)(1) is a
renumbering of the text of subsection (a)(2) of current section
7364. Proposed paragraph (1) of new subsection (b) is a
renumbering of the text of the second sentence of subsection
(a) of current section 7362. The language would be moved to new
section 7364 in order to group it with other provisions
addressing NPC funding issues.
Proposed new paragraph (2) of subsection (b) would
authorize VA to reimburse an NPC for all or a portion of the
pay or benefits, or both, of an NPC employee assigned to VA
under the Interagency Personnel Agreement. The Committee
believes that this authorization will remove any uncertainty
about the appropriateness of using VA funds to reimburse NPCs
for personnel appointed to VA pursuant to the IPA in the past
and going forward.
Proposed new subsection (c) of section 7364 would grant
powers to NPCs allowing them to disburse limited funds for
essential activities that must be accomplished prior to
research project approval. Such activities would include grant
proposal writing, development, and review. Currently, NPCs are
not permitted to disburse any funds in support of a research
program until that program has been approved by VA. The
Committee believes that this restriction is impractically
rigid, and hinders NPC ability to appropriately prepare for
project proposals.
Proposed new subsection (d) of section 7364 would grant
powers to NPCs allowing them to disburse limited funds for
essential activities that must be accomplished prior to
education and training activity approval. Such essential
activities would include grant request writing, strategy
development, creating presentations and briefings and perhaps
even making deposits to reserve meeting space. Currently, NPCs
are not permitted to disburse any funds in support of an
education activity until that program has been approved. The
Committee believes that this restriction is impractically
rigid, and hinders NPCs' ability to appropriately prepare for
education activities.
Proposed new subsection (e) of section 7364 would permit
the Under Secretary for Health to establish policies and
procedures for the spending of funds by NPCs. These policies
and procedures would be required to not only comply with
applicable regulations, but also to be designed to facilitate
the mission of NPCs as flexible funding mechanisms
Ms. McCartney voiced strong support for these provisions in
her testimony before the Committee on May 21, 2008. VA also
supported this provision in its testimony for the record of the
Committee's April 22, 2009 hearing.
Section 605. Redesignation of Section 7364A of title 38, U.S.C.
Section 605 of the Committee bill, would redesignate
section 7364A as section 7365, as a conforming amendment to the
provision in section (b)(2) of section 601 of the Committee
bill, which struck current section 7365 after moving the
contents of that section to new subsection (c) of section 7361.
Section 606. Improved accountability and oversight of
corporations.
Section 606 of the Committee bill would strengthen VA
oversight of NPCs.
Background. VA is responsible for oversight of the NPCs,
and a number of bodies carry out that duty. The Secretary
established the VA Nonprofit Corporation Oversight Board in
2004 to review the activities of VA NPCs for consistency with
VA policy and interests. Earlier, in 2003, VHA established the
Nonprofit Research and Education Corporation Program Office
(hereinafter, ``NPPO'') to provide oversight of NPC activities.
The NPPO is responsible for providing oversight and guidance
affecting operations and financial management, performing
substantive reviews of the annual reports submitted by each
NPC, compiling the information for VA's annual submission to
Congress, improving accountability, and ensuring deficiencies
are corrected. In accordance with the CFO Act of 1990 (Public
Law 101-576) and a 1994 General Counsel opinion, VHA's CFO also
has financial oversight responsibility for NPCs.
The May 2008 OIG report discussed earlier found a number of
problems with VA oversight of NPCs. The OIG found that ``NPCs
did not implement adequate controls to properly manage funds''
and that VA failed to adequately implement ``effective
oversight procedures,'' or require ``minimum control
requirements for NPC activities.'' While the OIG did not find
significant problems resulting from ineffective oversight, the
report concluded that ``VHA cannot be reasonably assured that
the NPCs are fully complying with applicable laws or
regulations or effectively managing research and education
funds.''
Committee Bill. Subsection (a) of section 606 of the
Committee bill would amend subsection (b) of section 7366 of
title 38 so as to require NPCs to include the corporation's
most recent IRS Form 990 `Return of Organization Exempt from
Income Tax' or equivalent documents, and the applicable
schedules, in an NPC's annual report to the Secretary. The
information in Form 990 is extensive, and would be valuable to
the Secretary in the conduct of thorough oversight.
Subsection (b) of section 606 would amend subsection (c) of
section 7366 so as to make the laws and regulations governing
conflicts of interest within NPCs conform to laws governing
similar entities, and to those governing conflicts of interest
among Federal employees, as discussed above under section 603
of the Committee bill.
Subsection (c) of section 606 would amend subsection
(d)(3)(c) of section 7366 so as to raise the threshold for
reporting identifying information for payees from $35,000 to
$50,000. Current law requires the Secretary, in annual reports
to Congress, to provide identifying information on every payee
paid more than $35,000. The proposed increase would make the
statute governing NPC practices consistent with IRS standards
for scrutinizing compensation for higher paid employees. The
Committee believes that the original intent of this reporting
requirement was to scrutinize large payments and compensation
of higher paid employees, and that rising salaries over time
have simply overtaken the current statute.
Section 607. Repeal of sunset.
This provision repeals Section 7368, which prohibited the
creation of NPCs after December 31, 2008. This is necessary to
permit the formation of multicenter NPCs as otherwise
authorized within Title VI of the Committee bill.
TITLE VII--MISCELLANEOUS PROVISIONS
Section 701. Expansion of authority for Department of Veterans Affairs
police officers.
Section 701 of the Committee bill would expand certain
authorities set out in title 38 relating to VA police officers
so as to better reflect the current scope of their duties and
responsibilities.
Background. When originally enacted, section 902 of title
38 was formulated in a manner that suited a health care system
that delivered the majority of its services in centralized
campus environments. As a result, VA police officers rarely had
official business off VA property. Today, however, VA medical
facilities now include large campuses, urban hospitals,
Community Based Outpatient Clinics, and storefront Vet Centers.
VA's increasingly decentralized delivery points for care
necessitates that VA police officers travel frequently among VA
facilities and off-campus sites. This includes travel off
Department property to conduct administrative portions of
investigations, such as interviewing witnesses or crime
victims. It also includes travel off-campus to bring about the
safe return of high-risk patients who have eloped and are a
danger to themselves or others. The responsibilities of VA
police officers also extend to responding to emergencies and
disasters at the local, regional, and national levels.
Because the jurisdiction of VA police officers is limited
by current law to Department property, VA police officers are
not able to carry their Department-issued weapons off property
when conducting official business or on official travel.
Committee Bill. Subsection (a)(1) of section 701 of the
Committee bill would amend section 902(a) of title 38 so as to
permit VA police officers to: (1) carry VA-issued weapons,
including firearms, while off Department property in an
official capacity or while in official travel status; (2)
conduct investigations, on and off Department property, of
offenses that may have been committed on Department property,
consistent with agreements with affected local, state, or
Federal law enforcement agencies; and (3) carry out, as needed
and appropriate, any of the duties described in section
902(a)(1), as revised, when engaged in such duties pursuant to
other Federal statutes and (4) execute any arrest warrant
issued by a competent judicial authority.
Subsection (a)(2) of section 701 would further amend
section 902 of title 38 to specify that the powers granted to
VA police officers be exercised in accordance with guidelines
approved by the Secretary and the Attorney General of the
United States.
Under current law, a VA officer who observes criminal
activity beyond Department property cannot legally respond when
a VA patient or provider is the victim. It is the Committee's
view that this limitation unduly restricts the ability of VA
police to fully carry out their assigned responsibilities.
Extending these authorities would be consistent with powers
Congress has granted to other Federal law enforcement officers,
such as those in the Federal Protective Service, the Department
of Homeland Security, the Pentagon Force Protection Agency, and
the United States Capitol Police. The Fraternal Order of Police
expressed support for this provision in a letter to Chairman
Akaka and Ranking Member Burr. The Committee requested input
from the Department of Justice on this provision, which was not
provided by the date of this report.
Section 702. Uniform allowance for Department of Veterans Affairs
police officers.
Section 702 of the Committee bill as incorporated into
S.252, would amend title 38 so as to modify the authority of VA
to pay an allowance to VA police officers for the purchase of
uniforms.
Background. VA employs approximately 2,600 uniformed police
officers. VA uniformed police officers are generally paid
approximately $40,000 per year. Under current law, which was
enacted in 1991, VA may pay no more than $200 per fiscal year,
with authority to increase the amount to $400 in one fiscal
year. Because there has been no increase since 1991, VA
uniformed police officers have to pay out of their own funds to
supplement their initial uniform purchases and maintain their
uniforms. OPM has published new regulations to increase the
authorized uniform allowance for other, non-VA Federal police
officers to $800 for initial and annual purchases.
Committee Bill. Section 702 of the Committee bill would
amend section 903(b) of title 38, which governs the uniform
allowance for VA police officers, to limit the allowable amount
to the lesser of: (1) the amount prescribed by the OPM; or (2)
the estimated or actual costs as determined by periodic surveys
conducted by VA. The provision would also amend section 903(c)
of title 38 to provide that the allowance established under
subsection (b) of section 902 of title 38, as modified by the
Committee bill, shall be paid at the beginning of an officer's
appointment for those appointed on or after October 1, 2008,
and for other officers at the request of the officer, subject
to the fiscal year limitations established in subsection (b),
as modified by the Committee bill.
The Committee believes that in order to compete for good
candidates to become VA police officers and to retain those
already employed by VA, there is a need to increase the uniform
allowance and for VA to ensure that the annual allowance
remains at an appropriate level. VA supported this provision in
testimony for the Committee's April 22, 2009 hearing.
Committee Bill Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the CBO, estimates that enactment of
the Committee bill would, relative to current law, increase
discretionary spending by almost $900 million over the 2010-
2014 period, assuming appropriation of the necessary amounts.
The Committee bill would not increase direct spending, based on
information supplied by the CBO. Enactment of the Committee
bill would not affect receipts, and would not affect the budget
of state, local or tribal governments.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office
Washington, DC, July 16, 2009.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S.252, the Veterans
Health Care Authorization Act of 2009.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Douglas W. Elmendorf,
Director.
Enclosure
S.252, Veterans Health Care Authorization Act of 2009
Summary: S.252 would make several changes to existing
veterans' health care programs and create a number of new
health care programs for veterans. In total, CBO estimates that
implementing the bill would cost almost $900 million over the
2010-2014 period, assuming appropriation of the specified and
estimated amounts. Enacting the bill would affect direct
spending and revenues, but CBO estimates that impact would not
be significant.
S.252 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of S.252 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--
--------------------------------------------------------
2010 2011 2012 2013 2014 2010-22014
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa
Pilot Program for Dental Insurance:
Estimated Authorization Level...................... 10 65 85 85 85 330
Estimated Outlays.................................. 9 59 82 84 85 319
Health Care for Female Veterans:
Estimated Authorization Level...................... 37 34 30 31 34 166
Estimated Outlays.................................. 34 33 30 31 34 162
Education Assistance:
Estimated Authorization Level...................... 11 27 39 43 48 168
Estimated Outlays.................................. 10 25 37 42 47 161
Medical Personnel:
Estimated Authorization Level...................... 18 18 19 19 20 94
Estimated Outlays.................................. 16 18 19 19 20 92
Quality Management:
Authorization Level................................ 25 25 0 0 0 50
Estimated Outlays.................................. 23 25 2 0 0 50
Pilot Programs:
Estimated Authorization Level...................... 10 10 7 7 7 41
Estimated Outlays.................................. 10 10 7 7 7 41
Expanded Eligibility for Vet Centers:
Authorization Level................................ 10 9 6 6 6 37
Estimated Outlays.................................. 9 9 6 6 6 36
Specialized Residential and Rehabilitation Care:
Authorization Level................................ 2 3 5 6 8 24
Estimated Outlays.................................. 2 3 5 6 8 24
Studies:
Authorization Level................................ 3 0 0 0 0 3
Estimated Outlays.................................. 3 * 0 0 0 3
Uniforms for Police Offices:
Authorization Level................................ 1 1 1 1 1 5
Estimated Outlays.................................. 1 1 1 1 1 5
Other Provisions:
Authorization Level................................ 1 1 1 1 1 5
Estimated Outlays.................................. 1 1 1 1 1 5
----------------------------------------------------------------------------------------------------------------
Total Changes:
Estimated Authorization Level................ 128 193 193 199 210 923
Estimated Outlays............................ 118 184 190 197 209 898
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000; numbers may not sum to totals because of rounding.
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
enacting S.252 would increase direct spending and revenues by less than $500,000 a year.
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted near the start of fiscal year 2010,
that the authorized and estimated amounts will be appropriated
each year, and that outlays will follow historical spending
patterns for similar programs.
Spending subject to appropriation
CBO estimates that implementing S.252 would cost $898
million over the 2010-2014 period, assuming appropriation of
the specified and estimated amounts.
Pilot Program for Dental Insurance. Section 214 would
require the Department of Veterans Affairs (VA) to implement a
pilot program to provide dental insurance to all enrolled
veterans and their survivors and dependents. VA would be
directed to carry out the 3-year program in at least two but no
more than four Veterans Integrated Services Networks (VISNs;
regional networks of medical facilities). CBO estimates that
implementing this provision would cost about $320 million over
the 2010-2014 period, assuming appropriation of the estimated
amounts.
The bill would require VA to contract with a dental insurer
who would administer the program. Veterans would be required to
pay premiums and copayments. However, the bill would grant VA
wide discretion in designing several critical parameters of the
program, such as the covered benefits, requirements for
enrollment and disenrollment, and premiums. For purposes of
this estimate, CBO assumes that the pilot program would be
carried out at three VISNs and that the program would be
similar to the TRICARE Dental Program, which is available to
reservists, their family members, and active-duty
servicemembers.
CBO estimates that the program would begin accepting
enrollees around the middle of fiscal year 2010, and based on
the participation rates for the TRICARE program, that about
12,000 veterans, survivors, and dependents would join that
year. We estimate that enrollment would rise to 78,000 in 2011
and 97,000 in 2012 before stabilizing at a level of about
90,000 a year.
The TRICARE program pays up to $1,200 a year for
nonorthodontic services, and many diagnostic and preventive
services do not count toward the cap. Based on costs for the
TRICARE program and for dental care provided by VA to a limited
number of veterans, CBO estimates that in 2010 VA would pay
about $800 per enrollee under the pilot program. After
adjusting for inflation, CBO estimates that the pilot program
would have initial costs of $9 million in 2010, rising to $59
million in 2011, before stabilizing at slightly more than $80
million a year thereafter.
Health Care for Female Veterans. Title III of the bill
would authorize several programs targeted to women veterans.
CBO estimates that implementing that title would cost $162
million over the 2010-2014 period, assuming appropriation of
the authorized and estimated amounts.
Care for Newborns. Section 309 would authorize VA to
provide care for up to seven days to the newborn children of
female veterans who receive maternity care through the
department. Based on data from VA, CBO estimates that about
6,600 babies would become eligible for such care in 2010 at an
average cost of $2,770 per baby. After adjusting for inflation
and population growth--the number of female veterans of child-
bearing age is expected to rise in future years--CBO estimates
that implementing this provision would cost $102 million over
the 2010-2014 period.
Training for Mental Health Providers. Section 304 would
require VA to educate, train, and certify mental health
professionals who specialize in treating sexual trauma. Based
on information from VA's Office of Mental Health Services, CBO
estimates that VA would need 66 employees a year to provide
training at a cost of $46 million over the 2010-2014 period.
Report and Study on Female Veterans. Section 301 would
require the Secretary to conduct a study of the barriers faced
by women veterans in receiving VA health care. Based on
information from VA, CBO estimates that implementing this
provision would cost $3 million over the 2010-2014 period.
Section 303 would require VA to contract with an outside
entity to conduct a study on the health consequences facing
female veterans of Operation Iraqi Freedom and Operation
Enduring Freedom (OIF/OEF) as a result of their service. Based
on information from VA, CBO estimates that implementing this
provision would cost $4 million over the 2010-2014 period.
Counseling for Female Veterans. Section 305 would require
VA to implement a pilot program to provide counseling in group
retreat settings to female veterans who have recently separated
after lengthy deployments, and would authorize the
appropriation of $2 million per year for 2010 and 2011 for that
purpose. CBO estimates that this pilot program would cost $4
million over the 2010-2014 period.
Child Care. Section 308 would require VA to implement a
pilot program to provide child care for certain female veterans
who use VA medical facilities, and would authorize the
appropriation of $1.5 million per year for 2010 and 2011 for
that purpose. CBO estimates that this pilot program would cost
$3 million over the 2010-2014 period.
Education Assistance. Three separate provisions in section
103 would authorize VA to provide scholarships and assistance
with education loans to certain employees. In total, CBO
estimates that enacting those provisions would cost $161
million over the 2010-2014 period, assuming appropriation of
the estimated amounts.
Health Professionals Scholarship Program. Section 103(a)
would reinstate a scholarship program for health professionals
that expired in 1998. The provision would give VA the authority
to provide funds to cover tuition, fees, and other costs
related to their education. In exchange for financial
assistance, recipients would be obligated to work at VA for a
specified period of time.
Based on information from VA, CBO estimates that after a
six-month period to establish the program, VA would grant about
100 awards in 2010 with an average award of $46,000. In the
following years, CBO estimates VA would grant 200 new awards a
year. Based on information from VA, CBO expects that
scholarships would last an average of two years. After
adjusting for an estimated 5.5 percent annual increase in
tuition and other costs, CBO estimates that implementing this
provision would cost $5 million in 2010 and $82 million over
the 2010-2014 period, assuming appropriation of the estimated
amounts.
Debt Reduction. Two other provisions of section 103 would
allow VA to help employees repay education loans. Subsection
(b) would expand eligibility for the Education Debt Reduction
Program from those recently appointed to all employees involved
in direct patient care. In 2008, about 6,500 employees received
an average annual benefit of $5,800 under this program, which
reimburses employees over a five-year period. Based on
information from VA, CBO estimates that 450 additional
employees each year would become eligible. After adjusting for
inflation, CBO estimates that implementing this provision would
cost $44 million over the 2010-2014 period, assuming
appropriation of the estimated amounts.
The second provision, subsection 103(c), would allow
certain clinical researchers at VA who have disadvantaged
backgrounds to use a National Institutes of Health (NIH)
program for repayment of education loans. The NIH program
provides an annual benefit of up to $35,000 per employee. Based
on information from VA, CBO estimates that 100 new employees
each year would receive an average amount of $30,000 a year
over three years. Assuming appropriation of the estimated
amounts, CBO estimates that implementing this provision would
cost $35 million over the 2010-2014 period.
Medical Personnel. Section 101 contains several provisions
that would affect compensation for medical personnel. In total,
CBO estimates that implementing those provisions would cost $92
million over the 2010-2014 period, assuming appropriation of
the necessary amounts.
