[Senate Report 111-80]
[From the U.S. Government Publishing Office]
Calendar No. 167
111th Congress Report
SENATE
1st Session 111-80
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CAREGIVER AND VETERANS HEALTH SERVICES ACT
OF 2009
_______
September 25, 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. 801]
The Committee on Veterans' Affairs (hereinafter, ``the
Committee''), to which was referred the bill (S. 801), to amend
title 38, United States Code, to waive charges for humanitarian
care provided by the Department of Veterans Affairs
(hereinafter, ``VA'' or ``the Department'') to family members
accompanying veterans severely injured after September 11,
2001, as they receive medical care from the Department, and to
provide assistance to family caregivers, and for other
purposes, reports favorably thereon with an amendment, and
recommends that the bill, (as amended) do pass.
Introduction
On April 2, 2009, Chairman Akaka introduced S. 801, the
proposed ``Family Caregiver Program Act of 2009.'' S. 801, as
introduced, would create a national program for the caregivers
of seriously injured veterans to provide them with education,
grants, counseling, and other support.
Earlier, on February 10, 2009, Senator Akaka introduced
S. 404, the proposed ``Veterans'' Emergency Care Fairness Act
of 2009.'' S. 404 would expand veteran eligibility for
reimbursement by the Secretary of Veterans Affairs for
emergency treatment furnished in a non-Department facility.
On March 6, 2009, Senator Durbin introduced S. 543, the
proposed ``Veteran and Servicemember Caregiver Support Act of
2009.'' S. 543 would require a pilot program on training,
certification, and support for family caregivers of seriously
disabled veterans.
On March 19, 2009, Senator Tester introduced S. 658, the
proposed ``Rural Veterans Improvement Act of 2009.'' S. 658
would, among other things, improve health care for veterans who
live in rural areas.
On March 30, 2009, Senator Akaka introduced S. 734, the
proposed ``Rural Veterans Health Care Access and Quality Act of
2009.'' This bill would improve the capacity of the Department
of Veterans Affairs to recruit and retain physicians in
underserved areas known as Health Professional Shortage Areas
(hereinafter, ``HPSAs'') and improve the provision of health
care to veterans in rural areas.
On April 2, 2009, Senator Brown introduced S. 793, the
proposed ``Department of Veterans Affairs Vision Scholars Act
of 2009.'' S. 793 would direct the Secretary of Veterans
Affairs to establish a scholarship program for students seeking
a degree or certificate in the areas of visual impairment and
orientation and mobility.
On February 26, 2009, the Committee held a hearing on
caring for veterans in rural areas. Testimony was offered by:
Kara Hawthorne, Director, Office of Rural Health, Veterans
Health Administration; Adam W. Darkins, M.D., Chief Consultant
for Care Coordination, Veterans Health Administration; Reverend
Ricardo Flippin, Project Coordinator, West Virginia Council of
Churches, CARE-NET: Caring Beyond the Yellow Ribbon; H. Alan
Watson, Chief Executive Officer, St. Mary's Medical Center of
Campbell County, Lafollette, Tennessee; Tom Loftus, Commander,
The American Legion, Post 45, Clarksville, Virginia; and Matt
Kuntz, Executive Director, National Alliance for the Mentally
Ill, Montana Chapter.
On April 22, 2009, the Committee held a hearing on pending
health care legislation. Testimony was offered by: Gerald M.
Cross, M.D., Principal Deputy Under Secretary for Health,
Department of Veterans Affairs, accompanied by Walter A. Hall,
Assistant General Counsel, and 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, representing the American
Federation of Government Employees; and Blake Ortner, Senior
Associate Legislative Director, Paralyzed Veterans of America.
Committee Meeting
After carefully reviewing the testimony from the foregoing
hearings, the Committee met in open session on May 21, 2009, to
consider, among other legislation, an amended version of
S. 801, consisting of provisions from S. 801 as introduced, and
other legislation noted above, as well as several freestanding
provisions. The Committee voted unanimously to report favorably
S. 801, as amended.
Summary of S. 801 as Reported
S. 801, as reported, would amend the title of the original
bill (hereinafter, ``the Committee bill'' or ``this Act''), and
would provide for a program of support for caregivers of
seriously injured veterans, improve health care provided to
veterans residing in rural areas, and make other enhancements
and expansions to VA health care.
TITLE I--CAREGIVER SUPPORT
Section 101 would authorize VA to waive the cost of
furnishing hospital care or medical services for caregivers of
veterans in emergency cases.
Section 102 would create a comprehensive program to provide
assistance to the caregivers of severely injured veterans.
Section 103 would authorize the Secretary to pay for the
caregivers' lodging and subsistence as well as the expenses of
travel for the period consisting of travel to and from a
treatment facility and the duration of a treatment episode at
that facility.
Section 104 would require VA to collaborate with the
Department of Defense (hereinafter, ``DOD'') to conduct, and
thereafter submit to Congress, a national survey of family
caregivers.
TITLE II--RURAL HEALTH IMPROVEMENTS
Section 201 would authorize the Secretary to include
education loan repayment in offers of employment in an amount
equal to the potential employee's total indebtedness.
Section 202 would create a new visual impairment,
orientation and mobility professionals' education assistance
program.
Section 203 would require VA to transfer funds to the
Department of Health and Human Services for the purpose of
listing VA facilities on the National Health Service Corps
list.
Section 204 would mandate the expansion of telehealth
services, promote the training of health care personnel in
telemedicine technologies, and require appropriate
reimbursement to facilities offering those services.
Section 205 would authorize rural health demonstration
projects which may include partnering with other agencies or
community entities.
Section 206 would authorize VA to contract-out mental
health services for Operation Iraqi Freedom (hereinafter,
``OIF'') and Operation Enduring Freedom (hereinafter, ``OEF'')
veterans in rural areas.
Section 207 would promote improved partnership and
collaboration between VA and the Indian Health Service
(hereinafter, ``IHS'') to enhance care for Indian veterans.
Section 208 would require VA to reimburse certain veterans
requiring air travel transportation for treatment at VA
facilities.
Section 209 would require the VA Office of Rural Health to
develop a 5-year strategic plan for improving access to quality
health care for veterans who live in rural areas.
Section 210 would provide incentives for providers paid by
VA through contracts or on a fee-for-service basis to implement
certain quality improvement measures.
Section 211 would authorize VA to use volunteers and other
individuals to provide readjustment counseling, and to expedite
the credentialing and privileging of licensed independent
health care providers working on a volunteer basis in
readjustment counseling centers.
Section 212 would require VA to establish rural health
Centers of Excellence.
Section 213 would authorize a pilot program that
incentivizes physicians to assume inpatient responsibilities at
community hospitals in health professional shortage areas.
Section 214 would require reports on the implementation of
sections 209 through 213 of the Committee bill and a report on
VA fee-basis health care and outreach programs.
Section 215 would authorize grants to veterans service
organizations for the purposes of providing certain
transportation services to veterans.
TITLE III--OTHER HEALTH CARE MATTERS
Section 301 would authorize VA to reimburse certain
veterans for emergency treatment received at a non-VA medical
facility, without regard to insurance coverage.
Section 302 would exempt veterans who are catastrophically
disabled from copayment requirements for the receipt of
hospital care or medical services.
TITLE IV--CONSTRUCTION AND NAMING MATTERS
Section 401 would authorize funds for design and
construction at the VA Medical Center, Walla Walla, Washington.
Section 402 would designate the VA outpatient clinic in
Havre, Montana as the ``Merril Lundman Department of Veterans
Affairs Outpatient Clinic.''
Background and Discussion
TITLE I--CAREGIVER SUPPORT
Title I of the Committee bill contains a number of
provisions that are designed to help caregivers of veterans.
Many veterans returning from the conflicts in Iraq and
Afghanistan sustained severe injuries and need substantial
care. According to VA, as of January 2009, 981,834 OEF/OIF
servicemembers had left active duty, and 425,538 (or 43
percent) had accessed VA health care.
Congress has recognized the need for VA to provide
assistance to caregivers of severely injured veterans. Public
Law 109-461, Section 214 authorized $5,000,000 for each of the
fiscal years (FY) 2007 and 2008 for VA to carry out pilot
caregiver assistance programs. VA began eight caregiver
assistance pilot programs in October 2007. A 1-year extension
of the authority for these pilot programs was approved in
Public Law 110-329, the ``Consolidated Security, Disaster
Assistance, and Continuing Appropriations Act, 2009.''
These pilot programs offer such services as caregiver
education, training, improved care coordination, and peer
networking. They do not provide health care, mental health
counseling, or financial assistance to caregivers. Based on the
comprehensive needs of caregivers, Ralph Ibson, Health Policy
Senior Fellow of the Wounded Warrior Project (hereinafter,
``WWP'') testified before the Committee at its April 22, 2009,
health legislation hearing that ``the time for pilot programs
is past.''