Overtime Pay. Section 101(l) would loosen certain pay
restrictions, thereby allowing nurses, physician assistants,
and certain other employees to earn additional pay for evening
or weekend work. Under current law, employees can earn
additional pay for working evenings or weekends only on their
regular tour of duty. The bill would allow such pay for any
evening or weekend hours worked, even if they were occasional
or ad-hoc. In 2008, such employees worked roughly 1.8 million
hours of overtime at an average overtime rate of about $55 an
hour. CBO estimates that under current law VA does not pay
night or weekend differentials for 75 percent of those hours
(1.4 million hours). After adjusting for inflation, CBO
estimates that under the bill VA would pay additional night
differentials of $6 per hour for about 485,000 hours and
weekend differentials of $15 per hour for 385,000 hours, for a
total cost of $46 million over the 2010-2014 period, assuming
appropriation of the estimated amounts.
Higher Pay for Nurses. Subsections 101(h) and 101(i) would
increase the pay caps for registered nurses and certified
registered nurse anesthetists. Based on information from VA,
CBO estimates that the department would pay an average
additional amount of $10,000 a year to about 560 nurses at a
cost of $6 million a year. Subsection (j) would increase the
maximum special pay for nurse executives from $25,000 to
$100,000. Based on information from VA, CBO estimates that the
department would pay an average additional amount of $10,000 to
about 135 nurse executives at a cost of about $1 million a
year. In total, CBO estimates that implementing those three
provisions would increase pay for nurses by $7 million a year.
Incentive Pay for Pharmacist Executives. Section 101(f)
would allow VA to pay additional compensation of up to $40,000
a year to pharmacist executives as a recruitment and retention
tool. Based on information from VA, CBO estimates that the
department would pay an additional $40,000 a year to 40 people
for a total cost of $8 million over the 2010-2014 period.
Increased Pay Scale for Appointees. Section 101(e) would
allow VA to pay certain appointees using a higher pay scale.
Based on information from VA, CBO estimates that the department
would pay an average additional amount of $14,000 to about 40
people, for a total cost of $3 million over the 2010-2014
period.
Quality Management. Section 206 would require VA to
designate a quality management officer (QMO) for each of its
135 medical facilities and VISNs as well as a principal QMO who
would report directly to the Undersecretary for Health. VA
already has QMOs serving at all levels specified in the bill.
This section also would authorize the appropriation of $25
million each year in 2010 and 2011 for assessing the
reliability of existing measures of the quality of VA care and
developing a new aggregate metric. CBO estimates that
implementing this provision would cost $50 million over the
2010-2014 period, assuming appropriation of the authorized
amounts.
Pilot Programs. Several sections of S.252 would require VA
to carry out pilot programs to provide or pay for health care
and related benefits. In total, CBO estimates that enacting
those provisions (not including the dental pilot program, which
is discussed above) would cost $41 million over the 2010-2014
period, assuming appropriation of the specified and estimated
amounts.
Homeless Veterans. Title V would require VA to carry out
three separate pilot programs to provide outreach and various
services to homeless veterans and would authorize the
appropriation of $36 million over the 2010-2014 period for
those purposes. CBO estimates that implementing those pilot
programs would cost $35 million over the 2010-2014 period.
Transition Assistance. Section 208 would require VA to
implement a pilot program to provide grants to community-based
organizations and state and local entities that provide
assistance to veterans transitioning to civilian life. The
program would operate in five locations for a period of two
years. VA currently provides similar assistance through Vet
Centers. Vet Centers are community-based counseling centers
that provide free mental health services to combat veterans and
their families. Based on information from VA regarding spending
on Vet Centers, CBO estimates that implementing that program
would cost $6 million over the 2010-2014 period.
Expanded Eligibility for Vet Centers. Section 401 would
allow members of the Armed Forces, including reservists, who
served in OIF/OEF to receive readjustment counseling and
related services through VA's Vet Centers. According to VA
data, there are currently 232 centers nationwide, and they
served roughly 167,000 veterans in 2008. In 2009, Vet Centers
received $185 million in appropriated funds.
Data from the Department of Defense (DOD) on OIF/OEF
deployments indicate that roughly 1.1 million servicemembers
are currently or have previously been deployed and are
nonveterans (that is, they are still on active duty or in the
reserves). After adjusting for expected separations (OIF/OEF
veterans are eligible under current law) and smaller expected
deployments starting in 2011, CBO estimates that of those
remaining, about a third would seek mental health services.
However, DOD indicates that servicemembers are already offered
free counseling similar to that provided through Vet Centers.
Therefore, CBO estimates that about 18,500 servicemembers (5
percent of those seeking mental health services) would use Vet
Centers in 2010 and that the number of users would decline to
about 9,000 in 2014. Using a per person cost of $550 in 2010
(about half the expected cost for veterans, because
servicemembers also have access to free DOD counseling) and
adjusting for annual inflation, CBO estimates that implementing
this provision would cost $36 million over the 2010-2014
period, assuming appropriation of the necessary amounts.
Specialized Residential and Rehabilitation Care. Section
209 would require VA to contract with appropriate entities to
provide specialized care to OIF/OEF veterans whose Traumatic
Brain Injuries (TBI) are so severe that they cannot live
independently and would otherwise require nursing home care.
According to VA, some veterans with TBI but without sufficient
family support or financial means to afford private residential
care often end up in nursing homes that do not provide
appropriate care. Under the bill, VA would place such veterans
in specialized programs that would provide appropriate
residential and rehabilitation care.
Based on information from VA regarding the number of such
veterans and the cost of their care, CBO estimates that in
2010, VA would initially care for 20 veterans with TBI at a
cost of roughly $84,000 per person. After adjusting for
inflation, CBO estimates that over the 2010-2014 period, VA
would pay for care provided to about 50 veterans a year at an
average annual cost of $5 million, and that implementing this
provision would cost $24 million over that period, assuming
appropriation of the necessary amounts.
Studies. Section 211 would require an expanded study on the
health impact of chemical and biological testing conducted by
DOD in the 1960s and 1970s. Based on information from VA
regarding a similar ongoing study, CBO estimates that
implementing this provision would cost about $2 million over
the 2010-2014 period, assuming appropriation of the necessary
amounts.
Section 403 would require VA to conduct a study and report
to the Congress on the number of veterans who died by suicide
between 1997 and the date of enactment of the bill. VA would be
required to coordinate with DOD, veterans service
organizations, the Centers for Disease Control and Prevention,
and state public health offices and veterans agencies. Based on
information from VA, CBO estimates that implementing this
provision would cost $1 million in 2010 and less than $500,000
in 2011, assuming availability of appropriated funds.
Together, CBO estimates that those two studies would cost
$3 million over the 2010-2014 period, assuming appropriation of
the necessary amounts.
Uniforms for Police Officers. Section 702 would double the
uniform allowances payable to about 2,600 department police
officers from $400 for initial purchases and $200 for recurring
purchases to $800 and $400, respectively. CBO estimates that
implementing this provision would cost about $1 million a year
over the 2010-2014 period, assuming availability of
appropriated funds.
Other Provisions. Several sections of the bill, when taken
individually, would have no significant impact on spending
subject to appropriation (most would have costs, but a few
would have savings). Taken together, CBO estimates that
implementing the following provisions would have a net cost of
$1 million a year, assuming availability of appropriated funds:
Sections 201 would repeal a reporting requirement
pertaining to nurses' pay.
Section 202 would modify a reporting requirement
pertaining to Gulf War veterans.
Section 205 would require veterans receiving care
through the department to provide their Social Security number
as well as pertinent information about their coverage through
other health plans. Based on information from VA, CBO estimates
that under the bill the department would be able to better
match patient records with those of the Internal Revenue
Service and the Social Security Administration, and would
collect an additional $100 each from roughly 36,500 veterans.
Those additional collections of $4 million a year would be
retained by the department and spent on medical care and
services.
Section 207 would require annual reports on the
quality of the department's physicians and health care.
Section 210 would allow VA to disclose the names
and addresses of veterans and servicemembers who use VA care to
third-party insurers, so that VA can recover the costs of such
care. Based on a VA field survey, CBO estimates that under the
bill the department would collect an additional $9 million a
year. Those amounts would be retained by the department and
spent on medical care and services.
Section 212 would modify authority granted to VA
under Public Law 110-181 to pay for care provided to veterans
with TBI to conform to how VA is implementing the program under
current law.
Section 306 would require a report on managers of
programs for female veterans.
Section 404 would require VA to transfer $5
million to the Secretary of Health and Human Services for an
education program in psychology.
Direct spending and revenues
Section 701 would enhance the law enforcement authorities
of VA police officers. Because those prosecuted and convicted
under the bill could be subject to criminal fines, the Federal
Government might collect additional fines if the legislation is
enacted. Criminal fines are recorded as revenues, then
deposited in the Crime Victims Fund, and later spent. CBO
expects that any additional revenues and direct spending would
not be significant because of the relatively small number of
cases likely to be affected.
In addition, section 603 would authorize certain VA
research and education facilities to charge fees for education
and training programs. Those fees would be retained and spent
by the facilities, and CBO estimates that enacting this
provision would have no net significant effect on direct
spending.
Intergovernmental and private-sector impact: S.252 contains
no intergovernmental or private-sector mandates as defined in
UMRA. State, local, and tribal governments that provide
assistance to veterans would benefit from grants and other
programs authorized in the bill.
Previous CBO estimate: On June 16, 2009, CBO transmitted a
cost estimate for H.R. 1211, the Women Veterans Health Care
Improvement Act, as ordered reported by the House Committee on
Veterans' Affairs on June 10, 2009. Sections 101, 201, 202, and
203 of H.R. 1211 are similar to sections 301, 309, 304, and 308
of S.252 respectively, as are their estimated costs.
Estimate prepared by: Federal Costs: Sunita D'Monte; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Elizabeth Bass.
Estimate approved by: Theresa Gullo, Deputy Assistant
Director for Budget Analysis.
REGULATORY IMPACT STATEMENT
In compliance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee on Veterans Affairs
has made an evaluation of the regulatory impact that would be
incurred in carrying out the Committee bill. The Committee
finds that the Committee bill would not entail any regulation
of individuals or businesses or result in any impact on the
personal privacy of any individuals and that the paperwork
resulting from enactment would be minimal.
Tabulation of Votes Cast In Committee
In compliance with paragraph 7 of rule XXVI of the Standing
Rules of the Senate, the following is a tabulation of votes
cast in person or by proxy by Members of the Committee on
Veterans' Affairs at its May 21, 2009, meeting. On that date,
the Committee ordered S.252 reported favorably to the Senate by
roll call vote, without dissent. The Committee bill was agreed
to by a 14 to 0 vote.
----------------------------------------------------------------------------------------------------------------
Yeas Senator Nays
----------------------------------------------------------------------------------------------------------------
X (by proxy) Mr. Rockefeller
X Mrs. Murray
X (by proxy) Mr. Sanders
X Mr. Brown
X Mr. Webb
X Mr. Tester
X Mr. Begich
X Mr. Burris
X (by proxy) Mr. Specter
X Mr. Burr
X Mr. Isakson
X (by proxy) Mr. Wicker
X Mr. Johanns
Mr. Graham
X Mr. Akaka, Chairman
----------------------------------------------------------------------------------------------------------------
14 TALLY 0
----------------------------------------------------------------------------------------------------------------
Agency Report
On April 22, 2009, Gerald M. Cross, M.D., Principal Deputy
Under Secretary for Health, Department of Veterans Affairs,
appeared before the Committee and submitted testimony on the
Committee bill. Excerpts of the testimony are reprinted below:
PREPARED STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS
Good Afternoon Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to present the
Administration's views on a number of bills that would affect
Department of Veterans Affairs (VA) programs of benefits and
services. With me today are Walter A. Hall, Assistant General
Counsel and Joleen Clark, Chief Workforce Management and
Consulting Officer for VHA.
* * * * * * *
S.252 ``VETERANS HEALTH CARE AUTHORIZATION ACT OF 2009''
S.252 contains seven separate titles addressing a wide
range of issues including personnel matters, homeless veterans,
nonprofit research and education corporations and many health
care matters including provisions specific to mental health and
women veterans health care. Title I contains several provisions
intended to enhance VA's ability to recruit and retain nurses
and other health-care professionals and set certain standards
for appointment and practice of physicians. These provisions
are virtually identical to those reported in S.2969 from the
110th Congress. We appreciated the opportunity to work with
Committee staff on the prior bill and to provide technical
comments and operational observations. We note that the
reported bill and now Title I of S.252 address many of our
concerns and comments. However, there are several provisions we
cannot support.
Section 101 contains provisions for the enhancement of
authorities for retention of medical professionals.
Secretarial Authority to Extend Hybrid Status to Additional
Occupations Subsection (a) would provide the Secretary
authority to extend hybrid status to additional occupations. It
would add ``nurse assistants'' to the list of so-called hybrid
occupations for which the Secretary is authorized to appoint
and to determine qualifications and rates of pay under title
38. In addition, it would authorize the Secretary to extend
hybrid status to ``such other classes of health care
occupations as the Secretary considers necessary for the
recruitment and retention needs of the Department'' subject to
a requirement to provide 45 days' advance notice to the
Veterans' Affairs Committees and OMB. Before providing such
notice, VA would be required to solicit comments from unions
representing employees in such occupations.
VA favors such a provision. Nursing Assistants are critical
to the Veterans Health Administration's (VHA) ability to
provide care for a growing population of older veterans, who
are high-acuity patients and/or frail elderly requiring 24-hour
nursing care. Turnover data, 11.1 percent for 2007 and 10.96
percent for 2008, illustrate the great difficulty VA
experiences in retaining this occupation. It is increasingly
critical for VHA to be able to quickly and easily employ these
nurse extenders. The same holds true for other hard-to-recruit
health care occupations. This bill would give the Secretary the
ability to react quickly when it is determined that these
authorities would be useful to help recruit and retain a
critical occupation without seeking additional legislative
authority. However, the bill language should be modified to
specifically apply to occupations that clearly involve the
delivery of health care. In addition, because this authority
involves the conversion of title 5 occupations to title 38
hybrids, the 45-day notice requirement should be modified to
add OPM. Thus, we recommend modifying subsection 2(a) of the
bill to read:
(a) Secretarial Authority to Extend Title 38 Status to
Additional Positions.
(1) In general.--Paragraph (3) of section 7401 of title
38, United States Code, is amended by striking ``and
blind rehabilitation outpatient specialists.'' and
inserting in its place the following: ``blind
rehabilitation outpatient specialists, and such other
classes of health care occupations who
(A) are employed in the Administration (other than
administrative, clerical, and physical plant
maintenance and protective services employees);
(B) are paid under the General Schedule pursuant to
section 5332 of title 5;
(C) are determined by the Secretary to be providing
either direct patient care services or services
incident to direct patient-care services; and
(D) would not otherwise be available to provide medical
care and treatment for veterans;
(E) as the Secretary considers necessary for the
recruitment and retention needs of the Department.
(2) Notwithstanding chapter 71 of title 5, United
States Code, the Secretary's authority provided in
paragraph (1) is subject to the following requirements:
``(A) Not later than 45 days before the Secretary
appoints any personnel for a class of health care
occupations that is not specifically listed in this
paragraph, the Secretary shall submit to the Committee
on Veterans' Affairs of the Senate, the Committee on
Veterans' Affairs of the House of Representatives, the
Office of Personnel Management, and the Office of
Management and Budget notice of such appointment.
``(B) Before submitting notice under subparagraph (A),
the Secretary shall solicit comments from any labor
organization representing employees in such class and
include such comments in such notice.''
Probationary Periods for Part-Time Nurses
Subsection (b) provides for probationary periods for part-
time (PT) Registered Nurses (RN) and revises the probationary
period for RNs, both fulltime (FT) and PT, from 2 years to a
maximum of its equivalency in hours, 4180. It also provides
that a PT appointee who previously served on a FT basis in a
``pure'' title 38 position (7401(1)), and completed a
probationary period in the FT position, would not have to serve
a probationary period in the PT ``pure'' title 38 position. VA
opposes this provision. We believe this provision is
technically flawed and would not be helpful.
Part-time title 38 employees, including RNs, do not serve
probationary periods. Probationary periods apply to full-time,
permanent employees. We see no benefit to creating a
probationary period for part-time nurses as these positions are
temporary.
Prohibition on Temporary Part-Time Nurse Appointments In Excess of
4,180 Hours
Subsection (c) would add a new section 7405(g) that would
provide that part-time appointments of RNs are no longer
temporary after no more than 4180 hours. After completion of
the 4180 hours, the RN in essence would be converted to a
permanent employee under section 7403(a) who has completed the
probationary period. VA opposes this provision because it would
impair our ability to adapt to changing demands in patient need
and resource allocations. VA currently has the authority to
create temporary appointments for up to three years. If this
proposal is enacted, VA would lose this valuable flexibility.
VA uses this flexibility to manage positions during periods of
changing patient care needs and budgets. Without this current
flexibility, VA's ability to make adjustments in the size of
our temporary workforce would be limited. VA and its employees
would be put into an untenable dilemma of either preemptively
dismissing employees just prior to the expiration of the their
probationary periods when patient demand justifies their
continued employment or allowing a nurse to convert and retain
employment, even if patient demand no longer justifies that
position. In either scenario, patient care would be placed in
competition with organizational flexibility, while the current
system allows VA to achieve and maintain both.
Reemployed Annuitant Offset Waiver
Subsection (d) generally provides that annuitants may be
temporarily reemployed in a title 38 position without being
subject to having their salary offset by the amount of their
annuity. VA opposes this provision as 5 U.S.C. 8344 and 8468
provide the agency access to retired title 38 health care
providers.
Rate of Basic Pay for Section 7306 Appointees Set to Rate of Basic Pay
for SES
Subsection (e) would amend section 7404(a) to add a
provision setting the basic pay of non-physician/dentist
section 7306 employees in accordance with the rate of basic pay
for the Senior Executive Service (SES). This amendment would be
effective the first pay period that is 180 days after
enactment.
VA supports the principle of pay equity with SES rates for
its section 7306 nonphysician/dentist executives as a tool
needed to meet the challenge of recruitment and retention.
Equity in pay for executive level managers and consultants is
essential to attracting and retaining candidates for key
positions. The pay schedule for 38 U.S.C. Sec. 7306 appointees
is capped at the pay rate for Level V of the Executive Schedule
(currently $143,500). Locality pay is paid up to the rate for
Level III (currently $162,900).
Individuals appointed under 38 U.S.C. Sec. 7306 serve in
executive level positions that are equivalent in scope and
responsibility to positions in the SES. By comparison,
employees in the SES receive a significantly higher rate of
basic pay. The maximum SES pay limitation is the rate for Level
II (currently $177,200) pending OPM certification that the
agency meets all regulatory criteria for certified performance
appraisal systems, including that the employing agency makes
meaningful distinctions based on performance. We estimate the
costs of this provision to be $343,917 in FY 2010 and
$3,765,786 over a 10-year period.