Fully supporting caregiving activities is also cost
effective, as the cost of providing care in an institutional
setting can be much greater than the cost of providing care in
the home. According to a survey conducted in 2005 by MetLife's
Mature Market Institute, the average cost of a private room in
a nursing home in the United States was $74,095 per year. VA is
obligated to provide nursing home care for veterans who need
such care, and who meet one of the following criteria: a
service-connected disability rating of 70 percent or more; a
need for nursing home care for a service-connected disability;
or a rating of 60 percent when a veteran is either unemployable
or permanently and totally disabled. In its 2009 budget
submission, VA projected that the average daily census in its
institutional care settings, including community living
centers, community nursing homes, and state veterans homes,
would reach 90,654 in 2010, an increase of 25.3 percent over
2009 levels.
Many veterans, however, prefer care in the home, especially
younger veterans such as those now returning from the conflicts
in Afghanistan and Iraq. As the WWP witness, Ralph Ibson,
testified before the Committee at its April 22, 2009, health
legislation hearing:
These individuals usually want to return to, or remain
in, their homes, and strongly resist being
institutionalized * * *. Most warriors want to be cared
for by their loved ones, if possible, rather than
agency personnel. Most families want the same for their
wounded warrior. But the extraordinary demands of
caregiving invariably takes a toll on family
caregivers--physically, psychologically, emotionally,
and financially.
At the same hearing, the witness representing the American
Federation of Government Employees (hereinafter, ``AFGE''),
Ammie Hilsabeck, also called the contributions of today's
caregivers ``invaluable economically as they obviate the rising
costs of traditional institutional care.''
The financial toll on caregivers can be substantial,
however. The 2006 MetLife Caregiving Cost Study estimated that
15 to 20 percent of the nation's workforce as a whole is
engaged in caregiving at any one time. According to CNA's April
2009 report Economic Impact on Caregivers of the Seriously
Wounded, Ill, and Injured, 84 percent of veteran caregivers
were either working or in school prior to becoming a caregiver.
MetLife's cost study estimated that employer costs for working
caregivers totaled up to $33.6 billion in lost productivity. In
addition, an employed caregiver lost an average of about
$659,000 in wages, pension, and Social Security benefits over a
``career'' of caregiving.
These financial burdens may impact the ability of
caregivers to obtain health insurance. According to a 2001
Kaiser Family Foundation study, half of all caregivers have an
annual household income of less than $35,000. In the Family
Caregiver Alliance's September 2003 policy brief, authors
reported that 25 percent of women caregivers had difficulty
obtaining medical insurance compared to 16 percent of non-
caregiving women.
Mental health concerns are often prevalent in this
population as well. Caregivers report unmet needs in the areas
of finding time for themselves (35 percent) and of managing
emotional and/or physical stress (29 percent). In one study, 30
to 59 percent of caregivers reported depressive disorders or
symptoms.\1\ Testifying before the Committee at its April 22,
2009, health legislation hearing, the WWP witness said:
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\1\Cohen, D., Luchins, D., Eisdorfer, C., Paveza, G., Ashford, J.,
Gorelick, P., et al. (1990). Caring for relatives with Alzheimer's
Disease: The mental health risks to spouses, adult children, and other
family caregivers. Behavior, Health and Aging, 1, 171-182.
Highlighting the need for access to counseling and
other health care services, the studies also show that
family caregivers experience an increased likelihood of
stress, depression, and mortality compared to their
non-caregiving peers * * *. Caregivers report poorer
levels of perceived health, more chronic illnesses, and
poorer immune responses to viral challenges.
Sec. 101. Waiver of Charges for Humanitarian Care.
Section 101, which is derived from S. 801 as introduced,
would modify VA's authority to furnish humanitarian care so
that caregivers who accompany veterans would be exempt from
charges for emergency medical services.
Background. Non-veterans may receive medical care from VA
in emergency cases under current law, but VA charges them for
such services. Charging caregivers who accompany veterans to VA
facilities, and subsequently need emergency care, adds to the
economic impact of caregiving on veterans' families.
Committee Bill. Section 101 of the Committee bill would
revise section 1784 of title 38, to amend existing law which
authorizes VA to furnish and charge for hospital care or
medical services in emergencies, so as to authorize VA to
furnish such services, without charge, in emergency cases to
attendants accompanying certain veterans when the veterans are
receiving care from or through VA.
Subsections (a) and (b) of revised section 1784 are a
restatement of current law which authorizes VA to furnish and
charge for care in emergencies. New subsection (c) of section
1784 would require VA to waive charges for such services if
those services are provided to an ``attendant of a covered
veteran'' while the attendant is accompanying such a veteran
receiving care at a VA facility, or at a non-VA facility that
is under contract with the Department or which is providing
care on a fee-for-service basis to the veteran. For purposes of
this section, an attendant is defined as a family member of the
veteran; an individual eligible to receive ongoing family
caregiver assistance under other provisions of this title; or
any other individual the Secretary determines to have a
relationship with the veteran sufficient to demonstrate a close
affinity with the veteran and who provides a significant
portion of the veteran's care.
This new subsection would also authorize VA to bill third
parties for health care provided should an attendant be
entitled to care or services under a health plan contract or
have other legal recourse against a third party that would
extinguish some or all liability associated with the charges.
New subsection (d) of section 1784 would define a covered
veteran as any veteran with a severe injury incurred or
aggravated in the line of duty in the active military, naval or
air service on or after September 11, 2001. ``Severe injury''
would be defined as any physiological, psychological or
neurological condition that renders a veteran unable to live
independently.
The WWP testified in support of these provisions before the
Committee at its April 22, 2009, health legislation hearing,
noting the economic impact of caregiving on the family.
Sec. 102. Family Caregiver Assistance.
Section 102 of the Committee bill, which is derived from
S. 801 as introduced, contains a number of provisions that
would require VA to provide training, medical care, a financial
stipend and other support for caregivers of veterans sustaining
or aggravating a severe injury after September 11, 2001, while
on active duty.
Background. While family caregivers may currently receive
certification and training through home health agencies, and
become employees of those agencies, according to a recent
survey conducted by VHA, only 233 family caregivers received
such training and certification through existing home health
agencies in FY 2008. The study also found that in FY 2009, VA
referred only 168 family caregivers to home care agencies for
training and certification. This suggests that the population
of caregivers who would be eligible for stipends under this
section would be very small.
A report from the Principal Deputy Assistant Secretary of
the Air Force for Manpower and Reserve Affairs found that there
was a greater need for caregiving services. The Assistant
Secretary was tasked by the Joint Department of Defense and
Department of Veterans Affairs Wounded, Ill, and Injured Senior
Oversight Committee (hereinafter, ``SOC'') to evaluate issues
of personnel, pay, and financial support, including the
economic impact borne by caregivers of the seriously wounded,
ill, and injured. This review, conducted by the Center for
Naval Analyses (hereinafter, ``CNA''), a non-partisan non-
profit research organization, found that 37 percent of
caregivers had unmet financial obligations, and that three out
of every four caregivers had quit, or taken time off from work
or school. CNA estimated that approximately 720 seriously
wounded, ill, or injured veterans annually would need the
services of a caregiver. Further, these servicemembers were
expected to require the services of a caregiver for an average
of 19 months.
The WWP witness testified before the Committee at its April
22, 2009, hearing on health legislation that proper caregiver
training and health care reduces the chances of injury to both
the caregiver and the recipient of the care. Current law limits
VA's ability to provide those services. Under section 1782 of
title 38, VA is authorized to provide counseling, training, and
mental health services to members of the veteran's immediate
family, the veteran's legal guardian, and to the individual in
whose household the veteran certifies an intention to live.
These services, however, are only available for: (1) veterans
receiving treatment for a service-connected disability if the
services are necessary in connection with that treatment; and
(2) veterans receiving treatment for other than a service-
connected disability if the services are necessary in
connection with the treatment, the services were initiated
during the veteran's hospitalization, and the continued
provision of the services on an outpatient basis is essential
to permit the discharge of the veteran from the hospital. There
is no requirement to provide these services if care can be
provided by individuals other than the family caregiver, or if
the caregiver does not live with the veteran.
In a letter to the Committee, Shawn Moon, General Manager
for Government and Education Services of Franklin Covey, a
national organization with specific expertise in the design of
training programs, said the following:
A family caregiver assistance program that emphasizes
awareness; prevention and wellness; early intervention
and treatment; and proactive health risk, condition or
disease management is a prudent federal investment.
Over the long term, the benefits of this approach will
be realized in improved care and outcomes for wounded
warriors, better health and quality of life for family
caregivers, reduced health care utilization, and
increased cost savings.
Committee Bill. Section 102 of the Committee bill would
create a comprehensive program to provide assistance to the
caregivers of severely injured veterans.
Subsection (a)(1) of this section of the Committee bill
would amend subchapter II of chapter 17 by adding a new
section, section 1717A, entitled ``Family caregiver
assistance.''