As noted, the SES pay system conditions pay up to EX Level
II on OPM certification that an agency's SES rating system
meets all regulatory criteria for certified performance
appraisal systems. In this regard we note that VHA uses the
same rating system for its section 7306 executives as it uses
for its SES members. OPM has certified this system in the past,
and just last year recertified VA through July 2010. For
consistency, we recommend that the bill be modified to require
that the Secretary make the same certification for the rating
system covering section 7306 employees. Thus, we suggest that
section 101(e)(3) be modified to read as follows:
(3) Positions to which an Executive order applies under
paragraph (1) and are not described by paragraph (2)
shall be paid basic rates of pay in accordance with
section 5382 of title 5 for Senior Executive Service
positions and not greater than the rate of basic pay
payable for level III of the Executive Schedule; or if
the Secretary certifies that the employees are covered
by a performance appraisal system meeting the
certification criteria established by regulation under
section 5307(d), level II of the Executive Schedule.
Comparability Pay Program for Section 7306 and SES Appointees
Subsection (f) would amend section 7410 to add a new
subsection to establish ``comparability pay'' for VHA non-
physician/dentist section 7306 employees and SES employees of
not more than $100,000 per employee in order to achieve annual
pay levels comparable to the private sector. Similar to
provisions for RN Executive Pay in section 7452(g), it would
provide that ``comparability pay'' would be in addition to
other pay, awards and bonuses; would be considered base pay for
retirement purposes; would not be base pay for adverse action
purposes; and could not result in aggregate pay exceeding the
annual pay of the President.
VA supports the concept of comparability pay for its non-
physician/dentist executives. However, we recommend that the
new administration be given an opportunity to review this
matter. Public sector executive pay is dramatically below the
private sector for comparable positions, particularly in the
health care sector. This proposal would allow VA executives to
receive salaries far exceeding executives in other agencies
which also must compete with the private sector. It would be a
potentially precedent-setting departure from the unitary
approach to governmentwide SES pay.
Special Incentive Pay for Department Pharmacist Executives
Subsection (g) would further amend section 7410 to
authorize recruitment and retention special incentive pay for
pharmacist executives of up to $40,000. VA's determination of
whether to provide and the amount of such incentive pay would
be based on: grade and step, scope and complexity of the
position, personal qualifications, characteristics of the labor
market concerned, and such other factors as the Secretary
considers appropriate. As with RN Executive Pay and
comparability pay proposed by subsection (f), this subsection
would provide that ``comparability pay'' would be in addition
to other pay, awards and bonuses; would be considered base pay
for retirement purposes; would not be base pay for adverse
action purposes; and could not result in aggregate pay
exceeding the annual pay of the President.
This provision will provide a retention incentive to about
40 positions: pharmacy benefit managers (PBM), consolidated
mail outpatient pharmacy (CMOP) directors and VISN formulary
leaders (VFL). VA supports this provision. Long-standing,
severe and worsening pay compression exists within the ranks of
senior pharmacy program managers in VHA. A national survey
performed yearly by the American Society of Health System
Pharmacists provides evidence that a similar trend exists in
the private sector. Currently VHA has had extreme difficulty in
recruiting pharmacists for leadership positions. Some examples
include: the VA Medical Center in Bay Pines has not had a
permanent Pharmacy Manager for two years; the VA Medical
Center, Portland, Oregon position has been vacant for one year;
the VA Medical Center, Asheville, NC has been vacant over one
year; and numerous other facilities are experiencing the same
recruiting difficulties. Several other facilities with extended
vacancies that were recently been filled include: the VA
Medical Center, Omaha, NE for two years; VA Medical Center
Dayton, OH for two years; and VA Medical Center, Las Vegas, NV
vacant for one year. The current pay rate that we are able to
pay executives varies minimally from staff pharmacist positions
and therefore is not an incentive to recruit pharmacy
executive/those in leadership roles to VA. This provision will
provide a mechanism to alleviate this compression. VA is still
developing costs for this proposal and will submit them for the
record when they are available.
Physician/Dentist Pay
Subsection (h) concerns physician/dentist pay. VA supports
this provision. Paragraph (1) would provide that the title 5
non-foreign cost of living adjustment allowance for physicians
and dentists would be determined as a percentage of base pay
only. This would clarify the application of the title 5 non-
foreign cost of living adjustment allowance to VHA physicians
and dentists. The VA physician/dentist pay statute, 38 U.S.C.
Sec. 7431, does not address how the allowance is determined
for physicians and dentists. We recommend that this provision
be amended to clarify that it is applicable only to these
physicians and dentists employed at Department facilities in
Alaska, Guam, Hawaii, and Puerto Rico. These are the only
Department facilities to which the title 5 non-foreign cost of
living adjustment allowance is applicable.
Paragraph (2) would amend section 7431 (c)(4)(B)(i) to
exempt physicians and dentists in administrative or executive
leadership provisions from the panel process in determining the
amount of market pay and pay tiers for such physicians and
dentists. In situations where physicians or dentists occupy
these leadership positions as chief officers, network
directors, and medical center directors, the consultation of a
panel has some limitations. The small number of physicians and
dentists who would qualify as peers for these leaders results
in their serving on each other's compensation panels and, in
some cases, on their supervisor's panel. Providing the
Secretary with discretion to identify administrative or
executive physician/dentist positions that may be excluded from
the panel process would resolve these issues.
Paragraph (3) would provide an exception to the prohibition
on the reduction of market pay for changes in board
certification or reduction of privileges correcting an
oversight in the recent revision of the physician/dentist pay
statute. This modification would allow VA to address situations
where there is a loss of board certification or an adverse
reduction in clinical privileges. No costs are associated with
this provision.
RN and CRNA Pay
Subsections (i) and (j) relate to RN and Certified
Registered Nurse Anesthetist (CRNA) Pay. Subsection (i) would
amend the current cap for registered nurse from EL V to EL IV.
VA supports this provision. This would increase the cap from
level V to level IV for both RNs and CRNAs, consistent with the
pay cap that applies to the GS locality pay system. We note
that subsection (i) would obviate the need for subsection (j)
as the two pay scales affected are already tied to each other.
We estimate the cost of this provision to be $6.16 million for
FY 2010 and $72.31 million over a 10-year period.
Subsection (k) would make amendments to the RN locality pay
system (LPS). These provisions are not helpful and are
unnecessary. No costs are associated with this provision.
Paragraph (1) would require the Under Secretary for Health
to provide education, training, and support to VAMC directors
in the ``conduct and use'' of LPS surveys, including third
party surveys. Paragraph (2) would require the annual report
VAMCs must provide to VA Central Office to include the
methodology for every schedule adjustment. These reports form
the basis for the annual VA report to Congress. We are
concerned that this provision, especially in conjunction with
proposed paragraph 3, could result in the inappropriate
disclosure of confidential salary survey data, contrary to
current section 7451 (d)(5). It also would impose an onerous
burden inasmuch as VHA has nearly 800 nurse locality pay
schedules. We do note that VA policy does provide for how these
surveys are to be obtained or conducted. Paragraph (3) would
require the most recent VAMC report on nurse staffing to be
provided to any covered employee or employee's union
representative upon request. This provision should be modified
to specify at what point the report must be provided. It would
not be appropriate to provide an individual a copy of the VAMC
report before Congress receives the VA report.
Subsection (I) would increase the maximum payable for nurse
executive special pay to $100,000. This provision would make
the amount of nurse executive pay consistent with the Executive
Comparability Pay proposed in section 2(f) of this bill.
However, special pay of this amount would allow VA nurse
executives to receive salaries far exceeding executives in
other agencies that also must compete with the private section
and there is no evidence that such levels of pay are necessary.
Thus, VA opposes this provision.
The caption for subsection (m) suggests it provides for
eligibility of part-time nurses for certain nurse premium pay.
However, many of the substantive amendments are not limited to
part-time nurses, or to all registered nurses.
VA opposes subsection (m) as it has serious technical
flaws, is unnecessary, and is costly.
Subparagraph (1)(A) would amend section 7453 (a) to make
part-time nurses eligible for premium pay under that section.
However, part-time nurses already are eligible for section 7453
premium pay where they meet the criteria for such pay.
Subparagraphs (1)(B) and (1)(C) would require evening tour
differential to be paid to all nurses performing any service
between 6 pm and 6 am, and any service on a weekend, instead of
just those performing service on a tour of duty established for
those times to meet on-going patient care needs. Under current
law, these differentials are limited to the RN's normal tour of
duty and any additional time worked on an established tour.
The ``tour of duty'' requirement in the current law is
intended to ensure adequate professional care and treatment to
patients during off and undesirable tours. The limitation of
tour differential and weekend pay only for service on a ``tour
of duty'' rewards those employees who are subject to regular
and recurring night and weekend work requirements. If that is
changed to ``period of service'', any employees performing
night or weekend work on an occasional or ad-hoc basis would
also be entitled to this premium pay in addition to overtime
pay, providing an inappropriate windfall for performing
occasional work.
Subparagraph (2) would authorize title 5 VHA employees to
receive 25 percent premium pay for performing weekend work on
Saturday and Sunday. We understand the purpose of this
provision is to limit the expansion of weekend premium pay to
non-tour hours to registered nurses. However, it does not fully
achieve that purpose. Pursuant to section 7454(a) and (b)(2),
physician assistants, expanded-function dental auxiliaries, and
hybrids are also entitled to weekend pay under section 7453.
The expansion of weekend pay proposed in this subparagraph
would apply to them as well. In addition, because physician
assistants and expanded-function dental auxiliaries are
entitled to all forms of registered nurse premium pay under
section 7453, the expansion of the night differential premium
pay also would apply to them. Furthermore, where VA has
authorized section 7453 night differential for hybrids, the
expansion of the night differential premium pay would apply to
them as well.
Subsection (n) would add additional occupations to the
exemption to the 28th step cap on title 38 special salary
rates: LPNs, LVNs, and unspecified ``other nursing positions
otherwise covered by title 5''. Notwithstanding the exemption,
under current statute, title 38 special salary rates cannot
exceed the rate for EL V. It is not clear what positions
``nursing positions otherwise covered by title 5'' would
include. RNs are appointed under title 38, LPNs/LVNs are
hybrids, and section 101(a)(2) of the bill would convert
nursing assistants to hybrid. Moreover, it is not apparent why
only these positions and not all positions authorized title 38
special rates would be exempted. Using the same formula for the
cap on title 5 special rates would afford VA the most
flexibility in establishing maximum rates for title 38 special
rates. We also note that adopting the title 5 fixed-percentage
formula would render unnecessary the section 7455(c)(2) report
for exceeding 94 percent of the grade maximum and, so, propose
deleting it.
Thus we recommend amending section 7455 to read as follows:
(a)(1) Subject to subsections (b), (c), and (d), when
the Secretary determines it to be necessary in order to
obtain or retain the services of persons described in
paragraph (2), the Secretary may increase the minimum
rates of basic pay authorized under applicable statutes
and regulations, and may make corresponding increases
in all rates of the pay range for each grade. Any
increase in such rates of basic pay----
* * * * * * *
(c) The amount of any increase under subsection (a) in
the minimum rate for any grade may not exceed the
maximum rate of basic pay (excluding any locality-based
comparability payment under section 5304 of title 5 or
similar provision of law) for the grade or level by
more than 30 percent, and no rate may be established
under this section in excess of the rate of basic pay
payable for level IV of the Executive Schedule.
VA's concerns that pay setting authorized by this provision
may be subject to collective bargaining are discussed in
conjunction with S.362.
Section 102(a)(1) would add new section 7459, imposing
restrictions on nurse overtime. Section 7459 generally would
prohibit mandatory overtime for nurses (RNs, LPNs, LVNs,
nursing assistants, and any other nurse position designated by
the Secretary). It would permit mandatory overtime by nurses
under certain conditions: an emergency that could not have been
reasonably anticipated; the emergency is non-recurring and not
due to inattention or lack of reasonable contingency planning;
VA exhausted all good faith, reasonable attempts to obtain
voluntary workers; the affected nurses have critical skills and
expertise; and the patient work requires continuity of care
through completion of a case, treatment, or procedure. VA could
not penalize nurses for refusing to work prohibited mandatory
overtime. Section 7459 provides that nurses may work overtime
hours on a voluntary basis.
VA favors this mandatory overtime restriction with the
caveat that first and foremost, VA needs to be able to mandate
overtime where issues of patient safety are identified by
facility leadership. We note VAMCs currently have policies
preventing RNs from working more than 12 consecutive hours and
60 hours in a 7-day period pursuant to section 4(b) of Pub. L.
108-445.
Section 102(b) would amend 38 U.S.C. 7456 (the ``Baylor
Plan''), which authorizes VA to allow nurses who perform two
12-hour regularly scheduled tours of duty on a weekend to be
paid for 40 hours. This work-scheduling practice typically
would be used when facilities encounter significant staffing
difficulties caused by similar work scheduling practices in the
local community. It would delete current section 7456(c), the
current Baylor Plan requirement, which provides for a 5-hour
leave charge for each 3 hours of absence that reflects the
relative value of the truncated Baylor tour, in effect
increasing the value of leave for affected employees.
Currently, VA has only one employee working on the Baylor Plan.
VA opposes this provision as providing an unwarranted windfall.
Section 102(c) would amend section 7456A to change the 36/
40 alternate work schedule to a 72/80 alternate work schedule,
so that under the schedule six 12-hour ``periods of service''
anytime in a pay period would substitute for three ``12-hour
tours of duty'' in each week of the pay period. Similar changes
would be made to section 7456A's overtime, premium pay and
leave provisions.
VA is experiencing planning problems with the use of the
current 36/40 schedule. The problem stems from the 36/40
language requiring three 12-hour tours in a work week and
because VA defines ``work week'' as Sunday to Saturday. The
problem occurs because the work week requirement prevents
scheduling one of the 12-hour tours over two different weeks,
e.g., 6PM Saturday to 6AM Sunday. Changing ``work week'' to
``pay period'' only makes the problem occur every 2 weeks
instead of every week, so we do not view that as helpful. We do
support changing the 36/40 alternate work schedule to a 72/80
alternate work schedule, so that the six 12-hour tours can
occur anytime in a pay period, providing more work scheduling/
planning flexibility. We would be glad to provide appropriate
bill language.
Section 103 would make amendments to VA's Education
Assistance Programs. VA supports these proposals. Section
103(a) would amend section 7618 to reinstate the Health
Professionals Educational Assistance Scholarship Program
through the end of 2014. The program expired in 1998. The
Health Professional Scholarship Program would help reduce the
nursing shortage in VA by obligating scholarship recipients to
work for 2 years at a VA health care facility after graduation
and licensure. This proposal would also expand eligibility for
the scholarship program to all hybrid occupations. This would
be helpful in recruiting and retaining employees in the several
hard-to-fill hybrid occupations. We are still determining costs
for this provision and will forward them to the Committee as
soon as they are available.
Section 103(b) would make certain amendments to the
Education Debt Reduction Program. It would amend section
7681(a)(2) to add retention as a purpose of the program and
amend section 7682(a)(1) to make it available to ``an''
employee, in lieu of ``recently appointed.'' It would also
increase the authorized statutory amounts in section 7683 to
$60,000 and $12,000, respectively.
The ``recently appointed'' requirement limits eligibility
to employees who have been appointed within six months. VA's
experience has been that this is not a sufficient period. In
several instances, employees applying just missed the six-month
deadline. In many cases it takes more than six months for
employees to become aware of this very helpful recruitment and
retention program. This proposal offers greater flexibility to
VA in applying the program. VA also supports the increased
amounts in light of increased education costs since the program
was enacted. We note this program can be implemented in a cost-
neutral fashion.
Section 103(c) would authorize VA researchers from
``disadvantaged backgrounds'' to participate in a loan
repayment program that the VA may establish using the Public
Health Service Act authorities for the NIH Loan Repayment
Program. We agree that loan repayment incentives would be
helpful to clinicians with medical specialization and research
interests who might consider career clinical care or clinical
research opportunities relating to the work of VHA.
Section 104 is nearly identical to S.246, Section 2(a),
which I have previously discussed.
Section 201 would eliminate two reporting requirements: the
Nurse Pay Report and the Long-Term Planning Report. VA supports
this provision. There would be no discernible cost savings
associated with this provision. Similarly, VA supports Section
202 to amend the Persian Gulf War Veterans' Health Status Act
to change the due date of the annual report to Congress from
March 1 to July 1. This change would have no impact on cost.
VA also supports Section 203. Section 203 will provide
clarification of the legal authority beyond the existing
regulations that will prevent providers from collecting from
the beneficiary any amounts in excess of the CHAMPVA determined
allowable amount. VA favors this provision. There would be no
significant cost to VA.
Section 204, relating to payer provisions for care
furnished to certain children of Vietnam Veterans, has been
made moot by the passage of Pub. L. 110-387, Section 408,
``Spina Bifida Comprehensive Health Care.''
VA strongly supports Section 205 of S.252, which would
permit VA health care practitioners to disclose the relevant
portions of VA records of the treatment of drug abuse,
alcoholism and alcohol abuse, infection with the human
immunodeficiency virus, and sickle cell anemia to surrogate
decisionmakers who are authorized to make decisions on behalf
of patients who lack decisionmaking capacity, but to whom the
patient had not specifically authorized release of that legally
protected information prior to losing decisionmaking capacity.
This provision would only permit such a disclosure when the
practitioner deems the content necessary for the representative
to make an informed decision regarding the patient's treatment.
This provision is critical to ensure that a patient's surrogate
has all the clinically relevant information needed to provide
full and informed consent with respect to the treatment
decisions that the surrogate is being asked to make.
Section 206 would authorize VA to require that applicants
for, and recipients of, VA medical care and services provide
their health-plan contract information and social security
numbers to the Secretary upon request. It would also authorize
VA to require applicants for, or recipients of, VA medical care
or services to provide their social security numbers and those
of dependents or VA beneficiaries upon whom the applicant or
recipient's eligibility is based. Recognizing that some
individuals do not have social security numbers, the provision
would not require an applicant or recipient to furnish the
social security number of an individual for whom a social
security number has not been issued. Under this provision, VA
would deny the application for medical care or services, or
terminate the provision of, medical care or services, to
individuals who fail to provide the information requested under
this section. However, the legislation authorizes the Secretary
to reconsider the application for, or reinstate the provision
of, care or services once the information requested under this
section has been provided. Of note, this provision makes clear
that its terms may not be construed to deny medical care and
treatment to an individual in a medical emergency.
Given the significant privacy concerns related to this
provision, we defer views until further analysis can be made
and the new administration is given an opportunity to review
this matter.
Section 207 addresses quality management in VA facilities
and establishes quality management officer positions at the
national, VISN and facility level. Section 207 is similar to
S.246, Section 3, although the position established is termed
``Quality Management Officer'' (QMO), and there is no
stipulation that the position be filled by a board-certified
physician. Section 207 would require the QMO to be responsible
for and undertake specific actions to carry out VHA's quality
management program. Section 207 additionally would require the
National QMO to assess quality of care by developing an
aggregate quality metric from existing data sources, monitoring
and analyzing existing measures of quality, and encouraging
research and development in the area of quality metrics.
Section 207 would authorize appropriations necessary to carry
out the quality management program, including $25,000,000 for
the quality metric provisions during the 2 fiscal year period
following enactment. Mr. Chairman, we support the intent of
these provisions, that is enhancing VA's quality management
programs, and have already undertaken actions to achieve many
of the same goals. We would welcome the opportunity to meet
with the Committee to discuss recent actions we have undertaken
to improve the quality of care across the system, including
program oversight related measures.