New section 1717A would consist of eleven subsections, (a)
through (k), as follows:
Subsection (a) of new section 1717A would require the
Secretary to provide caregiver assistance as part of home
health services authorized by Section 1717, so as to reduce the
number of veterans who are receiving, or in need of,
institutional care. Such assistance would be furnished upon the
joint application of an eligible veteran and a family member or
other individual designated by the veteran. The Secretary would
be permitted to furnish such assistance only if it is in the
best interest of the veteran to furnish this assistance.
Subsection (b) of new section 1717A would define which
veterans would be eligible to receive caregiver assistance. An
eligible veteran would be either a veteran or a member of the
Armed Forces undergoing medical discharge who has a serious
injury incurred or aggravated in the line of duty in the active
military, naval, or air service on or after September 11, 2001,
and who is determined to be in need of personal care services
because of being unable to perform one or more independent
activities of daily living; or of needing supervision or
protection as a result of neurological or other impairment; or
because of other matters specified by VA. The Secretary would
have discretion to extend the program to other veterans after
the first 2 years.
Subsection (c) of new section 1717A would require the
Secretary to evaluate each eligible veteran applying for
caregiver services to identify the personal care services
required by the veteran, and to determine whether the
requirements could be significantly or substantially satisfied
by the individual designated by the veteran. This evaluation
would be carried out at a VA facility or a non-VA facility
determined appropriate by VA. The Secretary would also be
required to evaluate each family member or other designee of an
eligible veteran who makes a joint application to determine the
amount of basic instruction, preparation, and training
necessary for the individual to provide the personal care
services required by the veteran, as well as additional
instruction, preparation, and training required to be the
primary personal care attendant for the veteran.
Subsection (d) of new section 1717A would provide for the
training and approval of personal care attendants. The
Secretary would be required to provide the basic instruction,
preparation and training determined necessary to enable the
individual to provide personal care services. The Secretary
would be authorized to provide additional instruction,
preparation, and training determined to be required if the
caregiver is approved as the personal care attendant of the
veteran, and requests, with concurrence of the veteran, such
additional instruction.
Subsection (d) would require the Secretary to approve the
caregiver as a personal care attendant for the veteran
following completion of basic instruction, preparation and
training. If the Secretary determines that a personal care
attendant, once designated, is in need of additional training,
VA must provide that training.
Subsection (d) would require VA to provide for necessary
travel, lodging and per diem expenses incurred by the caregiver
of an eligible veteran in undergoing training under this
section.
Subsection (d) would require VA to provide respite care to
veterans whose caregivers are undergoing training if the
participation of the caregiver in this training would interfere
with the provision of personal care services to the veteran.
Subsection (e) of new section 1717A would provide for the
designation of one family member or designee as the primary
personal care attendant for such eligible veteran with at least
one eligible caregiver. Eligible caregivers would have to be
approved, would have to have completed all instruction,
preparation and training, would have to elect to provide
personal care services to the veteran, would have to have the
veteran's consent to be the primary provider, and would have to
be considered competent to provide such services to the
veteran.
Subsection (e) would allow a veteran to revoke consent with
respect to a caregiver at any time and would require the
Secretary to immediately revoke an individual's designation as
the primary personal care attendant if the individual fails to
meet the specified requirements. In such a case, the Secretary,
in consultation with the veteran or the veteran's surrogate,
would be authorized to designate a new primary personal care
attendant. In the case of a revocation, the Secretary would be
required to ensure that the revocation would not interfere with
the provision of personal care services required by a veteran.
Subsection (f) of new section 1717A would provide for any
ongoing family caregiver assistance including direct technical
support, counseling, and access to an interactive Web site on
caregiver services to all individuals meeting the
qualifications for personal care attendant. In addition, the
primary personal care attendant of each veteran would be
provided with that same assistance, as well as mental health
services, respite care of not less than 30 days annually,
medical care unless the individual is entitled to care or
services under a health plan contract U.S.C. 1725(f), and a
monthly caregiver stipend.
Respite care would be provided either through appropriate
VA facilities or through existing respite care contracts or, if
neither approach is appropriate, through other facilities or
arrangements that are medically and age appropriate.
Subsection (f) would allow VA to contract for insurance,
medical services, or health plans if VA determines that the
Department lacks the capacity to furnish medical care to
primary personal care attendants.
Subsection (f) would require VA to provide monthly personal
caregiver stipends in accordance with a schedule determined by
the Secretary and based on the amount and degree of personal
care services provided. To the extent practicable, the amount
of the personal caregiver stipend would not be less than the
amount a commercial home health entity would pay an individual
in the geographic area of the veteran to provide equivalent
personal care services. If personal care services are not
available from a commercial provider in the geographic area of
an eligible veteran, the Secretary would be allowed to consider
the costs of commercial providers of personal care services in
other geographic areas with similar costs of living.
Subsection (f) would require termination of caregiver
assistance if the veteran no longer requires personal care
services.
Subsection (g) of new section 1717A would grant the
Secretary the authority to appoint a surrogate for the veteran
if an eligible veteran lacks the capacity to submit
applications, provide consent, make a request, or concur with a
request under section 1717A.
Subsection (h) of new section 1717A would provide oversight
of the caregiver assistance program through contracts with
appropriate entities. Each veteran receiving personal care
services from a personal care attendant would be visited in his
or her home by such oversight entity no less often than once
every 6 months. An oversight entity visiting an eligible
veteran would be required to submit findings for each visit,
including whether the veteran is receiving the care the veteran
requires.
If an oversight entity finds that a veteran has not
received required care, the Secretary would be authorized to
take appropriate actions, including revoking a caregiver's
approval and designation as a primary personal care attendant.
If the Secretary were to terminate ongoing family caregiver
assistance under subsection (f) because of the findings of an
oversight entity, the Secretary would not be authorized to
provide compensation to such entity for the provision of
personal care services to such veteran, unless the Secretary
determines that it is in the best interests of the veteran to
do so.
Subsection (i) of new 1717A would provide for a program of
outreach to inform eligible veterans and their family members
of the availability and nature of family caregiver assistance
under section 1717A.
Subsection (j) of new section 1717A would specify that a
decision by the Secretary affecting the furnishing of caregiver
assistance shall be considered a medical determination, and
that nothing in section 1717A shall be construed to create
either an employment relationship between VA and someone
receiving family caregiver assistance, or any entitlements to
any service or stipend.
Subsection (k) of new section 1717A would define family
caregiver assistance, family member, and personal care services
for purposes of section 1717A.
Subsection (a)(2) of this section of the Committee bill
would provide for a clerical amendment.
Subsection (a)(3) of this section of the Committee bill
would amend section 1781(a) of title 38 so as to authorize
health care for primary personal care attendants designated
under new section 1717A who are not entitled to care or
services under some other health plan contract.
Subsection (a)(4) of this section of the Committee bill
would specify, in a freestanding provision, that any family
caregiver assistance furnished under new section 1717A would be
in addition to any family caregiver assistance furnished under
VA programs.
Subsection (a)(5) of this section of the Committee bill
provides that the amendments made by subsection (a) would take
effect 270 days after the date of the enactment of this Act.
The Disabled Veterans of America, the Paralyzed Veterans of
America, and the Wounded Warrior Project testified at the
Committee's April 22, 2009, hearing on health care legislation
in support of the need for the services that would be provided
under new section 1717A. AFGE provided written testimony
supporting the bill as a whole.
Subsection (b)(1) of section 102 of the Committee bill
would mandate the development of a plan for the implementation
of new section 1717A and require VA to submit a report on such
plan to the Veterans' Affairs Committees of the House of
Representatives and Senate not later than 180 days after the
date of the enactment of this Act.
Subsection (b)(2) of this section of the Committee bill
would require VA, in developing the plan in the implementation
of new section 1717A, to consult with veterans eligible for
family caregiver assistance; family members of veterans who
provide personal services to such veterans; veterans service
organizations; national organizations that specialize in the
provision of assistance to individuals with the types of
disabilities that personal care attendants will encounter while
providing personal care services; such other organizations with
an interest in the provision of care to veterans as the
Secretary considers appropriate; and the Secretary of Defense
with respect to matters concerning personal care services for
members of the Armed Forces undergoing medical discharge from
the Armed Forces who would be eligible to benefit from family
caregiver assistance that would be furnished under new section
1717A.
The report would be required to contain the plan; a
description of the veterans, caregivers and organizations
consulted by the Secretary; a description of such
consultations; recommendations of such individuals and
organizations that were not incorporated into the plan; and the
reasons the Secretary did not incorporate such recommendations
into the plan.
Subsection (c)(1) of section 102 of the Committee bill
would require VA, no later than 2 years after the effective
date of this Act and annually thereafter, to submit a
comprehensive report on the implementation of new section 1717A
of title 38 to the Veterans' Affairs Committees of the House of
Representatives and the Senate. This report would be required
to contain the number of individuals that received caregiver
assistance under section 1717A; a description of the outreach
activities carried out by the Secretary in accordance with
subsection (i) of new section 1717A; information on the
resources expended by the Secretary under 1717A; an assessment
of the manner in which resources are expended by the Secretary
under section 1717A, particularly with respect to the provision
of monthly personal caregiver stipends; a description of the
outcomes achieved by, and any measurable benefits of, carrying
out the requirements of section 1717A; a justification of any
determination to extend the time period under which veterans
would be eligible for family caregiver assistance; an
assessment of the effectiveness and efficiency of the
implementation of section 1717A; an assessment of how the
provision of family caregiver assistance fits into the
continuum of VA home health services and benefits; and such
recommendations, including recommendations for legislative or
administrative action, as the Secretary considers appropriate
in light of carrying out the requirements of section 1717A.