Section 208 requires submission of an annual report to
Congress describing progress toward implementing provisions of
Sections 104 and 207. VA has no objection to this requirement
and, in fact, supports the concept of transparency in health
care. We note that a comprehensive Hospital Quality Report was
prepared by the Department in 2008 and is updated annually.
We estimate that the requirement that the VISN Director
review all information needed for physician appointment would
require an additional FTEE (GS 14) at the VISN level. We also
estimate that the appointment of a board-certified physician to
serve as QAO at the facility and network levels would require
162 physicians for 141 medical staffs and 21 networks. We
estimate salary and benefits costs for each QAO to be
approximately $200,000 (actual will vary according to
specialty, time commitment, and local market factors). We
estimate total costs for a FTE MD QAO and FTE VISN coordinator
to be $35.10 million in the first year, $188.05 million over
five years, and approximately $413.22 million over 10 years. We
estimate that salaries plus benefits for the new positions will
include a 4% increase in costs for each subsequent year.
Section 209 would require the Secretary to conduct a pilot
program, in collaboration with the Secretary of Defense, to
assess the feasibility of training and certifying family
caregivers to be personal care attendants for veterans and
members of the of the Armed Forces suffering from TBI. The
pilot program would be conducted at three VA medical centers
and, if determined appropriate, at one DOD medical center. VA
would be required to determine the eligibility of a family
member to participate in the pilot programs, and such a
determination would have to be based on the needs of the
veteran or servicemember as determined by the patient's
physician. The training curricula would be developed by VA and
include applicable standards and protocols used by
certification programs of national brain injury care specialist
organizations and best practices recognized by caregiver
organizations. Training costs would be borne by VA, with DOD
required to reimburse VA for the costs of training family
members of servicemembers. Family caregivers certified under
this program would be eligible for VA compensation and may
receive assessments of their needs in the role of caregiver and
referrals to community resources to obtain needed services.
VA does not support section 209. Currently, we are able to
contract for caregiver services with home health and similar
public and private agencies. The contractor trains and pays
them, affords them liability protection, and oversees the
quality of their care. This remains the preferable arrangement
as it does not divert VA from its primary mission of treating
veterans and training clinicians. Moreover, it does not put VA
in the position of having to tell family members how, at the
risk of losing their caregiver compensation, they have to care
for their loved ones. If enacted, we estimate the cost of the
three-year pilot to be $178.4 million.
Section 210 would require VA, in collaboration with DOD, to
carry out a pilot program to assess the feasibility of
providing respite care to family caregivers of servicemembers
and veterans diagnosed with TBI, through the use of students
enrolled in graduate education programs in the fields of mental
health or rehabilitation. Students participating in the program
would provide respite relief to the servicemember's or
veteran's family caregiver, while also providing socialization
and cognitive skill development to the servicemember or
veteran. VA would be required to recruit these students, train
them in the provision of respite care, and work with the heads
of their graduate programs to determine the amount of training
and experience needed to participate in the pilot program.
VA does not support section 210. Individuals providing
respite care do not require advanced degrees, only appropriate
training. Respite care does not require specialized skills, and
its functions are not applicable to curricula objectives in the
graduate degree programs related to mental health or
rehabilitation that we are aware of. Further, section 210 would
require VA to use graduate students in roles that are not
permissible under academic affiliation agreements, and we have
serious doubts this proposal would be acceptable to graduate
schools.
Moreover, VA has a comprehensive respite care program. We
also have specialized initiatives underway for TBI patients to
reduce the strain on their caregivers, which overlap with this
bill. We also provide respite care by placing the veteran in a
local VA facility for the duration of the respite period.
Veterans may receive up to 30 days of respite care per year. We
estimate the costs of conducting the pilot program to be $3.5
million in the first year and approximately $11.4 million over
five years.
Section 211 would require the Secretary to carry out a two-
year pilot grant program (at five locations selected by the
Secretary) to assess the feasibility of using community-based
organizations and local and State government entities to
increase the coordination of VA benefits and services to
veterans transitioning from military service to civilian life,
to increase the availability of medical services available to
these veterans, and to provide their families with their own
readjustment services. Grantees could use grant funds for
purposes prescribed by the Secretary.
VA opposes section 211 because it is duplicative of the
Department's on-going efforts. Vet Centers are already
providing many of the services contemplated by this provision.
Additionally, VA case managers and Federal recovery
coordinators already coordinate the delivery of health care and
other VA services available to veterans transitioning from
military service to civilian life, including supportive
services for their families. VA is committing ever increasing
resources to these ends. The duplicated efforts required by the
bill would likely create significant confusion for the
beneficiary.
To the extent the Secretary determines external resources
are necessary to provide the services described in the bill, VA
already has the necessary authority to contract for them. We
favor using contracts instead of grants, as the former allow VA
to respond to changing local needs and assure the quality of
services provided. That approach also gives us an accurate way
to project the cost of the services. This provision, on the
other hand, would not. It would also not be cost-effective as
it is likely that a grant awarded under the program would be
for an amount significantly less than the cost VA incurs in
administering the grant. We also note the bill would not
include authority for VA to recapture unused grant funds in the
event a grantee fails to provide the services described in the
grant.
Although the proposed pilot project is limited to five
locations, the bill does not specify the number and amount of
the grants to be awarded. We are unable to estimate the cost of
this provision due to the lack of specificity.
Section 212 would authorize VA to contract for specialized
residential care and rehabilitation services for veterans of
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/
OIF) who: (1) suffer from Traumatic Brain Injury, (2) have an
accumulation of deficits in activities of daily living and
instrumental activities of daily living that affects their
ability to care for themselves, and (3) would otherwise receive
their care and rehabilitation in a nursing home. These veterans
do not require nursing home care, but they generally lack the
resources to remain at home and live independently; this
represents an extremely small subset of the OEF/OIF population.
In fact, for FY 2010, VA estimates only 10 veterans would
qualify and participate in this program. Age appropriate day
health and other community programs, VA's home based primary
care, and medical foster homes will be expanded to provide
these Veterans with long-term specialized rehabilitation
services. VA supports this legislation as it would enable us to
provide these veterans with long-term rehabilitation services
in a far more appropriate treatment setting than we are
currently authorized to provide. VA estimates the discretionary
cost of section 212 to be $923,000 for the first year, $12.2
million over five years, and $76.8 over ten years.
Section 213 would amend sections 5701 and 7332 of title 38,
United States Code. The amendments would authorize VA to
disclose individually-identifiable patient medical information
without the prior written consent of a patient to a third-party
health plan to collect reasonable charges under VA collections
authority for care or services provided for a non-service-
connected disability. The section 5701 amendment would
specifically authorize disclosure of a patient's name and
address information for this purpose. The section 7332
amendment would authorize disclosure of both individual
identifier information and medical information for purposes of
carrying out the Department's collection responsibilities.
Given the significant privacy concerns related to this
provision, we defer views on this section until further
analysis can be made and the new administration is given an
opportunity to review this matter.
Section 214 would require VA to enter into a contract with
the Institute of Medicine of the National Academies to conduct
an expanded study on the health impact of Project Shipboard
Hazard and Defense (Project SHAD). VA opposes this proposal.
The 2007 four-year, $3.8 million, VA-sponsored study by the
National Academies of Sciences (NAS) ``Long-Term Health Effects
of Participation in Project SHAD'' represented an exhaustive
effort to locate and evaluate the health of every living or
deceased SHAD veteran. That study found little or no long-term
health effects linked to SHAD participation, and spending
additional resources with the hope that possibly tracking down
a small number of additional SHAD veterans might significantly
change those results is unrealistic. We have been assured by
the NAS group who conducted the original study that they have
spared no effort in tracking down every SHAD participant as
part of their study. We estimate that such a study would cost
$2.5 million.
When VA is providing inpatient or outpatient care for a
patient with Traumatic Brain Injury, VA is required to develop
an individual plan for the veteran or servicemember. In
implementing such plans, 38 U.S.C. Sec. 1710E authorizes the
Secretary to provide hospital care and medical services through
cooperative agreements with appropriate public or private
entities that have established long-term neurobehavioral
rehabilitation and recovery programs. Section 215 would amend
this authority by defining covered individuals as
servicemembers or veterans receiving inpatient or outpatient
rehabilitative hospital care or medical services for Traumatic
Brain Injury to whom the Secretary is unable to provide
treatment or services at the frequency or for the duration
described in the plan, or for whom the Secretary determines
such care is optimal. This provision would also require that
facilities participating in such cooperative agreements
maintain standards for the provision of treatment or services
that have been established by an independent, peer-reviewed
organization that accredits specialized rehabilitation programs
for adults with Traumatic Brain Injury.
VA supports this provision but recommends that the plan
referenced in this provision be described as the VA
Individualized Rehabilitation and Reintegration Plan developed
in accordance with section 1710C. Further, the bill as
currently drafted states that the Secretary may not provide
treatment or services at the non-VA facility unless the
facility ``maintains standards for the provision of such
treatment or services established by an independent, peer-
reviewed organization that accredits specialized rehabilitation
programs for adults with Traumatic Brain Injury.''
Section 216 would include federally recognized tribal
organizations in certain State home programs. Specifically,
section 216(a) would authorize VA to treat a health facility or
certain beds in a health facility of a tribal organization as a
State nursing home for veterans. This would allow VA to pay per
diem to the organization for the nursing home care of veterans
in the home. The home would be required to meet the existing
standards for State homes and such other standards as VA
requires. In addition, the organization would have to
demonstrate that, but for treatment in the home, a substantial
number of veterans residing in the area would not have access
to nursing home care, and the Secretary would have to determine
that treatment of the facility or beds as a State home would
best meet the needs of veterans for nursing home care in the
area. Finally, tribal organizations would be subject to
limitations on the number of beds that could receive per diem
under this provision.
VA opposes Section 216(a). It would be very difficult to
maintain a critical mass of staff with expertise in the care of
frail, elderly patients in such a setting. Moreover, this would
duplicate the function of the existing Community Nursing Home
Program under which VA can pay for the care of Veterans placed
in nursing homes in the private sector. VA contracts with more
than 4,500 community nursing homes nationally and can add more
as needed to assure Veterans' access to care.
Section 216(b) would authorize VA to award grants to tribal
organizations for the construction or acquisition of state
homes in the same manner and under the same conditions as
grants awarded to States subject to exceptions prescribed by VA
to take into account the unique circumstances of tribal
organizations. This provision would require VA to give priority
to grant applications from tribal organizations that had not
previously applied for a grant even if the State in which the
tribal organization was located had previously applied for (or
received) a grant.
VA also opposes Section 216(b). The proposal would
disenfranchise the states for which the construction grant
program was expressly established since priority for awarding
of grants is prescribed in statute and regulation. The first
priority is for renovations necessary to protect the lives and
safety of Veterans residing in the home. The second priority is
for grants to states, or under this provision, tribal entities,
that have never previously received a grant from this program.
Since every state has received a grant and no tribal entity
ever has, all construction and renovation applications from
tribes would take precedence over all applications from states,
except for life safety grants, until all tribal entities that
wished to submit applications had done so. Since there are more
500 recognized tribal entities, it could be years before states
are again able to receive grants other than life safety grants,
and even then they would have to compete with more than 500
eligible applicants instead of the 50 states and a few
territories now eligible for the grants. The radical change
being proposed would be detrimental to the states for which
this program was specifically established.
VA estimates the cost of Section 216 to be $2.6 million for
the first year, $14.2 million over five years, and $31.5
million over ten years.
Section 217 would require the Secretary to carry out a
pilot program to assess the feasibility and advisability of
providing a dental insurance plan to veterans enrolled for VA
health care pursuant to section 1705 of title 38 and survivors
or dependants enrolled for care under section 1781 of title 38
(CHAMPVA). Under this plan, VA would manage and administer a
group dental plan. VA opposes section 217 as this provision
would establish an entirely new and dramatically different role
for VA.
Section 301 of this bill corresponds to section 101 of
S.597, another bill on today's agenda. This section would
require VA to contract with a qualified independent entity or
organization to carry out a comprehensive assessment of the
barriers encountered by women veterans seeking comprehensive
health care from VA, building on the VA's own ``National Survey
of Women Veterans in Fiscal Year 2007-2008'' (National Survey).
Many requirements related to sample size and the scope of the
survey would apply to the conduct of the assessment. Section
301 would also require the contractor-entity to conduct
research on the effects of the following concerns on the study
participants:
The perceived stigma associated with seeking
mental health care services.
The effect of driving distance or availability of
other forms of transportation to the nearest appropriate VA
facility on access to care.
The availability of child care.
The acceptability of integrated primary care, or
with women's health clinics, or both.
The comprehension of eligibility requirements for,
and the scope of services available under, such health care.
The perception of personal safety and comfort of
women veterans in inpatient, outpatient, and behavioral health
facilities of the Department.
The gender sensitivity of health care providers
and staff to issues that particularly affect women.
The effectiveness of outreach for health care
services available to women veterans.
The location and operating hours of health care
facilities that provide services to women veterans.
Such other significant barriers identified by the
Secretary.
Additionally, section 301 would require the Secretary to
ensure that the heads of the Center for Women Veterans and the
Advisory Committee on Women Veterans review the results of the
comprehensive assessment and submit their own findings with
respect to it to the Under Secretary for Health and other VA
offices that administer health care benefits to women veterans.
The results of our National Survey will not be available
until later in the fiscal year. Consequently, we do not think
it feasible to enter into a contract for the mandated
assessment and research until we have first had a chance to
complete and fully analyze the results of the National Survey.
Only in this way can the assessment and research adequately
build on the National Survey and reliably augment, rather than
duplicate, VA's efforts in this area. We estimate the cost of
section 101 to be $3.5 million.
The next section, section 302, corresponds to section 201
of S.597 and requires VA to develop a plan to improve the
provision of health care services to women veterans. VA fully
supports the evaluation and enhancement of care to women
veterans and initiated a planning and implementation program in
September 2008. Consequently, this provision is unnecessary as
the initiative is already underway.
Section 303 of S.252 corresponds to section 102 of S.597.
This section would require VA to enter into a contract with an
entity or organization to conduct a very detailed and
comprehensive assessment of all VA health care services and
programs provided to women veterans at each VA facility. The
assessment would have to include VA's specialized programs for
women with PTSD, homeless women, women requiring care for
substance abuse or mental illnesses, and those requiring
obstetric and gynecologic care. It would also need to address
whether effective health care programs (including health
promotion and disease prevention programs) are readily
available to, and easily accessed by, women veterans based on a
number of specified factors.
After the assessment is performed, the bill would require
VA to develop an extremely detailed plan to improve the
provision of health care services to women veterans, taking
into account, among other things, projected health care needs
of women veterans in the future and the types of services
available for women veterans at each VA medical center. VA
would then be required to report to Congress on the assessment
and plan, including any administrative or legislative
recommendations VA deems appropriate. What is unclear in the
bill is whether the contractor-entity conducting the assessment
would also be required to develop the follow-up ``plan,'' as
the terms of section 303 refer to the contractor's conduct of
``studies and research'' required by that section. VA supports
section 303 only if the development of the mandated plan would
be conducted by a contractor-entity. We estimate the total
costs of this section to be $4,354,000 during the period of
Fiscal Year 2010 through Fiscal Year 2012.
Section 304 corresponds to section 202 of S.597. This
provision would require the Secretary to establish a program
for education, training, certification and continuing medical
education for VA mental health professionals furnishing care
and counseling services for military sexual trauma (MST). VA
would also be required to determine the minimum qualifications
necessary for mental health professionals certified under the
program to provide evidence-based treatment. The provision
would establish extremely detailed reporting requirements. VA
would also have to establish education, training,
certification, and staffing standards for VA health care
facilities for full-time equivalent employees who are trained
to provide MST services.
We do not support the training-related requirements of
section 304 because they are duplicative of existing programs.
In FY 2007, VA funded a Military Sexual Trauma Support Team,
whose mission is, in part, to enhance and expand MST-related
training and education opportunities nationwide. VA also hosts
an annual four-day long training session for 30 clinicians in
conjunction with the National Center for PTSD, which focuses on
treatment of the after-effects of MST. VA also conducts
training through monthly teleconferences that attract 130 to
170 attendees each month. VA has recently unveiled the MST
Resource Homepage, a webpage that serves as a clearinghouse for
MST-related resources such as patient education materials,
sample power point trainings, provider educational
opportunities, reports of MST screening rates by facility, and
descriptions of VA policies and benefits related to MST. It
also hosts discussion forums for providers. In addition, VA
primary care providers screen their veteran-patients,
particularly recently returning veterans, for MST, using a
screening tool developed by the Department. We are currently
revising our training program to further underscore the
importance of effective screening by primary care providers who
provide clinical care for MST within primary care settings.
We object strongly to section 304's requirement for
staffing standards. Staffing-related determinations must be
made at the local level based on the identified needs of the
facility's patient population, workload, staffing, and other
capacity issues. Retaining this flexibility is essential to
permit VA and individual facilities to respond to changing
needs and available resources. Imposition of national staffing
standards would be an inefficient and ineffective way to manage
a health care system that is dynamic and experiences continual
changes in workload, utilization rates, etc.
Section 305 would require VA, not later than six months
after the date of enactment, to conduct a pilot program to
evaluate the feasibility of providing reintegration and
readjustment services in a group retreat setting to women
veterans recently separated from service after a prolonged
deployment. Participation in the pilot would be at the election
of the veteran. Services provided under the pilot would
include, for instance, traditional VA readjustment counseling
services, financial counseling, information on stress
reduction, and information and counseling on conflict
resolution.
We are unclear as to the purpose of and need for this
provision. The term ``group retreat setting'' is not defined,
but we assume it could not include VA medical facilities or Vet
Centers, as we could not limit Vet Center access to any one
group of veterans. Moreover, it is important to note that many
Vet Centers are already well designed to meet the individual
and group needs of women veterans. We estimate that the cost of
the pilot would be around $300,000.
Section 306 mandates a report to Congress to ensure that
health care needs of women are met and to assess whether there
is at least one full-time Women Veterans Program Manager
employed at each VAMC. This section is substantially similar to
section 103 of S.597. The report shall include an assessment of
whether there is at least one full-time employee at each VA
medical center who is a full-time women veterans program
manager. VA does not oppose this provision but we believe it is
unnecessary. VA is already reporting regularly on the
employment of Women Veteran Program Managers. To date, 137 of
the 144 positions have been filled as full-time employees. No
additional funds would be required to submit this report.
Next, section 307 (and the corresponding provision in
S.597, section 204) would require the Department's Advisory
Committee on Women Veterans, created by statute, to include
women veterans who are recently separated veterans. It would
also require the Department's Advisory Committee on Minority
Veterans to include recently separated veterans who are
minority group members. These requirements would apply to
committee appointments made on or after the bill's enactment.
We fully support section 307. These amendments would help both
Committees to better identify and address the needs of their
respective veteran-populations.