Sec. 103. Lodging and Subsistence for Attendants.
Background. Section 103 of the Committee bill, which is
derived from S. 801 as introduced, would modify current
authority for beneficiary travel so as to authorize VA to pay
certain costs of caregivers who must travel. Under Section
111(e) of title 38, VA is authorized to pay qualifying travel
expenses for an attendant traveling with an eligible veteran
when the veteran requires an attendant in order to perform such
travel. This provision does not provide authority for VA to pay
for lodging and subsistence costs associated with this travel.
The DOD, on the other hand, is authorized to provide for per
diem and travel costs for up to three family members while the
servicemember is an inpatient and during the outpatient
rehabilitative phase for qualified servicemembers.
Committee Bill. Section 103 of the Committee bill would
amend section 111(e) of title 38, which authorizes VA to pay
certain expenses of travel to an attendant who is required to
accompany a veteran when the veteran is traveling to receive VA
care, to add a new paragraph (2) which would authorize the
Secretary to also pay lodging and subsistence expenses for the
period consisting of travel to and from a treatment facility
and the duration of treatment episode at that facility. New
paragraph (2) would allow the Secretary to prescribe
regulations to carry out this section, including regulations
that limit the number of individuals who can receive these
travel expenses for a single treatment episode of a veteran,
and that require attendants to use certain travel services.
This section of the Committee bill would also add a new
paragraph (3) to section 111(e) of title 38 which would define
the meaning of attendant for the purposes of this section. An
attendant would be defined as a family member of the veteran;
an individual eligible to receive ongoing caregiver assistance
under other provisions of this title; or any other individual
whom the Secretary determines has a preexisting relationship
with the veteran and provides a significant portion of the
veteran's care.
Sec. 104. Survey of Informal Caregivers.
Background. Section 104 of the Committee bill, which is
derived from S. 543, would require VA, working with the DOD, to
survey family caregivers of veterans. In April 2009, the
Veterans Health Administration conducted a survey to determine
how many family caregivers had been referred by VA to home
health agencies to be trained and certified as home health
aides and to be hired by the agency as a paid caregiver for the
veteran. In FY 2008, only 233 family caregivers were referred
for such training and certification. VA was unable to provide
the total number of family members serving as caregivers, or to
provide additional information regarding this population.
Committee Bill. Section 104 of the Committee bill, in a
freestanding provision, would require VA, in collaboration with
the DOD, to carry out a national survey of family caregivers of
veterans and members of the Armed Forces who are seriously
disabled in order to gain a better understanding of the size
and characteristics of the population of such caregivers, and
of the types of care they provide such veterans and members.
This section would require VA to submit to Congress, in
collaboration with DOD, a report containing the findings of the
survey, with the results disaggregated by those who are
veterans and those who are still members of the Armed Forces;
by those who served in Operation Iraqi Freedom or Operation
Enduring Freedom; and by those who live in rural areas. This
report would be due not later than 540 days after the date of
enactment of the Committee Bill.
TITLE II--RURAL HEALTH IMPROVEMENTS
Title II of the Committee bill contains a variety of
provisions that are designed to enhance the Department's
ability to meet the needs of veterans living in rural areas.
Those living in rural areas are more than twice as likely
to serve in the armed services as those living in urban areas.
More than one third of veterans currently enrolled with VA live
in rural areas. This number can only be expected to grow as it
was estimated by 2007 that 44 percent of the active duty
military were from rural areas.
Ensuring access to health care for rural veterans remains a
challenge for VA. Hilda Heady, past president of the National
Rural Health Association (hereinafter, ``NRHA''), testified
during the Committee's April 22, 2009, health legislation
hearing:
There is a national misconception that all veterans
have access to comprehensive care. Unfortunately, this
is simply not true. Access to the most basic primary
care is often difficult in rural America. Access for
rural veterans can be daunting. Combat veterans
returning to their rural homes in need of specialized
care due to war injuries (both physical and mental)
will likely find access to that care extremely limited.
Recognizing the need to improve access to health care for
rural veterans, witnesses representing the NRHA, Paralyzed
Veterans Association (hereinafter, ``PVA''), Disabled American
Veterans (hereinafter, ``DAV''), and AFGE testified in support
of the provisions contained in Title II of the Committee bill
during the Committee's April 22, 2009, health legislation
hearing.
Sec. 201. Enhancement of Department of Veterans Affairs Education Debt
Reduction Program.
Section 201 of the Committee bill, which is derived from
S. 734, would expand the authority of VA to provide education
debt reduction to eligible employees, and require them to
notify those employees of an award in a timely manner.
Background. The Education Debt Reduction Program
(hereinafter, ``EDRP'') was authorized by the Veterans Programs
Enhancement Act of 1998 (Public Law 105-368), and amended by
the Department of Veterans Affairs Health Care Programs
Enhancement Act of 2001, Public Law 107-135. It provides loan
repayment for employees recently appointed to title 38
positions providing direct patient care services or services
incident to direct patient care.
Marisa Palkuti, Director of the Health Care Retention and
Recruitment Office of the VA testified before the Committee on
April 9, 2008, that the top three mission-critical occupations
within VHA are registered nurses, physicians, and pharmacists.
She also highlighted how VA must compete with the private
sector to recruit these individuals. In 2009, Merritt Hawkins
and Associates conducted an analysis entitled, ``Review of
Physician and Certified Registered Nurse Anesthetist Recruiting
Incentives.'' Of the 3,288 Merritt Hawkins assignments
reviewed, 31 percent of physician and CRNA positions offered
loan forgiveness, and 85 percent offered a signing bonus. The
average amount of the signing bonus alone was $24,850.
In VA, physicians providing direct patient care services
are eligible for EDRP. Currently, section 7683 of title 38
limits the award to a total of $44,000 over a 5-year period. VA
offers no signing bonuses. The EDRP award limit applies
regardless of occupation, difficulties in recruitment, or
actual costs of education.
The current statutory limit is particularly problematic
when used as a recruitment or retention tool for physicians. It
does not reflect the fact that, according to the American
Association of Medical Colleges, the cost of tuition at medical
schools has risen faster than the consumer price index for the
last 20 years. In addition, the mean educational debt of 2008
graduates from medical school was $154,607, or more than three
times VA's current statutory authority to grant loan repayment.
To enable VA to compete effectively with the private sector for
physicians and other health care providers, VA must have the
authority to provide loan repayment to the maximum extent
possible with available funds.
During recent oversight visits, majority Committee staff
were told that employees were not made aware of VA's loan
repayment program until after acceptance of employment,
eliminating any opportunity for the program to serve as a
recruitment incentive. Further, in some cases, employees did
not learn of the program until after they were employed with VA
for more than 6 months, eliminating their eligibility under
VA's definition of ``recently appointed.''
The ability of VA to recruit and retain health care workers
will be critical in the near future. According to a March 17,
2009, memorandum from the Congressional Research Service, there
were 218,000 Veterans Health Administration employees in FY
2007, and 11.5 percent of them were eligible to retire at the
end of that year. The Congressional Research Service also noted
that there were an estimated 1,700 vacancies for registered
nurses nationwide. VA does not currently have the personnel to
care for all veterans' health care needs. In FY 2008 alone, VA
spent more than $244 million on contract care for outpatient
services and $1.2 billion on fee-basis care.
EDRP's role in the retention of nurses has been well-
documented. From May 2002 to September 2007, registered nurses
received 2,704 of the 5,656 awards provided through EDRP, or
almost half of all awards. Seventy five percent of nurses and
pharmacists receiving those awards were still employed by VA 5
years after the conclusion of their service periods.
VA has the statutory authority to pay individuals through
EDRP on a monthly or annual basis. VA has chosen to do so once
a year. This means that employees must currently make student
loan payments monthly, and then are reimbursed at the end of
the year. Also, the statute allows VA to define ``recently
appointed'' but does not specify how a potential recipient is
made aware of the program, or when they would be notified of an
award.
VA has determined that an employee is recently appointed if
the employee has held the position for less than 6 months.
Therefore, after 6 months of employment with VA, an employee is
no longer eligible to apply for the program. Awards are made
for 1 to 5 years. Majority Committee staff have been told
during oversight visits that qualifying potential employees do
not currently routinely receive offers for loan repayment as
part of VA's initial offer for employment.
Committee Bill. Subsection (a) of section 201 of the
Committee bill would amend subsection (d) of section 7683 of
title 38, so as to remove the statutory limit to loan repayment
under the EDRP, thereby allowing VA to pay the full cost of
tuition and qualifying costs for a health care worker's
education.