Section 308 would require the Secretary, commencing not
later than six months after the date of enactment, to carry out
a two-year pilot program, at no fewer than three VISN sites, to
pay veterans the costs of childcare they incur to travel to and
from VA facilities for regular mental health services,
intensive mental health services, or other intensive health
care services specified by the Secretary. The provision is
gender-neutral. Any veteran who is a child's primary caretaker
and who is receiving covered health care services would be
eligible to participate in the pilot program. The corresponding
provision is in section 205 of S.597.
VA is very cognizant of the veterans' needs for convenient
access to health care; however, we oppose section 308 as this
expansion would divert resources from direct medical care.
We support section 309, which would authorize VA to furnish
health care services up to seven days after birth to a newborn
child of a female veteran who is receiving maternity care
furnished by VA if the veteran delivered the child in a VA
facility or in another facility pursuant to contract for
service related to such delivery. This provision corresponds to
section 206 of S.597. We estimate that the cost would be $55.3
million the first year, $293.6 million over five years, and
approximately $589.4 over ten years.
VA supports Section 401, which would make members of the
Armed Forces who serve in Operation Enduring Freedom or
Operation Iraqi Freedom eligible for counseling and services
through Readjustment Counseling Service, but we are concerned
with the precedent that would be established by providing
disparate eligibility to veterans of different conflicts. Under
this provision active duty combat veterans of OEF/OIF would
have access to Vet Centers for counseling and related mental
health services and behavioral health services, including
substance abuse assessment, counseling, and referral. Active
duty veterans of the Persian Gulf War or other prior or
subsequent combat would not have access to those services.
Providing these services to active duty OEF/OIF personnel would
cost approximately $3.7 million in the first year, $19.8 over
five years, and $44.1 million over ten years. DOD has
reimbursed VA for services provided to active duty members;
however, we have not yet discussed the funding of this
provision or possible reimbursement rates with DOD for
readjustment counseling services.
Until 1996, VA had specific statutory authority to refer
ineligible veterans to non-VA resources and to advise such
individuals of the right to apply for review of the
individual's discharge or release. VA supports Section 402,
which would reinstate these provisions. Reinstatement of these
provisions would give the Vet Centers the latitude to help
Veterans with problematic discharges with problems deemed by
Vet Center staff to be related to war trauma, through referral
to services outside the VA and/or referral for assistance with
discharge upgrades when appropriate. The total number of
Veterans this provision would affect is assumed to be small so
the costs of this provision would be negligible.
VA opposes Section 403, requiring VA to conduct a study to
determine the number of Veterans who have committed suicide
between January 1, 1997, and the date of the bill's enactment.
VA opposes conducting the study because other information, more
valuable in guiding VA's strategy for suicide prevention, is
already available and is continually being refined through
other research and data collection efforts. Moreover, we do not
believe that the new requirement would yield any additional
information of significant value.
Rates and counts of deaths from suicide are available from
2000 onward for Veterans who utilized the VHA Health Care
System. In addition, they are available on specific cohorts of
Veterans including those who served in OEF/OIF and in the first
Persian Gulf War, whether or not they utilize VHA health care
services. Finally, they are available on all individuals
identified at the times of their deaths as Veterans by their
families in the sixteen states that participate in the Centers
for Disease Control and Prevention's National Violent Death
Reporting System. VA estimates that the overall cost for
conducting such a study would be $2,356,000 in FY 2010 and
$7,224,000 over five years.
VA is opposed to Section 404, which would transfer $5
million from VA to the Department of Health and Human Services
(HHS) by the end of FY 2010 for a graduate psychology education
(GPE) program. This transfer of funds to the GPE Program would
reduce funding available for VA programs or services without
any clear benefit to VA in exchange for those services. VA much
prefers to target these funds to increasing internship and
post-doctoral training positions within VA facilities. VA
already supports 435 Psychology internship positions in 90
different programs and 200 postdoctoral fellowship programs in
54 programs. Thus we already provide the ``training of
psychologists in the treatment of Veterans with Post Traumatic
Stress Disorder, Traumatic Brain Injury, and other combat-
related disorders'' that this legislation aims to achieve.
Assuming that this $5 million would become a recurring transfer
of funds, the estimate over ten years is $50 million.
Sections 501 and 502 of S.252 would authorize VA to conduct
two five-year pilot grant programs under which public and non-
profit organizations (including faith-based and community
organizations) would receive funds for coordinating the
provision of local supportive services for very low income,
formerly homeless veterans who reside in permanent housing.
Under one of the pilot programs, VA would provide grants to
organizations assisting veterans residing in permanent housing
located on military property that the Secretary of Defense
closed or slated for closure as part of the 2005 Base
Realignment and Closure program and ultimately designated for
use in assisting the homeless. The other pilot program would
provide grants to organizations assisting veterans residing in
permanent housing on any property across the country. Both
pilot programs would require the Secretary to promulgate
regulations establishing criteria for receiving grants and the
scope of supportive services covered by the grant program.
The 2005 Base Realignment and Closure process has been
completed and local plans have already been developed.
Therefore the new authority as proposed in section 501 would be
ineffective. Further, the Veterans Mental Health and Other Care
Improvement Act of 2008, Public Law 110-387, Title VI, Section
604 provided authorization for VA to facilitate the provision
of supportive services for very low income veterans for veteran
families in permanent housing. VA is in the process of writing
regulations and hopes to offer funding later this year. Section
604 allows VA to effectively aid veterans better than either of
the two pilots. We respectfully suggest that the two pilots are
no longer needed and believe that the supportive services
grants under Pub. L. 110-387 which this Committee approved last
year to be a more effective way to assist veterans.
Section 503 of S.252 would require that VA establish a
pilot program for financial support of entities that provide
outreach to inform certain veterans about pension benefits. To
this end, the bill would provide VA with additional authority
to make grants to public and non-profit organizations
(including faith-based and community organizations) for
purposes of providing outreach to inform low-income and elderly
veterans and their spouses residing in rural areas about
potential eligibility for VA pension. The bill authorized the
expenditure of $1,275,000 from General Operating Expenses (GOE)
in each of fiscal years 2010 through 2014. Although VA supports
the intent of Section 503 of S.252, we oppose the bill because
it duplicates ongoing outreach efforts by VBA to conduct
outreach to low income and elderly veterans and their spouses
and dependents. If this legislation is enacted, VA would need
additional GOE to administer the pilot program and to train the
public and non-profit organizations to accurately discuss VA
benefit programs.
VA's outreach efforts to elderly veterans and their
survivors include several approaches. We have provided the
Social Security Administration with our pamphlet ``Federal
Benefits for Veterans and Dependents.'' Additionally, we have
participated and will continue to participate in the annual
conference of the American Association of Retired Persons
(AARP). This year VA will participate in the National
Convention of the Association of Directors of Assisted Living
Facilities. From January 2008 to January 2009 the number of
veterans receiving disability pension declined about two
percent or less than 7,000 veterans. That decline can be almost
entirely accounted for by the decline in the number of World
War II veterans receiving pension. The decline in this
population accounted for 85 percent of the decline. The Vietnam
Era veteran population is only now reaching age 65 where
entitlement exists based on age. We expect their participation
in the pension program to rise. With respect to survivor
pension, the number of widow(ers) on the rules has increased
5,924 or 7.2 percent over the same January to January period.
In light of the significantly lower allowable income limits for
survivors, this rise is primarily attributable to entitlement
being established as a result of high medical expenses. The
rise is reflective of our work with social security and AARP
and soon with the assisted living organizations.
Section 504 of the bill would authorize a 3-year pilot
program to assess the feasibility of providing grants to public
or nonprofit organizations as a means of providing expanded
services to veterans participating in vocational rehabilitation
programs under chapter 31 of title 38, United States Code.
Under this program, VA would provide financial assistance
through grants to public or nonprofit organizations that would
then establish new programs or activities, or expand or modify
existing programs or activities, to provide assistance to
veterans participating in vocational rehabilitation programs
under chapter 31. The type of assistance to be provided
includes transportation, childcare, and clothing to facilitate
participation in a vocational rehabilitation program or related
activity. The pilot program would be used to assess the
feasibility of providing such expanded services to veterans
through these types of grants.
VA supports efforts to facilitate successful completion of
vocational rehabilitation programs under chapter 31. However,
VA does not support the use of grant programs to achieve this
objective. The administrative burden associated with creating
and administering such a grant program would be prohibitive,
particularly since VA must continue to monitor grantee's
activities to ensure alignment with VA program objectives and
each program participant's individual rehabilitation plan. VA
personnel already use existing systems to process direct
reimbursements to veterans for authorized, necessary costs
associated with participation in their specific vocational
rehabilitation programs. VA believes that, subject to the
availability of funding for the purpose, any incentive programs
to facilitate completion of vocational rehabilitation programs
should be built onto existing VA reimbursement authorities.
The Department would be authorized $5 million from the
amounts available in VA's GOE account in each of fiscal years
2010 through 2012 to carry out section 504 of this bill.
Section 505 would require that not less than one year
before the expiration of the authority to carry out the pilot
programs established under section 501 through 504, VA would
submit a report to Congress including the following: lessons
learned, recommendations on whether to continue such pilot
program, the number of veterans and dependents served by such
pilot program, an assessment of the quality of service provided
to veterans and dependents, the amount of funds provided to
grant recipients, and the names of organizations that have
received grants.
VA supports sections 601 to section 606 of Title VI, which
would update and clarify provisions of Public Law 100-322
authorizing VA-affiliated Nonprofit Research Corporations
(NPCs). Title VI promulgates revisions that will allow the NPCs
to better serve VA research and education programs while
maintaining the high degree of oversight applied to these
nonprofits. There are no added costs associated with Title VI.
VA supports Title VI.
Subsection (a)(1) of section 701 of the bill would amend
section 902(a) of title 38, U.S.C., so as to permit VA police
officers to: (1) carry VA-issued weapons, including firearms,
while off VA property in an official capacity or while in
official travel status; (2) conduct investigations, on and off
VA property, of offenses that may have been committed on VA
property, consistent with agreements with affected local,
state, or Federal law enforcement agencies; (3) carry out, as
needed and appropriate, any of the duties described in section
902(a)(1), as revised, when engaged in such duties pursuant to
other Federal statutes; and (4) execute any arrest warrant
issued by a competent judicial authority. Subsection (a)(2) of
section 701 would further amend section 902 of title 38 to
specify that the powers granted to VA police officers be
exercised in accordance with guidelines approved by the
Secretary and the Attorney General of the United States. VA
will work with the Department Justice to formulate our views on
this proposed legislation. We will submit our views at a later
date.
Section 702 of the Committee bill would amend section
903(b) of title 38, U.S.C., which governs the uniform allowance
for VA police officers, to limit the allowable amount to the
lesser of: (1) the amount prescribed by the OPM; or (2) the
estimated or actual costs as determined by periodic surveys
conducted by VA. The provision would also amend section 903(c)
of title 38 to provide that the allowance established under
subsection (b) of section 902 of title 38, as modified by the
Committee bill, shall be paid at the beginning of an officer's
appointment for those appointed on or after October 1, 2008,
and for other officers at the request of the officer, subject
to the fiscal year limitations established in subsection (b),
as modified by the Committee bill.
VA supports these provisions. Under current section 903,
uniformed Department of Veteran Affairs Police are paid $400
for an initial uniform allowance, and then $200 annually
throughout their careers. This is a marginal amount and does
not cover the actual costs of uniforms and equipment required
by the Department for our officers. VA Police officer uniforms
are required by the Department and purchased by the officers
using the statutorily authorized allowance. These amounts were
last updated in 1991. Our Police Officers generally have to
reach into their own pockets to supplement both the initial
purchases and annual upkeep.
The Office of Personnel Management (OPM) published new
regulations in the Federal Register that increase the
authorized uniform allowance amount up to $800 initially and
$800 annually. Section 702 would allow the Department to
occasionally review and increase initial allowances up to the
OPM-authorized maximum, if that is necessary.
The Department requires that all VA police officers present
an image of professionalism and authority. Authorizing an
updated uniform allowance will help to achieve that. We also
note that uniform allowances are a recruiting tool. We estimate
costs at $1.58 million for one year, $6.5 million for five
years, and $16.82 million for ten years.
* * * * * * *
Changes in Existing Law
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, changes in existing law made by the
Committee 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. VETERANS' BENEFITS
PART I. GENERAL PROVISIONS
* * * * * * *
CHAPTER 5. AUTHORITY AND DUTIES OF THE SECRETARY
* * * * * * *
Subchapter III. Advisory Committees
* * * * * * *
SEC. 542. ADVISORY COMMITTEE ON WOMEN VETERANS
(a)(1) * * *
(2)(A) * * *
(i) * * *
(ii) individuals who are recognized authorities in
fields pertinent to the needs of women veterans,
including the gender-specific health-care needs of
women; [and]
(iii) representatives of both female and male
veterans with service-connected disabilities, including
at least one female veteran with a service-connected
disability and at least one male veteran with a
service-connected disability[.] ; and
(iv) women veterans who are recently separated from
service in the Armed Forces.
* * * * * * *
SEC. 544. ADVISORY COMMITTEE ON MINORITY VETERANS
(a)(1) * * *
(2)(A) * * *
(i) * * *
(ii) * * *
(iii) veterans who are minority group members and who
have experience in a military theater of operations;
[and]
(iv) veterans who are minority group members and who
do not have such experience[.] ; and
(v) women veterans who are minority group members and
are recently separated from service in the Armed
Forces.
* * * * * * *
CHAPTER 9. SECURITY AND LAW ENFORCEMENT ON PROPERTY UNDER THE
JURISDICTION OF THE DEPARTMENT
* * * * * * *
SEC. 902. ENFORCEMENT AND ARREST AUTHORITY OF DEPARTMENT POLICE
OFFICERS
(a)(1) Employees of the Department who are Department
police officers shall, with respect to acts occurring on
Department property[, enforce]--
(A) enforce Federal laws;
(B) enforce the rules prescribed under section 901 of
this title; [and]
(C) [subject to paragraph (2), traffic and motor
vehicle laws of a State or local government within the
jurisdiction of which such Department property is
located.] enforce traffic and motor vehicle laws of a
State or local government (by issuance of a citation
for violation of such laws) within the jurisdiction of
which such Department property is located as authorized
by an express grant of authority under applicable State
or local law;
(D) carry the appropriate Department-issued weapons,
including firearms, while off Department property in an
official capacity or while in an official travel
status;
(E) conduct investigations, on and off Department
property, of offenses that may have been committed on
property under the original jurisdiction of Department,
consistent with agreements or other consultation with
affected local, State, or Federal law enforcement
agencies; and
(F) carry out, as needed and appropriate, the duties
described in subparagraphs (A) through (E) of this
paragraph when engaged in duties authorized by other
Federal statutes.
[(2) A law described in subparagraph (C) of paragraph (1)
may be enforced under such subparagraph only as authorized by
an express grant of authority under applicable State or local
law. Any such enforcement shall be by the issuance of a
citation for violation of such law.]
(2) [(3)] Subject to regulations prescribed under
subsection (b), a Department police officer may make arrests on
Department property for a violation of a Federal law or any
rule prescribed under section 901(a) of this title, and on any
arrest warrant issued by competent judicial authority.
(b) * * *
(c) [The Secretary shall consult with the Attorney General
before prescribing regulations under paragraph (1) of
subsection (b).] The powers granted to Department police
officers designated under this section shall be exercised in
accordance with guidelines approved by the Secretary and the
Attorney General.
(d) * * *
SEC. 903. UNIFORM ALLOWANCE
(a) * * *
[(b) The amount of the allowance that the Secretary may pay
under this section--
[(1) may be based on estimated average costs or
actual costs;
[(2) may vary by geographic regions; and
[(3) except as provided in subsection (c), may not
exceed $200 in a fiscal year for any police officer.]
(b)(1) The amount of the allowance that the Secretary may
pay under this section is the lesser of--
(A) the amount currently allowed as prescribed by the
Office of Personnel Management; or
(B) estimated costs or actual costs as determined by
periodic surveys conducted by the Department.
(2) During any fiscal year no officer shall receive more
for the purchase of a uniform described in subsection (a) than
the amount established under this subsection.
(c) [The amount of an allowance under this section may be
increased to an amount up to $400 for not more than one fiscal
year in the case of any Department police officer. In the case
of a person who is appointed as a Department police officer on
or after January 1, 1990, an allowance in an amount established
under this subsection shall be paid at the beginning of such
person's employment as such an officer. In the case of any
other Department police officer, an allowance in an amount
established under this subsection shall be paid upon the
request of the officer.] The allowance established under
subsection (b) shall be paid at the beginning of a Department
police officer's employment for those appointed on or after
October 1, 2008. In the case of any other Department police
officer, an allowance in the amount established under
subsection (b) shall be paid upon the request of the officer.
PART II. GENERAL BENEFITS
* * * * * * *
CHAPTER 17. HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I. GENERAL
SEC.
1701. DEFINITIONS.
* * * * * * *
1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION AND
SOCIAL SECURITY NUMBER OF CERTAIN VETERANS
RECEIVING CARE.
* * * * * * *
SUBCHAPTER VIII. HEALTH CARE OF PERSONS OTHER THAN VETERANS
* * * * * * *
1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING MATERNITY
CARE.
Subchapter I. General
* * * * * * *
SEC. 1709. DISCLOSURE TO SECRETARY OF HEALTH-PLAN CONTRACT INFORMATION
AND SOCIAL SECURITY NUMBER OF CERTAIN VETERANS
RECEIVING CARE
(a) Required Disclosure of Health-Plan Contracts.--(1) Any
individual who applies for or is in receipt of care described
in paragraph (2) shall, at the time of such application, or
otherwise when requested by the Secretary, submit to the
Secretary such current information as the Secretary may require
to identify any health-plan contract (as defined in section
1729(i) of this title) under which such individual is covered,
to include, as applicable--
(A) the name, address, and telephone number of such
health-plan contract;
(B) the name of the individual's spouse, if the
individual's coverage is under the spouse's health-plan
contract;
(C) the plan number; and
(D) the plan's group code.
(2) The care described in this paragraph is--
(A) hospital, nursing home, or domiciliary care;
(B) medical, rehabilitative, or preventive health
services; or
(C) other medical care under laws administered by the
Secretary.
(b) Required Disclosure of Social Security Number.--(1) Any
individual who applies for or is in receipt of care described
in paragraph (2) shall, at the time of such application, or
otherwise when requested by the Secretary, submit to the
Secretary--
(A) the individual's social security number; and
(B) the social security number of any dependent or
Department beneficiary on whose behalf, or based upon
whom, such individual applies for or is in receipt of
such care.
(2) The care described in this paragraph is--
(A) hospital, nursing home, or domiciliary care;
(B) medical, rehabilitative, or preventive health
services; or
(C) other medical care under laws administered by the
Secretary.
(3) This subsection does not require an individual to
furnish the Secretary with a social security number for any
individual to whom a social security number has not been
assigned.
(c) Failure to Disclose Social Security Number.--(1) The
Secretary shall deny an individual's application for, or may
terminate an individual's enrollment in, the system of patient
enrollment established by the Secretary under section 1705 of
this title, if such individual does not provide the social
security number required or requested to be submitted pursuant
to subsection (b).
(2) Following a denial or termination under paragraph (1)
with respect to an individual, the Secretary may, upon receipt
of the information required or requested under subsection (b),
approve such individual's application or reinstate such
individual's enrollment (if otherwise in order), for such
medical care and services provided on and after the date of
such receipt of information.
(d) Construction.--Nothing in this section shall be
construed as authority to deny medical care and treatment to an
individual in a medical emergency.
Subchapter II. Hospital, Nursing Home, or
Domiciliary Care and Medical Treatment
* * * * * * *
SEC. 1710E. TRAUMATIC BRAIN INJURY: USE OF NON-DEPARTMENT FACILITIES
FOR REHABILITATION
(a) Cooperative agreements.-- * * *
(b) Covered Individuals.--The care and services provided
under subsection (a) shall be made available to an individual--
(1) who is described in section 1710C(a) of this
title; and
(2)(A) to whom the Secretary is unable to provide
such treatment or services at the frequency or for the
duration prescribed in such plan; or
(B) for whom the Secretary determines that it is
optimal with respect to the recovery and rehabilitation
for such individual.''
(c) [(b)] Authorities of State protection and advocacy
systems.-- * * *
(d) Standards.--The Secretary may not provide treatment or
services as described in subsection (a) at a non-Department
facility under such subsection unless such facility maintains
standards for the provision of such treatment or services
established by an independent, peer-reviewed organization that
accredits specialized rehabilitation programs for adults with
traumatic brain injury.
SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL
HEALTH SERVICES.
* * * * * * *
(c) Upon receipt of a request for counseling under this
section from any individual who has been discharged or released
from active military, naval, or air service but who is not
otherwise eligible for such counseling, the Secretary shall--
(1) provide referral services to assist such
individual, to the maximum extent practicable, in
obtaining mental health care and services from sources
outside the Department; and
(2) if pertinent, advise such individual of such
individual's rights to apply to the appropriate
military, naval, or air service, and to the Department,
for review of such individual's discharge or release
from such service.
(d) [(c)] The Under Secretary for Health may provide for
such training of professional, paraprofessional, and lay
personnel as is necessary to carry out this section
effectively, and, in carrying out this section, may utilize the
services of paraprofessionals, individuals who are volunteers
working without compensation, and individuals who are veteran-
students (as described in section 3485 of this title) in
initial intake and screening activities.
(e) [(d)](1) In furnishing counseling and related mental
health services under subsections (a) and (b) of this section,
the Secretary shall have available the same authority to enter
into contracts with private facilities that is available to the
Secretary (under sections 1703(a)(2) and 1710(a)(1)(B) of this
title) in furnishing medical services to veterans suffering
from total service-connected disabilities.
* * * * * * *
(f) [(e)] The Secretary, in cooperation with the Secretary
of Defense, shall take such action as the Secretary considers
appropriate to notify veterans who may be eligible for
assistance under this section of such potential eligibility.
(g) [(f)] For the purposes of this section:
(1) * * *
* * * * * * *
SEC. 1720. TRANSFERS FOR NURSING HOME CARE; ADULT DAY HEALTH CARE
* * * * * * *
(g) The Secretary may contract with appropriate entities to
provide specialized residential care and rehabilitation
services to a veteran of Operation Enduring Freedom or
Operation Iraqi Freedom who the Secretary determines suffers
from a traumatic brain injury, has an accumulation of deficits
in activities of daily living and instrumental activities of
daily living, and because of these deficits, would otherwise
require admission to a nursing home even though such care would
generally exceed the veteran's nursing needs.
* * * * * * *
SEC. 1720D. COUNSELING AND TREATMENT FOR SEXUAL TRAUMA
* * * * * * *
(d)(1) The Secretary shall implement a program for
education, training, certification, and continuing medical
education for mental health professionals to specialize in the
provision of counseling and care to veterans eligible for
services under subsection (a). In carrying out the program, the
Secretary shall ensure that all such mental health
professionals have been trained in a consistent manner and that
such training includes principles of evidence-based treatment
and care for sexual trauma.
(2) The Secretary shall determine the minimum
qualifications necessary for mental health professionals
certified by the program under paragraph (1) to provide
evidence-based treatment and therapy to veterans eligible for
services under subsection (a) in facilities of the Department.
(e) The Secretary shall submit to Congress each year a
report on the counseling and care and services provided to
veterans under this section. Each report shall include data for
the preceding year with respect to the following:
(1) The number of mental health professionals and
primary care providers who have been certified under
the program under subsection (d), and the amount and
nature of continuing medical education provided under
such program to professionals and providers who have
been so certified.
(2) The number of women veterans who received
counseling and care and services under subsection (a)
from professionals and providers who have been trained
or certified under the program under subsection (d).
(3) The number of training, certification, and
continuing medical education programs operating under
subsection (d).
(4) The number of trained full-time equivalent
employees required in each facility of the Department
to meet the needs of veterans requiring treatment and
care for sexual trauma.
(5) Such other information as the Secretary considers
appropriate.
(f) [(d)] In this section, the term ``sexual harassment''
means repeated, unsolicited verbal or physical contact of a
sexual nature which is threatening in character.
* * * * * * *
Subchapter VIII. Health Care of Persons
Other Than Veterans
SEC. 1781. MEDICAL CARE FOR SURVIVORS AND DEPENDENTS OF CERTAIN
VETERANS
(a) * * *
* * * * * * *
(e) Payment by the Secretary under this section on behalf
of a covered beneficiary for medical care shall constitute
payment in full and extinguish any liability on the part of the
beneficiary for that care.
* * * * * * *
SEC. 1786. CARE FOR NEWBORN CHILDREN OF WOMEN VETERANS RECEIVING
MATERNITY CARE
(a) In General.--The Secretary may furnish health care
services described in subsection (b) to a newborn child of a
woman veteran who is receiving maternity care furnished by the
Department for not more than 7 days after the birth of the
child if the veteran delivered the child in--
(1) a facility of the Department; or
(2) another facility pursuant to a Department
contract for services relating to such delivery.
(b) Covered Health Care Services.--Health care services
described in this subsection are all post-delivery care
services, including routine care services, that a newborn
requires.
* * * * * * *
PART V. BOARDS, ADMINISTRATIONS, AND SERVICES
CHAPTER 73. VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
* * * * * * *
SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION
SEC.
7311. QUALITY ASSURANCE.
7311A. QUALITY MANAGEMENT OFFICERS.
* * * * * * *
SUBCHAPTER IV. RESEARCH CORPORATIONS
* * * * * * *
7365. COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS LAWS.
[7364A. COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT CLAIMS LAWS.]
[7365. APPLICABLE STATE LAW.]
* * * * * * *
Subchapter II. General Authority and Administration
SEC. 7311. QUALITY ASSURANCE
* * * * * * *
(b)(1) * * *
* * * * * * *
(4) As part of the quality management program, the Under
Secretary for Health shall establish mechanisms through which
employees of Veterans Health Administration facilities may
submit reports, on a confidential basis, on matters relating to
quality of care in Veterans Health Administration facilities to
the quality management officers of such facilities under
section 7311A(b) of this title. The mechanisms shall provide
for the prompt and thorough review of any reports so submitted
by the receiving officials.
* * * * * * *
SEC. 7311A. QUALITY MANAGEMENT OFFICERS
(a) National Quality Management Officer.--(1) The Under
Secretary for Health shall designate an official of the
Veterans Health Administration to act as the principal quality
management officer for the quality management program required
by section 7311 of this title. The official so designated may
be known as the ``National Quality Management Officer of the
Veterans Health Administration'' (in this section referred to
as the ``National Quality Management Officer'').
(2) The National Quality Management Officer shall report
directly to the Under Secretary for Health in the discharge of
responsibilities and duties of the Officer under this section.
(3) The National Quality Management Officer shall be the
official within the Veterans Health Administration who is
principally responsible for the quality management program
referred to in paragraph (1). In carrying out that
responsibility, the Officer shall be responsible for the
following:
(A) Establishing and enforcing the requirements of
the program referred to in paragraph (1).
(B) Developing an aggregate quality metric from
existing data sources, such as the Inpatient Evaluation
Center of the Department, the National Surgical Quality
Improvement Program, and the External Peer Review
Program of the Veterans Health Administration, that
could be used to assess reliably the quality of care
provided at individual Department medical centers and
associated community based outpatient clinics.
(C) Ensuring that existing measures of quality,
including measures from the Inpatient Evaluation
Center, the National Surgical Quality Improvement
Program, System-Wide Ongoing Assessment and Review
reports of the Department, and Combined Assessment
Program reviews of the Office of Inspector General of
the Department, are monitored routinely and analyzed in
a manner that ensures the timely detection of quality
of care issues.
(D) Encouraging research and development in the area
of quality metrics for the purposes of improving how
the Department measures quality in individual
facilities.
(E) Carrying out such other responsibilities and
duties relating to quality management in the Veterans
Health Administration as the Under Secretary for Health
shall specify.
(4) The requirements under paragraph (3) shall include
requirements regarding the following:
(A) A confidential system for the submittal of
reports by Veterans Health Administration personnel
regarding quality management at Department facilities.
(B) Mechanisms for the peer review of the actions of
individuals appointed in the Veterans Health
Administration in the position of physician.
(b) Quality Management Officers for VISNs.--(1) The
Regional Director of each Veterans Integrated Services Network
(VISN) shall appoint an official of the Network to act as the
quality management officer of the Network.
(2) The quality management officer for a Veterans
Integrated Services Network shall report to the Regional
Director of the Veterans Integrated Services Network, and to
the National Quality Management Officer, regarding the
discharge of the responsibilities and duties of the officer
under this section.
(3) The quality management officer for a Veterans
Integrated Services Network shall--
(A) direct the quality management office in the
Network; and
(B) coordinate, monitor, and oversee the quality
management programs and activities of the
Administration medical facilities in the Network in
order to ensure the thorough and uniform discharge of
quality management requirements under such programs and
activities throughout such facilities.
(c) Quality Management Officers for Medical Facilities.--
(1) The director of each Veterans Health Administration medical
facility shall appoint a quality management officer for that
facility.
(2) The quality management officer for a facility shall
report directly to the director of the facility, and to the
quality management officer of the Veterans Integrated Services
Network in which the facility is located, regarding the
discharge of the responsibilities and duties of the quality
management officer under this section.
(3) The quality management officer for a facility shall be
responsible for designing, disseminating, and implementing
quality management programs and activities for the facility
that meet the requirements established by the National Quality
Management Officer under subsection (a).
(d) Authorization of Appropriations.--(1) Except as
provided in paragraph (2), there are authorized to be
appropriated such sums as may be necessary to carry out this
section.
(2) There are authorized to be appropriated to carry out
the provisions of subparagraphs (B), (C), and (D) of subsection
(a)(3), $25,000,000 for the two-year period of fiscal years
beginning after the date of the enactment of this section.
* * * * * * *
Subchapter III. Protection of Patient Rights
SEC. 7332. CONFIDENTIALITY OF CERTAIN MEDICAL RECORDS
* * * * * * *
(b)(2) * * *
(A) * * *
* * * * * * *
(F)(i) To a representative of a patient who lacks
decision-making capacity, when a practitioner deems the
content of the given record necessary for that
representative to make an informed decision regarding
the patient's treatment.
(ii) In this subparagraph, the term
``representative'' means an individual, organization,
or other body authorized under section 7331 of this
title and its implementing regulations to give informed
consent on behalf of a patient who lacks decision-
making capacity.
* * * * * * *
Subchapter IV. Research Corporations
SEC. 7361. AUTHORITY TO ESTABLISH; STATUS
(a) The Secretary may authorize the establishment at any
Department medical center of a nonprofit corporation to provide
a flexible funding mechanism for the conduct of approved
research and education at the medical center. [Except as
otherwise required in this subchapter or under regulations
prescribed by the Secretary, any such corporation, and its
directors and employees, shall be required to comply only with
those Federal laws, regulations, and executive orders and
directives which apply generally to private nonprofit
corporations.] Such a corporation may be established to
facilitate either research or education or both research and
education.
(b)(1) Subject to paragraph (2), a corporation established
under this subchapter may facilitate the conduct of research,
education, or both at more than one medical center. Such a
corporation shall be known as a ``multi-medical center research
corporation''.
(2) The board of directors of a multi-medical center
research corporation under this subsection shall include the
official at each Department medical center concerned who is, or
who carries out the responsibilities of, the medical center
director of such center as specified in section
7363(a)(1)(A)(i) of this title.
(3) In facilitating the conduct of research, education, or
both at more than one Department medical center under this
subchapter, a multi-medical center research corporation may
administer receipts and expenditures relating to such research,
education, or both, as applicable, performed at the Department
medical centers concerned.
(c) Any corporation established under this subchapter shall
be established in accordance with the nonprofit corporation
laws of the State in which the applicable Department medical
center is located and shall, to the extent not inconsistent
with any Federal law, be subject to the laws of such State. In
the case of any multi-medical center research corporation that
facilitates the conduct of research, education, or both at
Department medical centers located in different States, the
corporation shall be established in accordance with the
nonprofit corporation laws of the State in which one of such
Department medical centers is located.
(d)(1) Except as otherwise provided in this subchapter or
under regulations prescribed by the Secretary, any corporation
established under this subchapter, and its officers, directors,
and employees, shall be required to comply only with those
Federal laws, regulations, and executive orders and directives
that apply generally to private nonprofit corporations.
(2) A corporation under this subchapter is not--
(A) owned or controlled by the United States; or
(B) an agency or instrumentality of the United
States.
(e) [(b)] If by the end of the four-year period beginning
on the date of the establishment of a corporation under this
subchapter the corporation is not recognized as an entity the
income of which is exempt from taxation under section 501(c)(3)
of the Internal Revenue Code of 1986, the Secretary shall
dissolve the corporation.
(f) A corporation established under this subchapter may act
as a multi-medical center research corporation under this
subchapter in accordance with subsection (b) if--
(1) the board of directors of the corporation
approves a resolution permitting facilitation by the
corporation of the conduct of research, education, or
both at the other Department medical center or medical
centers concerned; and
(2) the Secretary approves the resolution of the
corporation under paragraph (1).
SEC. 7362. PURPOSE OF CORPORATIONS
(a) [Any corporation established under this subchapter
shall be established solely to facilitate] A corporation
established under this subchapter shall be established to
provide a flexible funding mechanism for the conduct of
approved research and education at one or more Department
medical centers and to facilitate functions related to the
conduct of research as described in section 7303(a) of this
title and education and training as described in sections 7302,
7471, 8154, and 1701(6)(B) of this title in conjunction with
the applicable Department medical center or centers. [Any funds
received by the Secretary for the conduct of research or
education at the medical center other than funds appropriated
to the Department may be transferred to and administered by the
corporation for these purposes.]
(b) For purposes of this section, [the term ``education and
training''] the term ``education'' includes education and
training and means the following:
(1) In the case of employees of the Veterans Health
Administration, such term means work-related
instruction or other learning experiences to--
(A) improve performance of current duties;
(B) assist employees in maintaining or
gaining specialized proficiencies; and
(C) expand understanding of advances and
changes in patient care, technology, and health
care administration.
[Such term includes (in the case of such employees)
education and training conducted as part of a residency
or other program designed to prepare an individual for
an occupation or profession.]
(2) In the case of veterans under the care of the
Veterans Health Administration, such term means
instruction or other learning experiences related to
improving and maintaining the health of veterans [to
patients and to the families] and includes education
and training for patients and families and guardians of
patients.
SEC. 7363. BOARD OF DIRECTORS; EXECUTIVE DIRECTOR
(a) The Secretary shall provide for the appointment of a
board of directors for any corporation established under this
subchapter. The board shall include--
(1) [the director of the medical center, the chief of
staff of the medical center, and as appropriate, the
assistant chief of staff for research for the medical
center and the assistant chief of staff for education
for the medical center, or, in the case of a facility
at which such positions do not exist, those officials
who are responsible for carrying out the
responsibilities of the medical center director, chief
of staff, and, as appropriate, the assistant chief of
staff for research and the assistant chief of staff for
education; and] with respect to the Department medical
center--
(A)(i) the director (or directors of each
Department medical center, in the case of a
multi-medical center research corporation);
(ii) the chief of staff; and
(iii) as appropriate for the activities of
such corporation, the associate chief of staff
for research and the associate chief of staff
for education; or
(B) in the case of a Department medical
center at which one or more of the positions
referred to in subparagraph (A) do not exist,
the official or officials who are responsible
for carrying out the responsibilities of such
position or positions at the Department medical
center; and
(2) subject to subsection (c), not less than two
members who are not officers or employees of the
Federal Government [and who are familiar with issues
involving medical and scientific research or education,
as appropriate.] and who have backgrounds, or business,
legal, financial, medical, or scientific expertise, of
benefit to the operations of the corporation.
(b) * * *
(c) An individual appointed under subsection (a)(2) to the
board of directors of a corporation established under this
subchapter may not be affiliated with[, employed by, or have
any other financial relationship with] or employed by any
entity that is a source of funding for research or education by
the Department unless that source of funding is a governmental
entity or an entity the income of which is exempt from taxation
under the Internal Revenue Code of 1986.
SEC. 7364. GENERAL POWERS
[(a) A corporation established under this subchapter may--
[(1) accept gifts and grants from, and enter into
contracts with, individuals and public and private
entities solely to carry out the purposes of this
subchapter; and
[(2) employ such employees as it considers necessary
for such purposes and fix the compensation of such
employees.
[(b) A corporation established under this subchapter may
not spend funds for a research project unless the project is
approved in accordance with procedures prescribed by the Under
Secretary for Health for research carried out with Department
funds. Such procedures shall include a peer review process.
[(c)(1) A corporation established under this subchapter may
not spend funds for an education activity unless the activity
is approved in accordance with procedures prescribed by the
Under Secretary for Health.
[(2) The Under Secretary for Health shall prescribe
policies and procedures to guide the expenditure of funds by
corporations under paragraph (1) consistent with the purpose of
such corporations as flexible funding mechanisms.]
(a) In General.--(1) A corporation established under this
subchapter may, solely to carry out the purposes of this
subchapter--
(A) accept, administer, retain, and spend funds
derived from gifts, contributions, grants, fees,
reimbursements, and bequests from individuals and
public and private entities;
(B) enter into contracts and agreements with
individuals and public and private entities;
(C) subject to paragraph (2), set fees for education
and training facilitated under section 7362 of this
title, and receive, retain, administer, and spend funds
in furtherance of such education and training;
(D) reimburse amounts to the applicable appropriation
account of the Department for the Office of General
Counsel for any expenses of that Office in providing
legal services attributable to research and education
agreements under this subchapter; and
(E) employ such employees as the corporation
considers necessary for such purposes and fix the
compensation of such employees.
(2) Fees charged under paragraph (1)(C) for education and
training described in that paragraph to individuals who are
officers or employees of the Department may not be paid for by
any funds appropriated to the Department.