Subsection (b) of section 201 of the Committee bill would
further amend section 7682 of title 38 by adding a new
subsection (d) which would require VA, to the maximum extent
possible, to include in any offer of employment to an
individual who would be eligible to participate in EDRP,
information on their eligibility to participate in the program.
Subsection (c) of section 201 of the Committee bill would
further amend section 7683 of title 38 to add a new subsection
(e) which would require VA to select for participation in EDRP
each individual who was provided notice that he or she would be
eligible for and selected to participate in EDRP upon
employment. The new subsection would also allow VA to offer
participation in EDRP to individuals who did not receive such
notice.
The Committee is aware of difficulties in determining award
availability based on the variability in annual appropriations.
The Committee therefore elected to qualify this provision,
requiring the Secretary to meet these notice requirements ``to
the maximum extent practicable.'' Nevertheless, it is the
Committee's expectation that the Secretary will provide this
notice in the vast majority of cases, because, without such
notice, EDRP cannot function as a recruitment incentive.
DAV, PVA, and AFGE testified in support of these provisions
at the Committee's April 22, 2009, hearing on health
legislation.
Sec. 202. Visual Impairment and Orientation and Mobility Professionals
Education Assistance Program.
Section 202 of the Committee bill, which is derived from
S. 793, would create a scholarship program for qualified
individuals pursuing degrees or certificates in blind
rehabilitation.
Background. According to Tom Zampieri, Director of
Government Relations at the Blinded Veterans Association, there
are 163,000 legally blind veterans in the United States, with
47,560 currently enrolled in VA. In addition, VA estimates that
there are over 1 million low-vision veterans in the U.S., and
incidences of blindness among the total veteran population of
24 million are expected to increase by about 40 percent over
the next two decades. This is because the most prevalent causes
of legal blindness and low vision are age-related, and the
average age of the veteran population is increasing.
In addition to this aging population, DOD data compiled
between 1999 and 2007 reported 182,828 eye injuries from all
causes over a 10-year period and 4,970 evacuees from OIF and
OEF operations with severe penetrating eye injuries. According
to Tom Zampieri of the Blinded Veterans Association, with the
growing numbers of wounded in both OIF and OEF who are entering
the VA health care and benefits system today, 13.9 percent with
a history of penetrating eye trauma and over 70 percent of
traumatic brain injury (hereinafter, ``TBI'') patients with
post trauma vision syndrome (hereinafter, ``PTVS''), more of
these highly skilled professionals are necessary and critical
for VA. While the number of legally blind OIF and OEF veterans
enrolled in the VA Blind Rehabilitative Service is
approximately 135, VA has identified 585 with functional visual
impairments that benefit from the rehabilitative skills of
Blind Rehabilitative Outpatient Specialists (hereinafter,
``BROS'') and Blind Instructors.
The health care costs of blindness are high. According to
the Blinded Veterans Association, research on blind and low
vision Americans show they are at high risk of falls or making
medication mistakes, which results in costly hospital
admissions every year and a loss of their ability to live
independently at home. Falls are the sixth leading cause of
death in senior citizens and a contributing factor to 40
percent of all nursing home admissions with annual federal
costs over $45,000 for each nursing home bed.
Tom Zampieri testified before the House Committee on
Veterans' Affairs, Subcommittee on Economic Opportunity, on
March 4, 2009, that falls are the sixth leading cause of death
in senior citizens and a contributing factor to 40 percent of
all nursing home admissions with annual federal costs over
$45,000 for each nursing home bed. In the Framingham Eye Study,
18 percent of all hip fractures among senior citizens--about
63,000 hip fractures a year--were attributable to vision
impairment. The cost of medical-surgical treatment for every
hip fracture is over $39,000; if outpatient rehabilitation
services prevented even 20 percent of these hip fractures, the
annual federal savings in health care costs would be over $441
million. Essential outpatient, cost-effective services that
would allow blind veterans to safely live independently at home
are vitally important.
Blind rehabilitation training can help give blind veterans
the ability to function independently in their surroundings.
Tom Zampieri also testified that, despite the demand for such
services, there are only 39 filled BROS with 30 vacant
positions. Only 19 U.S. universities in the nation offer
training programs for training specialists to provide
rehabilitation services and orientation and mobility
instruction for blind persons. Six universities offer training
in blind rehabilitation and 16 offer both blind instructor
training and orientation and mobility education. The program
for training Certified Vision Rehabilitation Therapists
(hereinafter, ``CVRT'') and Certified Orientation and Mobility
Specialists (hereinafter, ``COMS'') are located in programs
that have academic internship positions at various VA Blind
Centers but because of the cost of education and the higher
compensation available in the private sector, students often
enter private agency jobs after graduation.
Committee Bill. Section 202 of the Committee bill would
amend title 38 by adding a new Chapter 75, entitled ``Visual
Impairment and Orientation and Mobility Professionals Education
Assistance Program.'' This new chapter would consist of five
new sections, described below.
New section 7501--entitled, ``Establishment of scholarship
program; purpose''--would, in subsection (a), subject to the
availability of appropriations, establish a scholarship program
to provide financial assistance to an individual accepted for
enrollment or currently enrolled in a program of study leading
to a certificate or degree in visual impairment or orientation
and mobility or a dual degree in both such areas, at an
accredited educational institution in the United States. Such
individual would be required to enter into an agreement with
the Secretary to receive such assistance.
Subsection (b) of new section 7501 would provide that the
purpose of the scholarship program is to increase the supply of
qualified blind rehabilitation specialists for VA and the
Nation.
Subsection (c) of new section 7501 would require the
Secretary to publicize the scholarship program established
under this chapter to educational institutions throughout the
United States, with an emphasis on disseminating information to
institutions with high numbers of Hispanic students and to
Historically Black Colleges and Universities.
New section 7502--entitled ``Application and acceptance''--
would, in subsection (a), require individuals applying and
participating in the scholarship program to submit an
application together with an agreement described in new section
7504, under which the participant would agree to serve a period
of obligated service in the Department in return for payment of
educational assistance. This section would define information
that must be included with the application and agreement,
including a fair summary of the rights and liabilities of an
individual whose application is submitted and approved by the
Secretary and a full description of the terms and conditions
that apply to participation in the scholarship program and
service in the Department.
Subsection (b) of new section 7502 would require the
Secretary to notify an individual in writing upon the
Secretary's approval of the individual's participation in the
scholarship program.
New section 7503--entitled ``Amount of assistance;
duration''--would, in subsection (a), specify that the amount
of financial assistance provided will be determined by the
Secretary as that necessary to pay the tuition and fees of the
individual. For individuals enrolled in dual degree or
certification programs, this provision would specify that the
tuition and fees not exceed the amounts necessary for the
minimum number of credit hours to achieve such dual
certification or degree.
Subsection (b) of new section 7503 would allow funds under
this new program to supplement other educational assistance
providing that the total amount of assistance does not exceed
the total tuition and fees for the academic year.
Subsection (c) of new section 7503 would set a maximum
limit of $15,000 on the total amount of assistance provided
under this chapter for an academic year to full-time students,
and to part-time students at a ratio based on the relationship
of the part-time study to full-time study. This section also
would cap the total amounts of assistance under this program at
$45,000.
Subsection (d) of new section 7503 would place the maximum
duration of assistance provided under this chapter at not more
than 6 years.
New section 7504--entitled ``Agreement''--would require
that an agreement between the Secretary and a participant in
the scholarship program be in writing and signed by the
participant.
Paragraph (1) of new section 7504 would mandate that the
agreement contain the Secretary's agreement to provide the
participant with financial assistance.
Paragraph (2) would require the participant's agreement to
a number of conditions, including to accept the financial
assistance, to maintain enrollment and attendance in an
approved program of study, to maintain an acceptable level of
academic standing, and to serve as a full-time VA employee for
3 years following completion of the program of study, with such
service to be within the first 6 years after the participant
has completed the program and received a degree or certificate.
Paragraph (3) would permit the Secretary to set any other
terms or conditions that the Secretary determined to be
appropriate for carrying out this chapter.
New section 7505--entitled ``Repayment for failure to
satisfy requirements of agreement''--would provide for
repayment of the unearned amount of educational assistance when
the terms of the agreement are not satisfied and would allow
for the Secretary to waive or suspend repayment when
noncompliance is due to circumstances beyond the individual
participant's control or in the best interest of the United
States. A discharge in bankruptcy under title 11 would not
discharge an individual from his or her obligation to repay the
Secretary if the discharge order were entered less than 5 years
after the date of the termination of the agreement or contract
on which the debt were based.
New chapter 75 of title 38 would be implemented not later
than 6 months after the date of enactment of the Committee
bill.
DAV, PVA, and AFGE testified in support of these provisions
at the Committee's hearing on health legislation on April 22,
2009.
Sec. 203. Inclusion of Department of Veterans Affairs Facilities in
List of Facilities Eligible for Assignment of Participants in
National Health Service Corps Scholarship Program.
Section 203 of the Committee bill, which is derived from
S. 734, would require VA to transfer funds to the Department of
Health and Human Services for the purpose of making VA
facilities eligible for assignment of National Health Service
Corps scholars.
Background. The Department of Health and Human Services
offers a number of programs designed to improve recruitment and
retention in underserved areas known as health professional
shortage areas. HPSAs are areas designated to have provider
shortages based on geography, population groups or facilities
with access barriers to primary care services.
Section 254 of title 42, United States Code permits the
Secretary of Health and Human Services to designate any public
or nonprofit private medical facility a HPSA if the facility
otherwise meets certain criteria. Section 254e(a)(2) expressly
defines public or nonprofit private medical facilities to
include Federal medical facilities. Section 254e(b) also
authorizes the Secretary of Health and Human Services to
establish regulations governing the designation of medical
facilities as HPSAs.
The Health Care Safety Net Amendments of 2002, Public Law
107-251, granted automatic HPSA designations to all federally
qualified health centers. This automatic designation granted to
those facilities the right to recruit physicians through the
National Health Service Corps (hereinafter, ``NHSC''). There is
currently no statutory barrier to VA facilities being
designated HPSA sites.
The NHSC Scholarship Program, through scholarship and loan
repayment programs, helps HPSAs throughout the country attract
medical, dental and mental health providers. Since 1972, it is
estimated that more than 30,000 clinicians have served in the
Corps.
The NHSC is a competitive program that pays tuition and
fees and provides a living stipend to students enrolled in
accredited medical (Medical Doctor or Doctor of Osteopathy),
dental, nurse practitioner, certified nurse midwife and
physician assistant training. Upon graduation, scholarship
recipients serve as primary care providers between 2 and 4
years in a community-based site in a high-need HPSA that has
applied to and been approved by the NHSC as a service site.
Currently, psychiatry is a qualifying NHSC occupation, and
VA has listed this as its hardest specialty to fill. Also, no
VA sites are listed on the NHSC placement list.
Committee Bill. Section 203 of the Committee bill, in a
freestanding provision, would mandate that VA transfer $20
million to the Department of Health and Human Services for the
purpose of including VA facilities on the list maintained by
the Health Resources and Services Administration of facilities
eligible for assignments of participants in the National Health
Services Corps. This would enable veterans' health care
facilities, which would otherwise not be able to apply for the
Corps scholar placement, to do so.
In testimony before the Committee on February 26, 2009,
Kara Hawthorne, Director of the Office of Rural Health for the
Veterans Health Administration, said:
Every day, almost 60 million Americans in rural and
highly rural areas face numerous challenges regarding
health care, but one of the most significant in this
area is a shortage of providers--particularly specialty
providers. Recruitment and retention of health care
professionals in rural areas is a national problem, not
a VA-specific problem.
Sec. 204. Teleconsultation and Telemedicine.
Section 204 of the Committee bill, which is derived from
S. 734, would promote the increased utilization of
teleconsultation and telemedicine by requiring all Veterans
Integrated Service Networks (hereinafter, ``VISNs'') to fully
implement the existing teleretinal imaging program, to use
telehealth technologies for the screening of TBI and post
traumatic stress disorder (hereinafter, ``PTSD'') patients in
areas where these services are not otherwise available, and by
providing appropriate financial incentives for program
development.
Background. For decades, telemedicine has been considered a
means of overcoming barriers to providing rural health care.
According to Dr. Michael Hatzakis et al., a VA physician
writing in the Journal of Rehabilitation Research and
Development in May/June 2003, experimental programs in
telehealth were funded through existing grants on Indian
reservations, in psychiatric hospitals, in the prison systems,
and in medical schools between the 1950s and the 1970s. Dr.
Hatzakis also noted that none have survived, reflecting in
part, a failure to secure financial self-sufficiency. In recent
years, technological advances have improved the cost-
effectiveness of telemedicine technologies. For example, costs
for a telemedicine workstation were $50,000 to $100,000 in the
mid-1990s, but less than $10,000 by the year 2000.
Unlike private health care organizations, VA is not limited
by interstate licensure limitations. Therefore, there is no
concern regarding the practice of medicine across state lines.
Yet telehealth services are not widely used, even in VA. In FY
2008, for example, VA provided ambulatory services to a total
of 4,901,797 veterans. But a telehealth technology allowing
health care workers to monitor veterans' chronic diseases while
the veteran was at home was used on only 36,400 patients. This
is less than one percent of all veterans treated on an
outpatient basis.
In addition, while VA provides telemedicine services
utilizing real time conferencing between VA medical centers and
community based outpatient clinics (hereinafter, ``CBOCs''), it
is not universally available. Currently, VA provides these
services to some degree at most VA medical centers, but only at
353 out of a possible 679 CBOCs.
Under another program, VA provided general telehealth
services using real time conferencing to an estimated 48,000
veterans, 29,000 of which utilized the services for mental
health purposes. Adam Darkins, Chief Consultant, Office of Care
Coordination, in the Office of Patient Care Services, noted
that outcomes data for tele-mental health have demonstrated a
24.6 percent reduction in hospital admissions and a 24.4
percent reduction in bed days of care when these services are
utilized.
VA also offers teleretinal imaging at some facilities. This
is a method of taking digital images of the retina of the eye
and transmitting them to eye specialists remotely who are able
to interpret the images and diagnose disorders of the eye from
those images. In FY 2008, VA had these services available at
only 130 of its CBOCs.
In a March 2007 position statement, the American Telehealth
Association said:
There is a growing consensus that the supply of health
care providers across the professions is going to be
inadequate to meet the expanding needs for health care
of the U.S. population--both in the short term and in
the long term. Telehealth, while not the entire
solution to the problems presented by the shortage and
maldistribution of health care providers, can make
important contributions to alleviating those problems.
The ability of CBOCs to offer specialty services is
particularly important to the needs of returning OEF/OIF
veterans, many of whom return to remote areas with conditions
like PTSD or TBI. In RAND's 2008 report, Invisible Wounds of
War: Summary and Recommendations for Addressing Psychological
and Cognitive Injuries, RAND estimated that there were
approximately 300,000 servicemembers who had been deployed for
OIF/OEF suffering from PTSD or major depression and that
320,000 servicemembers reported experiencing a probable TBI
during deployment.
According to the report, among those with PTSD or major
depression, only 53 percent had seen a physician or mental
health provider for a mental health disorder in the past 12
months and those who received care, just over half had received
minimally adequate treatment.
Captain Constance Walker, President of the Southern
Maryland Chapter of the National Alliance on Mental Illness,
testified before the Committee on October 24, 2007, that:
* * * the likelihood of obtaining specialized services
[for PTSD and serious mental illnesses] on a consistent
basis is very small for veterans living in rural and
frontier areas beyond a reasonable commute to a VA
Medical Center or without access to an appropriately
and consistently staffed VA Community Based Outpatient
Clinic.
Tom Loftus, an American Legion Post Commander, also testified
before the Committee on February 26, 2009, regarding the lack
of availability of TBI and PTSD assessments in small
communities.
According to the National Rural Health Association, it has
been estimated that about 20-23 percent of the U.S. population
live in rural areas, but only 9-11 percent of physicians
practice in rural areas. Among 1253 communities designated as
Mental Health Professional Shortage Areas in 2007, for example,
almost 75 percent did not have a psychiatrist. For this reason,
VA psychiatrists, writing in the Journal of Academic Psychiatry
in November 2007, recommended ensuring competency in
telemedicine technologies as part of a curriculum designed to
emphasize rural practice in psychiatry residency training.
In addition, there is a need for more eye care services in
rural areas. According to Dr. Anthony A. Cavallerano, and Dr.
Paul R. Conlin, VA physicians writing in the Journal of
Diabetes Science and Technology in January 2008, diabetic
retinopathy, a condition of the eye resulting from diabetes, is
the most common cause of visual loss in the U.S. These
physicians further noted that only 60 percent of persons with
diabetes receive timely and appropriate eye examinations. In FY
2000, Congress recognized the importance of making eye care
accessible to all veterans when, in Senate Report 106-410 to
accompany the 2001 Department of Veterans Affairs and Housing
and Urban Development, and Independent Agencies Appropriations
Bill of 2001 (Public Law 106-271), the Appropriations Committee
recommended that VA collaborate with the DOD and the Joslin
Diabetes Center to implement the Joslin Vision Network. This
collaboration created a system allowing specialists at a remote
location to detect diabetic retinopathy and other eye
conditions by reviewing images transmitted across a
telecommunications network. Since that time, the program has
expanded to assist in providing eye care to almost 20 percent
of VA's diabetic veteran population.
In 2001, VA convened an expert panel to evaluate
teleretinal imaging to screen for diabetic retinopathy. In a
statement regarding the implementation of VA's teleretinal
program, this panel said:
The VHA envisions developing and deploying a nationwide
teleretinal imaging system that will be regionalized by
VISN and will build on the VHA's robust information
technologies for acquiring, transmitting, interpreting,
and storing digital retinal images * * *. A similar
system for screening for [diabetic retinopathy] has
been established in the United Kingdom.