(3) Amounts reimbursed to the Office of General Counsel
under paragraph (1)(D) shall be available for use by the Office
of the General Counsel only for staff and training, and related
travel, for the provision of legal services described in that
paragraph and shall remain available for such use without
fiscal year limitation.
(b) Transfer and Administration of Funds.--(1) Except as
provided in paragraph (2), any funds received by the Secretary
for the conduct of research or education at a Department
medical center or centers, other than funds appropriated to the
Department, may be transferred to and administered by a
corporation established under this subchapter for such
purposes.
(2) A Department medical center may reimburse the
corporation for all or a portion of the pay, benefits, or both
of an employee of the corporation who is assigned to the
Department medical center if the assignment is carried out
pursuant to subchapter VI of chapter 33 of title 5.
(3) A Department medical center may retain and use funds
provided to it by a corporation established under this
subchapter. Such funds shall be credited to the applicable
appropriation account of the Department and shall be available,
without fiscal year limitation, for the purposes of that
account.
(c) Research Projects.--Except for reasonable and usual
preliminary costs for project planning before its approval, a
corporation established under this subchapter may not spend
funds for a research project unless the project is approved in
accordance with procedures prescribed by the Under Secretary
for Health for research carried out with Department funds. Such
procedures shall include a scientific review process.
(d) Education Activities.--Except for reasonable and usual
preliminary costs for activity planning before its approval, a
corporation established under this subchapter may not spend
funds for an education activity unless the activity is approved
in accordance with procedures prescribed by the Under Secretary
for Health.
(e) Policies and Procedures.--The Under Secretary for
Health may prescribe policies and procedures to guide the
spending of funds by corporations established under this
subchapter that are consistent with the purpose of such
corporations as flexible funding mechanisms and with Federal
and State laws and regulations, and executive orders,
circulars, and directives that apply generally to the receipt
and expenditure of funds by nonprofit organizations exempt from
taxation under section 501(c)(3) of the Internal Revenue Code
of 1986.
SEC. 7365. [7364A.] COVERAGE OF EMPLOYEES UNDER CERTAIN FEDERAL TORT
CLAIMS LAWS
* * * * * * *
[SEC. 7365. APPLICABLE STATE LAW
[Any corporation established under this subchapter shall be
established in accordance with the nonprofit corporation laws
of the State in which the applicable medical center is located
and shall, to the extent not inconsistent with any Federal law,
be subject to the laws of such State.]
SEC. 7366. ACCOUNTABILITY AND OVERSIGHT
(a) * * *
[(b) Each such corporation shall submit to the Secretary an
annual report providing a detailed statement of its operations,
activities, and accomplishments during that year. A corporation
with revenues in excess of $300,000 for any year shall obtain
an audit of the corporation for that year. A corporation with
annual revenues between $10,000 and $300,000 shall obtain an
independent audit of the corporation at least once every three
years. Any audit under the preceding sentences shall be
performed by an independent auditor. The corporation shall
include the most recent such audit in the corporation's report
to the Secretary for that year.]
(b)(1) Each corporation shall submit to the Secretary each
year a report providing a detailed statement of the operations,
activities, and accomplishments of the corporation during that
year.
(2)(A) A corporation with revenues in excess of $300,000
for any year shall obtain an audit of the corporation for that
year.
(B) A corporation with annual revenues between $10,000 and
$300,000 shall obtain an audit of the corporation at least once
every three years.
(C) Any audit under this paragraph shall be performed by an
independent auditor.
(3) The corporation shall include in each report to the
Secretary under paragraph (1) the following:
(A) The most recent audit of the corporation under
paragraph (2).
(B) The most recent Internal Revenue Service Form 990
``Return of Organization Exempt from Income Tax'' or
equivalent and the applicable schedules under such
form.
(c)(1) Each member of the board of directors of a
corporation established under this subchapter, each officer and
each employee of such a corporation[, and each employee of the
Department who is involved in the functions of the corporation
during any year] shall be subject to Federal [laws and]
regulations applicable to Federal employees with respect to
conflicts of interest in the performance of official functions.
(2) Each corporation established under this subchapter
shall each year submit to the Secretary a statement signed by
the executive director of the corporation verifying that each
director, officer, and employee has certified awareness of the
laws and regulations referred to in paragraph (1) and of the
consequences of violations of those [laws and] regulations [in
the same manner as Federal employees are required to so
certify].
(d) * * *
* * * * * * *
(3) * * *
* * * * * * *
(C) if the amount expended with respect to
any payee exceeded [$35,000] $50,000,
information that identifies the payee.
* * * * * * *
CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL
SUBCHAPTER I. APPOINTMENTS
SEC.
7401. * * *
7402. * * *
7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS.
* * * * * * *
SUBCHAPTER IV. PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL
* * * * * * *
7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY.
* * * * * * *
Subchapter I. Appointments
* * * * * * *
SEC. 7401. APPOINTMENTS IN VETERANS HEALTH ADMINISTRATION
* * * * * * *
(3) Audiologists, speech pathologists, and
audiologist-speech pathologists, biomedical engineers,
certified or registered respiratory therapists,
dietitians, licensed physical therapists, licensed
practical or vocational nurses, nurse assistants,
medical instrument technicians, medical records
administrators or specialists, medical records
technicians, medical technologists, dental hygienists,
dental assistants, nuclear medicine technologists,
occupational therapists, occupational therapy
assistants, kinesiotherapists, orthotist-prosthetists,
pharmacists, pharmacy technicians, physical therapy
assistants, prosthetic representatives, psychologists,
diagnostic radiologic technologists, therapeutic
radiologic technologists, social workers, marriage and
family therapists, licensed professional mental health
counselors, blind rehabilitation specialists, [and
blind rehabilitation outpatient specialists.] blind
rehabilitation outpatient specialists, and such other
classes of health care occupations as the Secretary
considers necessary for the recruitment and retention
needs of the Department subject to the following
requirements:
(A) Such other classes of health care
occupations--
(i) are not occupations relating to
administrative, clerical, or physical
plant maintenance and protective
services;
(ii) that would otherwise receive
basic pay in accordance with the
General Schedule under section 5332 of
title 5;
(iii) provide, as determined by the
Secretary, direct patient care services
or services incident to direct patient
services; and
(iv) would not otherwise be available
to provide medical care or treatment
for veterans.
(B) Not later than 45 days before the
Secretary appoints any personnel for a class of
health care occupations that is not
specifically listed in this paragraph, the
Secretary shall submit to the Committee on
Veterans' Affairs of the Senate, the Committee
on Veterans' Affairs of the House of
Representatives, and the Office of Management
and Budget notice of such appointment.
(C) Before submitting notice under
subparagraph (B), the Secretary shall solicit
comments from any labor organization
representing employees in such class and
include such comments in such notice.
* * * * * * *
SEC. 7402A. APPOINTMENT AND PRACTICE OF PHYSICIANS: STANDARDS
(a) In General.--The Secretary shall, acting through the
Under Secretary for Health, prescribe standards to be met by
individuals in order to qualify for appointment in the Veterans
Health Administration in the position of physician and to
practice as a physician in medical facilities of the
Administration. The standards shall incorporate the
requirements of this section.
(b) Disclosure of Certain Information Before Appointment.--
Each individual seeking appointment in the Veterans Health
Administration in the position of physician shall do the
following:
(1) Provide the Secretary a full and complete
explanation of the following:
(A) Each lawsuit, civil action, or other
claim (whether open or closed) brought against
the individual for medical malpractice or
negligence.
(B) Each payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim covered by subparagraph (A).
(C) Each investigation or disciplinary action
taken against the individual relating to the
individual's performance as a physician.
(2) Provide the Secretary a written authorization
that permits the State licensing board of each State in
which the individual holds or has held a license to
practice medicine to disclose to the Secretary any
information in the records of such State on the
following:
(A) Each lawsuit, civil action, or other
claim brought against the individual for
medical malpractice or negligence covered by
paragraph (1)(A) that occurred in such State.
(B) Each payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim covered by subparagraph (A).
(C) Each medical malpractice judgment against
the individual by the courts or administrative
agencies or bodies of such State.
(D) Each disciplinary action taken or under
consideration against the individual by an
administrative agency or body of such State.
(E) Any change in the status of the license
to practice medicine issued the individual by
such State, including any voluntary or
nondisciplinary surrendering of such license by
the individual.
(F) Any open investigation of the individual
by an administrative agency or body of such
State, or any outstanding allegation against
the individual before such an administrative
agency or body.
(G) Any written notification by the State to
the individual of potential termination of a
license for cause or otherwise.
(c) Disclosure of Certain Information Following
Appointment.--(1) Each individual appointed in the Veterans
Health Administration in the position of physician after the
date of the enactment of this section shall, as a condition of
service under the appointment, disclose to the Secretary, not
later than 30 days after the occurrence of such event, the
following:
(A) A judgment against the individual for medical
malpractice or negligence.
(B) A payment made by or on behalf of the individual
to settle any lawsuit, action, or claim disclosed under
paragraph (1) or (2) of subsection (b).
(C) Any disposition of or material change in a matter
disclosed under paragraph (1) or (2) of subsection (b).
(D) Any lawsuit, disciplinary action, or claim filed
or undertaken after the date of the disclosures under
subsection (b).
(2) Each individual appointed in the Veterans Health
Administration in the position of physician as of the date of
the enactment of this section shall do the following:
(A) Not later than the end of the 60-day period
beginning on the date of the enactment of this section
and as a condition of service under the appointment
after the end of that period, submit the request and
authorization described in subsection (b)(2).
(B) Agree, as a condition of service under the
appointment, to disclose to the Secretary, not later
than 30 days after the occurrence of such event, the
following:
(i) A judgment against the individual for
medical malpractice or negligence.
(ii) A payment made by or on behalf of the
individual to settle any lawsuit, action, or
claim disclosed pursuant to subparagraph (A) or
under this subparagraph.
(iii) Any disposition of or material change
in a matter disclosed pursuant to subparagraph
(A) or under this subparagraph.
(3) Each individual appointed in the Veterans Health
Administration in the position of physician shall, as part of
the biennial review of the performance of the physician under
the appointment, submit the request and authorization described
in subsection (b)(2). The requirement of this paragraph is in
addition to the requirements of paragraph (1) or (2), as
applicable.
(d) Investigation of Disclosed Matters.--(1) The Director
of the Veterans Integrated Services Network (VISN) in which an
individual is seeking appointment in the Veterans Health
Administration in the position of physician shall perform an
investigation (in such manner as the standards required by this
section shall specify) of each matter disclosed under
subsection (b) with respect to the individual.
(2) The Director of the Veterans Integrated Services
Network in which an individual is appointed in the Veterans
Health Administration in the position of physician shall
perform an investigation (in a manner so specified) of each
matter disclosed under subsection (c) with respect to the
individual.
(3) The results of each investigation performed under this
subsection shall be fully documented.
(e) Approval of Appointments by Directors of VISNs.--(1) An
individual may not be appointed in the Veterans Health
Administration in the position of physician without the
approval of the Director of the Veterans Integrated Services
Network in which the individual will first serve under the
appointment, unless the medical center director and
credentialing and privileging manager of the facility hiring
the physician certify in writing that--
(A) a full investigation was carried out in
compliance with section 104 of this title; and
(B) an investigation did not disclose any actions
described in subsections (b), (c), and (d) of such
section.
(2) In approving the appointment under this subsection of
an individual for whom any matters have been disclosed under
subsection (b), a Director shall--
(A) certify in writing the completion of the
performance of the investigation under subsection
(d)(1) of each such matter, including the results of
such investigation; and
(B) provide a written justification why any matters
raised in the course of such investigation do not
disqualify the individual from appointment.
(f) Enrollment of Physicians With Practice Privileges in
Proactive Disclosure Service.--Each medical facility of the
Department at which physicians are extended the privileges of
practice shall enroll each physician extended such privileges
in the Proactive Disclosure Service of the National
Practitioner Data Bank.
(g) Encouraging Hiring of Physicians With Board
Certification.--(1) The Secretary shall, for each performance
contract with a Director of a Veterans Integrated Services
Network (VISN), include in such contract a provision that
encourages such director to hire physicians who are board
eligible or board certified in the specialty in which the
physicians will practice.
(2) The Secretary may determine the nature and manner of
the provision described in paragraph (1).
SEC. 7403. PERIOD OF APPOINTMENTS; PROMOTIONS
* * * * * * *
(b)(1) [Appointments] Except as otherwise provided in this
subsection, appointments described in subsection (a) shall be
for a probationary period of two years.
(2) With respect to the appointment of a registered nurse
under this chapter, paragraph (1) shall apply with respect to
such appointment regardless of whether such appointment is on a
full-time basis or a part-time basis.
(3) An appointment described in subsection (a) on a part-
time basis of a person who has previously served on a full-time
basis for the probationary period for the position concerned
shall be without a probationary period.
(4) [(2)] The record of each person serving under such an
appointment in the Medical, Dental, and Nursing Services shall
be reviewed from time to time by a board, appointed in
accordance with regulations of the Secretary. If such a board
finds that such person is not fully qualified and satisfactory,
such person shall be separated from the service.
* * * * * * *
SEC. 7404. GRADES AND PAY SCALES
(a)(1) The annual [The annual] rates or ranges of rates of
basic pay for positions provided in section 7306 of this title
shall be prescribed from time to time by Executive order as
authorized by chapter 53 of title 5 or as otherwise authorized
by law.
(2) The pay [The pay] of physicians and dentists serving in
positions to which an Executive order applies [under the
preceding sentence] under paragraph (1) shall be determined
under subchapter III of this chapter instead of such Executive
order.
(3)(A) The rate of basic pay for a position to which an
Executive order applies under paragraph (1) and is not
described by paragraph (2) shall be set in accordance with
section 5382 of title 5 as if such position were a Senior
Executive Service position (as such term is defined in section
3132(a) of title 5).
(B) A rate of basic pay for a position may not be set under
subparagraph (A) in excess of--
(i) in the case the position is not described in
clause (ii), the rate of basic pay payable for level
III of the Executive Schedule; or
(ii) in the case that the position is covered by a
performance appraisal system that meets the
certification criteria established by regulation under
section 5307(d) of title 5, the rate of basic pay
payable for level II of the Executive Schedule.
(C) Notwithstanding the provisions of subsection (d) of
section 5307 of title 5, the Secretary may make any
certification under that subsection instead of the Office of
Personnel Management and without concurrence of the Office of
Management and Budget.
* * * * * * *
SEC. 7405. TEMPORARY FULL-TIME APPOINTMENTS, PART-TIME APPOINTMENTS,
AND WITHOUT-COMPENSATION APPOINTMENTS
* * * * * * *
(g)(1) Except as provided in paragraph (3), employment of a
registered nurse on a temporary part-time basis under
subsection (a)(1) shall be for a probationary period of two
years.
(2) Except as provided in paragraph (3), upon completion by
a registered nurse of the probationary period described in
paragraph (1)--
(A) the employment of such nurse shall--
(i) no longer be considered temporary; and
(ii) be considered an appointment described
in section 7403(a) of this title; and
(B) the nurse shall be considered to have served the
probationary period required by section 7403(b).
(3) This subsection shall not apply to appointments made on
a term limited basis of less than or equal to three years of--
(A) nurses with a part-time appointment resulting
from an academic affiliation or teaching position in a
nursing academy of the Department;
(B) nurses appointed as a result of a specific
research proposal or grant; or
(C) nurses who are not citizens of the United States
and appointed under section 7407(a) of this title.
(h)(1) The Secretary may waive the application of sections
8344 and 8468 of title 5 (relating to annuities and pay on
reemployment) or any other similar provision of law under a
Government retirement system on a case-by-case basis for an
annuitant reemployed on a temporary basis under the authority
of subsection (a) in a position described under paragraph (1)
of that subsection.
(2) An annuitant to whom a waiver under paragraph (1) is in
effect shall not be considered an employee for purposes of any
Government retirement system.
(3) An annuitant to whom a waiver under paragraph (1) is in
effect shall be subject to the provisions of chapter 71 of
title 5 (including all labor authority and labor representative
collective bargaining agreements) applicable to the position to
which appointed.
(4) In this subsection:
(A) The term ``annuitant'' means an annuitant under a
Government retirement system.
(B) The term ``employee'' has the meaning under
section 2105 of title 5.
(C) The term ``Government retirement system'' means a
retirement system established by law for employees of
the Government of the United States.
* * * * * * *
SEC. 7410. ADDITIONAL PAY AUTHORITIES
(a) In General.--The Secretary may [The Secretary may]
authorize the Under Secretary for Health to pay advance
payments, recruitment or relocation bonuses, and retention
allowances to the personnel described in paragraph (1) of
section 7401 of this title, or interview expenses to candidates
for appointment as such personnel, in the same manner, and
subject to the same limitations, as in the case of the
authority provided under sections 5524a, 5706b, 5753, and 5754
of title 5.
(b) Special Incentive Pay for Department Pharmacist
Executives.--(1) In order to recruit and retain highly
qualified Department pharmacist executives, the Secretary may
authorize the Under Secretary for Health to pay special
incentive pay of not more than $40,000 per year to an
individual of the Veterans Health Administration who is a
pharmacist executive.
(2) In determining whether and how much special pay to
provide to such individual, the Under Secretary shall consider
the following:
(A) The grade and step of the position of the
individual.
(B) The scope and complexity of the position of the
individual.
(C) The personal qualifications of the individual.
(D) The characteristics of the labor market
concerned.
(E) Such other factors as the Secretary considers
appropriate.
(3) Special incentive pay under paragraph (1) for an
individual is in addition to all other pay (including basic
pay) and allowances to which the individual is entitled.
(4) Except as provided in paragraph (5), special incentive
pay under paragraph (1) for an individual shall be considered
basic pay for all purposes, including retirement benefits under
chapters 83 and 84 of title 5, and other benefits.
(5) Special incentive pay under paragraph (1) for an
individual shall not be considered basic pay for purposes of
adverse actions under subchapter V of this chapter.
(6) Special incentive pay under paragraph (1) may not be
awarded to an individual in an amount that would result in an
aggregate amount of pay (including bonuses and awards) received
by such individual in a year under this title that is greater
than the annual pay of the President.
* * * * * * *
Subchapter III. Pay for Physicians and Dentists
SEC. 7431. PAY
* * * * * * *
(b) * * *
* * * * * * *
(5) The non-foreign cost of living adjustment
allowance authorized under section 5941 of title 5 for
physicians and dentists whose pay is set under this
section shall be determined as a percentage of base pay
only.
* * * * * * *
(c) * * *
* * * * * * *
(4)(A) * * *
(B)(i) In determining the amount of the market pay
for a particular physician or dentist under this
subsection, and in determining a tier (if any) to apply
to a physician or dentist under subsection (e)(1)(B),
the Secretary shall consult with and consider the
recommendations of an appropriate panel or board
composed of physicians or dentists (as applicable). The
Secretary may exempt physicians and dentists occupying
administrative or executive leadership positions from
the requirements of the previous sentence.