The Committee is concerned that the VISNs currently have no
financial incentive to invest in this important technology. The
Veterans Equitable Resource Allocation (hereinafter, ``VERA'')
system is the method VA uses to distribute resources among its
21 VISNs. It distributes funds to each VISN based both on
patient workload, as well as on the complexity of care
provided. This system allocated $31.8 billion in general
purpose funds during FY 2009. Currently, VERA does not factor
all telemedicine and telehealth visits into its workload data.
Committee Bill. Section 204 of the Committee bill would
amend subchapter I of chapter 17 of title 38 by adding a new
section 1709, entitled ``Teleconsultation and teleretinal
imaging.''
Subsection (a) of new section 1709 would require VA to
carry out a program of teleconsultation for the provision of
remote mental health and traumatic brain injury assessments in
facilities of the Department that would not otherwise be able
to provide these assessments without using outside providers.
VA would be required to consult with appropriate professional
services in the development of technical and clinical care
standards for the use of teleconsultation services by VA.
Subsection (b) of new section 1709 would require the
Secretary to carry out a program of teleretinal imaging--
defined as a health care specialist using telecommunications,
digital retinal imaging, and remote image interpretation to
provide eye care--in each VISN.
The Committee believes that mandating that VA carry out
such a program in each VISN is necessary, particularly in light
of a recent decision by VA to halt 45 Information Technology
projects, including telehealth projects, that were either over
budget or behind schedule. Although the Committee agrees that
IT projects should be well-managed and resourceful, appropriate
priority and focus need to be given to projects that hold the
promise of delivering necessary patient care, including
telehealth projects. On a recent oversight visit, it became
clear that in certain areas, the number of telehealth visits is
declining rather than increasing.
Subsection (c) of new section 1709 would require that the
Secretary submit a report in each of fiscal years 2010 through
2015 to Congress on the teleconsultation and teleretinal
imaging programs. Such report shall include a description of
the efforts made by the Secretary to make available and utilize
teleconsultation in rural areas, and the rates of utilization
of teleconsultation by VISNs.
Subsection (b) of section 204 of the Committee bill would
require each VA facility that is involved in the training of
medical residents to work with their affiliated universities to
develop elective rotations in telemedicine for such residents.
Subsection (c) of section 204 of the Committee bill would
require VA to include telemedicine and telehealth visits in
calculations of facility workload. It also would require the
Secretary to provide incentives through the Department's
resource allocation process for networks which utilize
telemedicine and telehealth services.
In testimony before the Committee on April 22, 2009, VA
supported this section of the Committee bill.
Sec. 205. Demonstration Projects on Alternatives for Expanding Care for
Veterans in Rural Areas.
Section 205, which is derived from S. 658, would authorize
VA to develop pilot programs using innovative strategies to
provide health care to rural areas.
Background. The Consolidated Security, Disaster Assistance,
and Continuing Appropriations Act of 2009, Public Law 110-329,
appropriated $250 million to VA to carry-out rural veterans'
health care demonstration projects. These funds have been used
to expand telehealth initiatives, deploy mobile clinics, open
new CBOCs and fund numerous other innovative ways of delivering
health care to veterans in rural and highly rural areas.
Similar funding is included in the Fiscal Year 2010 version of
the bill.
When VA receives funding for demonstration projects without
those projects being prescribed by legislative action, VA can
solicit ideas from the field and choose the best ideas for
implementation. With the $250 million VA received in FY 2009 to
fund rural health initiatives, for example, VA implemented
projects partnering with the community to improve outreach,
developed better ways of monitoring intensive care units and
expanded telehealth initiatives.
Committee Bill. Section 205, in a freestanding provision,
would authorize the Secretary to carry out demonstration
projects on alternatives for expanding rural veterans' health
care.
This provision would allow VA to consider innovative
strategies for providing health care services to veterans who
reside in rural and highly rural areas. These demonstration
projects could include VA partnership with the Centers for
Medicare and Medicaid Services to coordinate care for veterans
in rural areas at critical access hospitals; VA partnership
with the Department of Human Services to coordinate care for
such veterans in community health centers; and increased
coordination between VA and Indian Health Service to expand
care for Indian veterans. The Secretary would ensure that the
demonstration projects are located at facilities that are
geographically distributed throughout the United States.
The Committee expects VA to solicit proposals directly from
field facilities so as to encourage local innovation.
Section 205 of the Committee bill also requires VA to
report to the Committees on Veterans' Affairs of the House of
Representatives and the Senate and the Appropriations
Committees of the House of Representatives and the Senate on
the implementation of these projects 2 years after the date of
enactment of this Act.
Sec. 206. Program on Provision of Readjustment and Mental Health Care
Services to Veterans Who Served in Operation Iraqi Freedom and
Operation Enduring Freedom.
Section 206, which is derived from S. 658, would mandate
that VA provide peer outreach and certain services to family
members and of returning veterans and members themselves
through Vet Centers.
Background. There is a significant need for mental health
providers throughout rural America, and VA and private practice
often find themselves competing for the same pool of
prospective employees. A recent report by the Inspector General
found that, as a result of providing VA with authority to
contract-out mental health services, the percentage of veterans
within 30 minutes' drive of a mental health therapist or
medication management rose from 60 percent to 90 percent.
These services are particularly important, considering the
numbers of Guard and Reservists returning to remote areas
without the services found on a military base.
Committee Bill. Section 206, in a freestanding provision,
would require VA, not later than 180 days after the date of
enactment of this Act, to establish a program to provide
certain mental health services to veterans of OIF and OEF,
especially those who served in the National Guard and Reserves,
and to their immediate families.
Under this program, VA would be required to provide peer
outreach services, peer support services, readjustment
counseling services, and mental health services to veterans.
For immediate family members of such veterans during the 3-
year period following a veteran's return from OIF/OEF, VA would
be required to provide education, support, counseling and
mental health services to assist in the readjustment of such
veterans to civilian life; in the recovery of any veteran
sustaining an illness or injury during deployment; and in the
readjustment of the family following the return of such
veteran.
Subsection (b) would require VA to contract with community
mental health centers and other qualified entities to furnish
services under the program in areas that VA determines are not
adequately served by VA facilities. The community entities
would be required, to the extent practicable, to use telehealth
services and employ veterans trained to provide peer outreach
and peer support.
The community entities would be required to provide VA with
clinical summary information for each veteran furnished mental
health services. The community entities would be required to
participate in specified VA training and comply with applicable
VA protocols before incurring any liability on behalf of VA for
the provision of services under the program.
Subsection (c) would require VA to contract with a national
not-for-profit mental health care organization to carry out a
national program of training for veterans providing certain
mental health services. VA would also be required to provide
training programs for clinicians of community entities
providing services under this program to ensure that such
clinicians can furnish services in a way that recognizes
factors unique to OIF/OEF veterans.
VA would be required to submit a report, not later than 45
days after the date of enactment of this Act, to the Committees
on Veterans' Affairs of the House of Representatives and Senate
which contains VA's plan for implementing this program.
The provisions in this section of the Committee bill are
not intended to replace the VA as a mental health provider for
veterans, but rather to address a practical need in rural areas
by providing a clear authority to contract for mental health
services for OIF/OEF veterans in rural areas, when mental
health services from VA are not available.
Sec. 207. Improvement of Care of American Indian Veterans.
Section 207 of the Committee bill, which is derived from
S. 658, would improve coordination between IHS and VA with
respect to the treatment of American Indians, as well as the
sharing of information and transfer of surplus equipment.
Background. American Indians have a long history of service
in the U.S. military, dating back to the American Indians who
served alongside General George Washington. According to the
DOD, per capita, American Indians and Alaska Natives are more
likely to serve in the military than any other major racial or
ethnic group. According to VA, American Indian and Alaska
Native veterans are nearly 50 percent more likely than the
average veteran to have a confirmed service-connected
disability, and studies from the National Center for PTSD have
found that American Indian veterans may be at a much-higher
risk of PTSD. There is an obvious additional need for primary
care and mental health services within this population. Despite
a clear and historic participation in the military and current
need for medical attention related to their service, American
Indian veterans continue to face additional barriers to
receiving quality care.
American Indian veterans who reside in rural communities
and on reservations often suffer disproportionate adverse
health outcomes due to access limitations and under-resourced
health care infrastructure. While IHS facilities are often more
accessible to American Indian veterans, a lack of resources
such as medical equipment and information technology limits the
quality of care. Also, existing barriers between VHA and IHS in
areas such as record-sharing have a negative impact on veterans
who receive care at VHA and IHS. Additionally, there is a clear
need to resolve cultural barriers that too often limit the
effectiveness of VA care given to American Indian veterans.
Improved collaboration and partnership between VA and IHS can
improve care. Some VA facilities are making progress addressing
these issues through the use of coordinators who address care
issues for American Indians in a culturally-competent fashion.