* * * * * * *
(7) No adjustment of the amount of market pay of a
physician or dentist under paragraph (6) may result in
a reduction of the amount of market pay of the
physician or dentist while in the same position or
assignment at the medical facility of the Department
[concerned.] concerned, unless there is a change in
board certification or reduction of privileges.
* * * * * * *
Subchapter IV. Pay for Nurses and Other
Health-Care Personnel
SEC. 7451. NURSES AND OTHER HEALTH-CARE PERSONNEL: COMPETITIVE PAY
* * * * * * *
(c)(1) * * *
(2) The maximum rate of basic pay for any grade for a
covered position may not exceed the maximum rate of basic pay
established for positions in [level V] level IV of the
Executive Schedule under section 5316 of title 5. The maximum
rate of basic pay for a grade for the position of certified
registered nurse anesthetist pursuant to an adjustment under
subsection (d) may exceed the maximum rate otherwise provided
in the preceding sentence.
* * * * * * *
(d)(3)(A) * * *
* * * * * * *
(F) The Under Secretary for Health shall provide
appropriate education, training, and support to directors of
Department health care facilities in the conduct and use of
surveys, including the use of third-party surveys, under this
paragraph.
* * * * * * *
(e)(4) * * *
* * * * * * *
(D) In any case in which the director conducts such a
wage survey during the period covered by the report and
makes adjustment in rates of basic pay applicable to
one or more covered positions at the facility,
information on the methodology used in making such
adjustment or adjustments.
(E) [(D)] In any case in which the director, after
finding that there is, or is likely to be, in
accordance with criteria established by the Secretary,
a significant pay-related staffing problem at that
facility for any covered position, determines not to
conduct a wage survey with respect to that position, a
statement of the reasons why the director did not
conduct such a survey.
* * * * * * *
(e)(5) * * *
(6)(A) Upon the request of an individual described in
subparagraph (B) for a report provided under paragraph (4) with
respect to a Department health-care facility, the Under
Secretary for Health or the director of such facility shall
provide to the individual the most current report for such
facility provided under such paragraph.
(B) An individual described in this subparagraph is--
(i) an individual in a covered position at a
Department health-care facility; or
(ii) a representative of the labor organization
representing that individual who is designated by that
individual to make the request.
* * * * * * *
[(f) Not later than March 1 of each year, the Secretary
shall submit to the Committees on Veterans' Affairs of the
Senate and House of Representatives a report regarding any pay
adjustments under the authority of subsection (d) effective
during the 12 months preceding the submission of the report.
Each such report shall set forth, by health-care facility, the
percentage of such increases and, in any case in which no
increase was made, the basis for not providing an increase.]
(f) [(g)] For the purposes of this section, the term
``health-care facility'' means a medical center, an independent
outpatient clinic, or an independent domiciliary facility.
SEC. 7452. NURSES AND OTHER HEALTH-CARE PERSONNEL: ADMINISTRATION OF
PAY
* * * * * * *
(g)(1) * * *
(2) The amount of special pay paid to a nurse executive
under paragraph (1) shall be not less than $10,000 or more than
[$25,000] $100,000.
* * * * * * *
SEC. 7453. NURSES: ADDITIONAL PAY
(a) In addition to the rate of basic pay provided for
nurses, [a nurse] a full-time nurse or part-time nurse shall
receive additional pay as provided by this section.
(b) A nurse performing service [on a tour of duty], any
part of which is within the period commencing at 6 postmeridian
and ending at 6 antemeridian, shall receive additional pay for
each hour of [service on such tour] such service at a rate
equal to 10 percent of the nurse's hourly rate of basic pay if
at least four hours [of such tour] of such service fall between
6 postmeridian and 6 antemeridian. When less than four hours
[of such tour] of such service fall between 6 postmeridian and
6 antemeridian, the nurse shall be paid the differential for
each hour of service performed between those hours.
(c) A nurse performing service [on a tour of duty], any
part of which is within the period commencing at midnight
Friday and ending at midnight Sunday, shall receive additional
pay for each hour of [service on such tour] such service at a
rate equal to 25 percent of such nurse's hourly rate of basic
pay.
(d) * * *
(e)(1) A nurse performing officially ordered or approved
hours of service in excess of 40 hours in an administrative
workweek, or in excess of [eight hours in a day] eight
consecutive hours, shall receive overtime pay for each hour of
such additional service. The overtime rates shall be one and
one-half times such nurse's hourly rate of basic pay.
* * * * * * *
(5) * * *
(A) such travel occurs during such nurse's [tour of
duty] period of service; or
* * * * * * *
SEC. 7454. PHYSICIAN ASSISTANTS AND OTHER HEALTH CARE PROFESSIONALS:
ADDITIONAL PAY
(b)(1) * * *
* * * * * * *
[(3) Employees appointed under section 7408 of this title
shall be entitled to additional pay on the same basis as
provided for nurses in section 7453(c) of this title.]
(3) Employees appointed under section 7408 of this title
performing service on a tour of duty, any part of which is
within the period commencing at midnight Friday and ending at
midnight Sunday, shall receive additional pay in addition to
the rate of basic pay provided such employees for each hour of
service on such tour at a rate equal to 25 percent of such
employee's hourly rate of basic pay.
(c) * * *
SEC. 7455. INCREASES IN RATES OF BASIC PAY
* * * * * * *
[(c)(1) The amount of any increase under subsection (a) in
the maximum rate for any grade may not (except in the case of
nurse anesthetists, pharmacists, and licensed physical
therapists) exceed by two times the amount by which the maximum
for such grade (under applicable provisions of law other than
this subsection) exceeds the minimum for such grade (under
applicable provisions of law other than this subsection), and
the maximum rate as so increased may not exceed the rate paid
for individuals serving as Assistant Under Secretary for
Health.
[(2) Whenever the amount of an increase under subsection
(a) results in a rate of basic pay for a position being equal
to or greater than the amount that is 94 percent of the maximum
amount permitted under paragraph (1), the Secretary shall
promptly notify the Committees on Veterans' Affairs of the
Senate and House of Representatives of the increase and the
amount thereof.]
(c)(1) Subject to paragraph (2), the amount of any increase
under subsection (a) in the minimum rate for any grade may not
exceed the maximum rate of basic pay (excluding any locality-
based comparability payment under section 5304 of title 5 or
similar provision of law) for the grade or level by more than
30 percent.
(2) No rate may be established under this section in excess
of the rate of basic pay payable for level IV of the Executive
Schedule.
* * * * * * *
SEC. 7456. NURSES: SPECIAL RULES FOR WEEKEND DUTY
* * * * * * *
[(c) A nurse described in subsection (b)(1) who is absent
on approved sick leave or annual leave during a regularly
scheduled 12-hour tour of duty shall be charged for such leave
at a rate of five hours of leave for three hours of absence.]
(c) [(d)] The Secretary shall prescribe regulations for the
implementation of this section.
SEC. 7456A. NURSES: ALTERNATE WORK SCHEDULES
(a) * * *
(b) [36/40] 72/80 work schedule.
(1)(A) Subject to paragraph (2), if the Secretary
determines it to be necessary in order to obtain or
retain the services of registered nurses at any
Department health-care facility, the Secretary may
provide, in the case of nurses employed at such
facility, that such nurses who work [three regularly
scheduled 12-hour tours of duty within a work week
shall be considered for all purposes to have worked a
full 40-hour basic work week.] six regularly scheduled
12-hour tours of duty within a 14-day period shall be
considered for all purposes to have worked a full 80-
hour pay period.
(B) A nurse who works under the authority in
subparagraph (A) shall be considered a 0.90 full-time
equivalent employee in computing full-time equivalent
employees for the purposes of determining compliance
with personnel ceilings.
(2)(A) Basic and additional pay for a nurse who is
considered under paragraph (1) to have worked a full
[40-hour basic work week] 80-hour pay period shall be
subject to subparagraphs (B) and (C).
(B) The hourly rate of basic pay for a nurse covered
by this paragraph for service performed as part of a
[regularly scheduled 36-hour tour of duty within the
work week] scheduled 72-hour tour of duty within the
bi-weekly pay period shall be derived by dividing the
nurse's annual rate of basic pay by 1,872.
(C) The Secretary shall pay overtime pay to a nurse
covered by this paragraph who--
(i) performs a period of service in excess of
such nurse's [regularly scheduled 36-hour tour
of duty within an administrative work week]
scheduled 72-hour tour of duty within an
administrative pay period;
(ii) for officially ordered or approved
service, performs a period of service in excess
of 8 hours on a day other than a day on which
such nurse's [regularly] scheduled 12-hour tour
of duty falls;
(iii) performs a period of service in excess
of 12 hours for any day included in the
[regularly scheduled 36-hour tour of duty work
week] scheduled 72-hour tour of duty pay
period; or
(iv) performs a period of service in excess
of 40 hours during an administrative work week.
(D) The Secretary may provide a nurse to whom this
subsection applies with additional pay under section
7453 of this title for any period included in a
[regularly] scheduled 12-hour tour of duty.
(3) A nurse who works a work schedule described in
this subsection who is absent on approved sick leave or
annual leave during a [regularly] scheduled 12-hour
tour of duty shall be charged for such leave at a rate
of ten hours of leave for every nine hours of absence.
SEC. 7459. NURSING STAFF: SPECIAL RULES FOR OVERTIME DUTY
(a) Limitation.--Except as provided in subsection (c), the
Secretary may not require nursing staff to work more than 40
hours (or 24 hours if such staff is covered under section 7456
of this title) in an administrative work week or more than
eight consecutive hours (or 12 hours if such staff is covered
under section 7456 or 7456A of this title).
(b) Voluntary Overtime.--(1) Nursing staff may on a
voluntary basis elect to work hours otherwise prohibited by
subsection (a).
(2) The refusal of nursing staff to work hours prohibited
by subsection (a) shall not be grounds to discriminate (within
the meaning of section 704(a) of the Civil Rights Act of 1964
(42 U.S.C. 2000e-3(a))) against the staff, dismissal or
discharge of the staff, or any other adverse personnel action
against the staff.
(c) Overtime Under Emergency Circumstances.--(1) Subject to
paragraph (2), the Secretary may require nursing staff to work
hours otherwise prohibited by subsection (a) if--
(A) the work is a consequence of an emergency that
could not have been reasonably anticipated;
(B) the emergency is non-recurring and is not caused
by or aggravated by the inattention of the Secretary or
lack of reasonable contingency planning by the
Secretary;
(C) the Secretary has exhausted all good faith,
reasonable attempts to obtain voluntary workers;
(D) the nurse staff have critical skills and
expertise that are required for the work; and
(E) the work involves work for which the standard of
care for a patient assignment requires continuity of
care through completion of a case, treatment, or
procedure.
(2) Nursing staff may not be required to work hours under
this subsection after the requirement for a direct role by the
staff in responding to medical needs resulting from the
emergency ends.
(d) Nursing Staff Defined.--In this section, the term
`nursing staff' includes the following;
(1) A registered nurse.
(2) A licensed practical or vocational nurse.
(3) A nurse assistant appointed under this chapter or
title 5.
(4) Any other nurse position designated by the
Secretary for purposes of this section.
* * * * * * *
CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM
* * * * * * *
Subchapter II. Scholarship Program
* * * * * * *
SEC. 7612. ELIGIBILITY; APPLICATION; AGREEMENT
* * * * * * *
(b)(1) * * *
(2) A qualifying field of education or training for
purposes of this subchapter is education or training leading to
employment as an appointee under paragraph (1) or (3) of
section 7401 of this title. [(under section 7401 of this title)
as any of the following:]
[(A) A physician, dentist, podiatrist, optometrist,
nurse, physician assistant, or expanded function dental
auxiliary.
[(B) A psychologist described in section 7401(3) of
this title or a certified or registered respiratory
therapist, licensed physical therapist, or licensed
practical or vocational nurse.]
* * * * * * *
SEC. 7618. EXPIRATION OF PROGRAM
The Secretary may not furnish scholarships to new
participants in the Scholarship Program after [December 31,
1998] December 31, 2014.
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Subchapter VII. Education Debt Reduction Program
SEC. 7681. AUTHORITY FOR PROGRAM
(a) In general.--
(1) * * *
(2) The purpose of the Education Debt Reduction
Program is to assist in the recruitment and retention
of qualified health care professionals for positions in
the Veterans Health Administration for which
recruitment or retention of an adequate supply of
qualified personnel is difficult.
(b) * * *
SEC. 7682. ELIGIBILITY
(a) Eligibility.--An individual is eligible to participate
in the Education Debt Reduction Program if the individual--
(1) is [a recently appointed] an employee in the
Veterans Health Administration serving in a position
(as determined by the Secretary) providing direct-
patient care services or services incident to direct-
patient care services for which recruitment or
retention of qualified health-care personnel (as so
determined) is difficult; and
* * * * * * *
[(c) Recently appointed individuals.--For purposes of
subsection (a), an individual shall be considered to be
recently appointed to a position if the individual has held
that position for less than 6 months.]
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PART VI. ACQUISITION AND DISPOSITION OF PROPERTY
CHAPTER 81. ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY
FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL
PROPERTY
SUBCHAPTER I. ACQUISITION AND OPERATION OF MEDICAL FACILITIES
SEC.
* * * * * * *
[8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES.]
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SUBCHAPTER III. STATE HOME FACILITIES FOR FURNISHING DOMICILIARY,
NURSING HOME, AND HOSPITAL CARE
* * * * * * *
8133A. TRIBAL ORGANIZATIONS.
* * * * * * *
Subchapter I. Acquisition and Operation of
Medical Facilities
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[SEC. 8107. OPERATIONAL AND CONSTRUCTION PLANS FOR MEDICAL FACILITIES
[(a) In order to promote effective planning for the
efficient provision of care to eligible veterans, the
Secretary, based on the analysis and recommendations of the
Under Secretary for Health, shall submit to each committee an
annual report regarding long-range health planning of the
Department. The report shall be submitted each year not later
than the date on which the budget for the next fiscal year is
submitted to the Congress under section 1105 of title 31.
[(b) Each report under subsection (a) shall include the
following:
[(1) A five-year strategic plan for the provision of
care under chapter 17 of this title to eligible
veterans through coordinated networks of medical
facilities operating within prescribed geographic
service-delivery areas, such plan to include provision
of services for the specialized treatment and
rehabilitative needs of disabled veterans (including
veterans with spinal cord dysfunction, blindness,
amputations, and mental illness) through distinct
programs or facilities of the Department dedicated to
the specialized needs of those veterans.
[(2) A description of how planning for the networks
will be coordinated.
[(c) The Secretary shall submit to each committee not later
than January 31 of each year a report showing the location,
space, cost, and status of each medical facility (1) the
construction, alteration, lease, or other acquisition of which
has been approved under section 8104(a) of this title, and (2)
which was uncompleted as of the date of the last preceding
report made under this subsection.
[(d)(1) The Secretary shall submit to each committee, not
later than January 31 of each year, a report showing the
current priorities of the Department for proposed major medical
construction projects. Each such report shall identify the 20
projects, from within all the projects in the Department's
inventory of proposed projects, that have the highest priority
and, for those 20 projects, the relative priority and rank
scoring of each such project and the projected cost of such
project (including the projected operating costs, including
both recurring and nonrecurring costs). The 20 projects shall
be compiled, and their relative rankings shall be shown, by
category of project (including the categories of ambulatory
care projects, nursing home care projects, and such other
categories as the Secretary determines).
[(2) The Secretary shall include in each report, for each
project listed, a description of the specific factors that
account for the relative ranking of that project in relation to
other projects within the same category.
[(3) In a case in which the relative ranking of a proposed
project has changed since the last report under this subsection
was submitted, the Secretary shall also include in the report a
description of the reasons for the change in the ranking,
including an explanation of any change in the scoring of the
project under the Department's scoring system for proposed
major medical construction projects.]
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Subchapter III. State Home Facilities for Furnishing Domiciliary,
Nursing Home, and Hospital Care
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SEC. 8131. DEFINITIONS
* * * * * * *
(5) The term ``tribal organization'' has the meaning
given such term in section 3765 of this title.
SEC. 8132. DECLARATION OF PURPOSE
The purpose of this subchapter is to assist the several
States and tribal organizations to construct State home
facilities (or to acquire facilities to be used as State home
facilities) for furnishing domiciliary or nursing home care to
veterans, and to expand, remodel, or alter existing buildings
for furnishing domiciliary, nursing home, adult day health, or
hospital care to veterans in State homes.
SEC. 8133. AUTHORIZATION OF APPROPRIATIONS
* * * * * * *
SEC. 8133A. TRIBAL ORGANIZATIONS
(a) Authority To Award Grants.--The Secretary may award a
grant to a tribal organization under this subchapter in order
to carry out the purposes of this subchapter.
(b) Manner and Condition of Grant Awards.--(1) Grants to
tribal organizations under this section shall be awarded in the
same manner, and under the same conditions, as grants awarded
to the several States under the provisions of this subchapter,
subject to such exceptions as the Secretary shall prescribe for
purposes of this subchapter to take into account the unique
circumstances of tribal organizations.
(2) For purposes of according priority under subsection
(c)(2) of section 8135 of this title to an application
submitted under subsection (a) of such section, an application
submitted under such subsection (a) by a tribal organization of
a State that has previously applied for award of a grant under
this subchapter for construction or acquisition of a State
nursing home shall be considered under subparagraph (C) of such
subsection (c)(2) an application from a tribal organization
that has previously applied for such a grant.
* * * * * * *
SEC. 8138. TREATMENT OF CERTAIN HEALTH FACILITIES AS STATE HOMES
* * * * * * *
(d) * * *
(e)(1) A health facility (or certain beds in a health
facility) of a tribal organization is treatable as a State home
under subsection (a) in accordance with the provisions of that
subsection.
(2) Except as provided in paragraph (3), the provisions of
this section shall apply to a health facility (or certain beds
in such facility) treated as a State home under subsection (a)
by reason of this subsection to the same extent as health
facilities (or beds) treated as a State home under subsection
(a).
(3) Subsection (f) shall not apply to the treatment of
health facilities (or certain beds in such facilities) of
tribal organizations as a State home under subsection (a).
(f) [(e)] The Secretary may not treat any new health
facilities (or any new certain beds in a health facility) as a
State home under subsection (a) after September 30, 2009.
* * * * * * *
PERSIAN GULF WAR VETERANS' HEALTH STATUS ACT
(Public Law 102-585; 106 Stat. 4943; 38 U.S.C. 527 Note)
* * * * * * *
TITLE VII. PERSIAN GULF WAR VETERANS' HEALTH STATUS
* * * * * * *
SEC. 707. COORDINATION OF HEALTH-RELATED GOVERNMENT ACTIVITIES ON THE
PERSIAN GULF WAR
* * * * * * *
(c) Reports.--
(1) [Not later than March 1 of each year] Not later
than July 1, 2010, and July 1 of each of the five
following years, the head of the department or agency
designated under subsection (a) shall submit to the
Committees on Veterans' Affairs of the Senate and House
of Representatives a report on--
(A) the status and results of all such
research activities undertaken by the executive
branch during the previous year; and
(B) research priorities identified during
that year.
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