Committee Bill. Section 207 of the Committee bill would
amend subchapter II of chapter 73 by adding a new section
7330B--entitled ``Indian Veterans Health Care Coordinators''--
which would require VA to assign certain VA employees to the
position of Indian Health Coordinator in each of the 10 VA
Medical Centers that serve communities with the greatest number
of Indian veterans per capita. These Coordinators would improve
outreach to tribal communities; coordinate the medical needs of
Indian veterans; expand the access and participation of the
Department, the IHS, and tribal members in the Department of
Veterans Affairs Tribal Veterans Representative program; act as
ombudsmen for Indian veterans enrolled in the health care
system of the VHA; and advocate for the incorporation of
traditional medicine and healing in Department treatment plans
for Indian veterans in need of care and services provided by
the Department.
This section of the Committee bill, in a freestanding
provision, would require that not later than 1 year after the
date of enactment of this Act, VA and the Department of Health
and Human Services would enter into a Memorandum of
Understanding to ensure that the health records of Indian
veterans may be transferred electronically between VA and IHS.
This section of the Committee bill, in a freestanding
provision, would authorize VA to transfer surplus medical and
information technology equipment to the IHS. VA would be
authorized to transport and install medical or information
technology equipment in IHS facilities. This section would
provide that not later than 1 year after the date of enactment
of this Act, the Secretary and the Secretary of Health and
Human Services shall jointly submit to Congress a report on the
feasibility and advisability of the joint establishment and
operation by VHA and IHS of health clinics on Indian
reservations to serve the populations of such reservations,
including Indian veterans.
Sec. 208. Travel Reimbursement for Veterans Receiving Treatment at
Facilities of the Department of Veterans Affairs.
Section 208, which is derived from both S. 658 and S. 734,
would allow VA to adjust mileage rates and compensate veterans
for airfare when that is the only practical way to reach a VA
facility.
Background. Under section III of title 38, VA is authorized
to pay for an eligible veteran's travel to and from a facility
for the purpose of examination, treatment or care. In addition
to mileage amounts, VA can reimburse a veteran for the actual
cost of ferry fares, and bridge, road and tunnel tolls. The
statute does not authorize reimbursement for airfare.
There are occasions when veterans must travel by air to
receive health care, either because their physical condition
requires it, or because that is the only practical way to reach
a facility. States such as Hawaii and Alaska, for example, have
unique geography requiring veterans to travel by air in order
to obtain certain health care services. The expense of such
services is often well beyond the means of the veterans who
need these services.
Committee Bill. Subsection (a) of section 208 of the
Committee bill would amend section 111 of title 38, relating to
VA payment of an allowance for certain travel, in two ways.
First, it would amend subsection (a) of section 111 to insert a
specific reimbursement rate--41.5 cents per mile. Second, it
would amend subsection (g) of section 111 so as to, beginning 1
year after the date of enactment of this Act, permit the
Secretary to adjust the newly specified mileage rate for travel
reimbursement so that that rate would be equal to the mileage
reimbursement rate for the use of privately owned vehicles by
Government employees on official business. If such an
adjustment would result in a lower mileage rate than that which
would be specified in subsection (a) of section 111, the
Secretary would be required to submit to Congress, no later
than 60 days before the implementation of the revised mileage
rate, a report setting forth the justification for the decision
to adjust the rate.
Subsection (b) of section 208 of the Committee bill would
further amend subsection (a) to specify that the actual
necessary expense of travel would include travel by air if such
travel is the only practical way for the person traveling to
reach a VA facility.
Subsection (c) of section 208 of the Committee bill would
amend subsection (b)(1)(D)(i) to affect the limitation on
travel eligibility related to pension rate.
Subsection (d) of section 208 of the Committee bill would
amend subsection (b) of section 111 by adding a new paragraph
(4) which would require the Secretary to consider the medical
condition of the veteran and any other impediments to ground
transportation in determining whether travel by air is the only
practical way to reach a VA facility.
Subsection (e) of section 208 of the Committee bill would
specify that the amendments to section 111 of title 38 made by
subsections (b) and (d) of section 208 of the Committee bill,
relating to travel by air, cannot be construed as expanding or
modifying eligibility for payments or allowances for
beneficiary travel.
Subsection (f) of section 208 of the Committee bill would
require VA, not later than 30 days after enactment of this
legislation, to reverse the VHA handbook to clarify that an
allowance for travel based on mileage paid under section 111(a)
of title 38 may exceed the cost of such travel by public
transportation regardless of medical necessity.
The Committee believes it is an issue of equity to include
travel by air. Expenses associated with air travel are
generally much greater than those associated with ground
transportation. For example, the average cost of travel by air
is $60 per hour. Assuming mileage rates of 41.5 cents per mile
at an average of 60 miles per hour, a vehicle can be operated
for less than half the cost of airfare. Veterans traveling by
air deserve special consideration regarding compensation for
travel.
Sec. 209. Office of Rural Health Five-Year Strategic Plan.
Section 209 of the Committee bill, which is derived from
S. 734, would require VA's Office of Rural Health to develop a
5-year strategic plan.
Background. In 2006, Public Law 109-461 established the VA
Office of Rural Health (hereinafter, ``ORH''). One of ORH's
functions is to improve health care for veterans living in
rural areas by developing best practices. In both FY 2008 and
FY 2009, VA received $250 million for rural health initiatives.
While VA has spent these funds on a variety of innovative
pilot projects, it is important that ORH develop a strategy
that will address the needs of veterans living in rural areas
for years to come. Providing health care to veterans in rural
areas is a national problem, not just a VA problem, and careful
stewardship of available resources is important so as to ensure
that VA meets the needs of the greatest number of veterans
possible.
Committee Bill. Section 209 of the Committee bill, in a
freestanding provision, would require the Director of the
Office of Rural Health to develop a 5-year strategic plan for
the ORH not later than 180 days after the date of enactment of
this Act. This provision would require that the plan contain
specific goals for the recruitment and retention of health care
personnel in rural areas; it be developed in conjunction with
the Director of the Health Care Retention and Recruitment
Office of the Department of Veterans Affairs; it include
specific goals for ensuring the timeliness and quality of
health care delivery in rural communities by contract and fee-
basis providers, developed in conjunction with the Director of
the Office of Quality and Performance of the Department; it
include specific goals for the expansion and implementation of
telemedicine services in rural areas, developed in conjunction
with the Director of the Office of Care Coordination Services
of the Department; and it set incremental milestones describing
specific actions to be taken to achieve the goals described
above.
The Committee expects that these provisions will ensure
that ORH engages in sound fiscal planning with respect to the
additional funds appropriated by Congress for rural health care
development.
PVA testified in support of this provision at the April 22,
2009, health legislation hearing.
Sec. 210. Oversight of Contract and Fee-Basis Care.
Section 210 of the Committee bill, which is derived from
S. 734, would create incentives for providers paid by VA
through contracts or on a fee-for-service basis to implement
certain quality improvement measures.
Background. In FY 2008, VA spent over $244 million for
contracted outpatient care, and over $1.2 billion for
outpatient fee-basis care. For providers paid on a fee-for-
service basis, VA measures the timeliness of claims processing
but does not otherwise monitor the quality of patient care
provided in a systematic way.
In February 2007, the NRHA wrote in an issue paper
addressing the quality of care provided to rural veterans:
The NRHA calls on the VA and VHA to extend through
these contracts access for rural health providers and
facilities to the VA's exemplar[y] health care quality
improvements systems.
The NRHA also called on VA to improve coordination between
community health providers and VA in rural areas.
VA currently requires some indicators for services
purchased by contract under Project Hero related to timeliness
and access to care, but does not otherwise have uniform quality
measures in place in all contracts for the provision of medical
services. In the FY 2010 Independent Budget, the Independent
Budget Veteran Service Organizations (hereinafter, ``IB VSOs'')
recommended that VA develop a set of quality standards to
ensure that contract providers maintain the same quality of
care as VA health care providers.
Committee Bill. Section 210 of the Committee bill would
amend subchapter I of chapter 17 by adding a new section,
section 1703A--entitled ``Oversight of contract and fee-basis
care''--so as to provide for increased attention to the
management of contract and fee-basis care in rural areas.
Subsection (a) of new section 1703A would require the
Secretary to designate a rural outreach coordinator at each
CBOC where at least 50 percent of the veterans enrolled reside
in a highly rural area. These coordinators would be responsible
for coordinating care at and through the CBOC and collaborating
with providers in the community who furnish care to enrolled
veterans on fee-basis or under a contract.
Subsection (b) of new section 1703A would mandate that the
Secretary adjust fee-basis compensation paid to community
providers in order to encourage such providers to obtain
accreditation from recognized accrediting entities of their
medical practice. In making the adjustments in compensation,
the Secretary would be required to consider the increased costs
of acquiring and maintaining such accreditation.
Subsection (c) of new section 1703A would require the
Secretary to adjust the fee-basis compensation of health care
providers which are not accredited by a recognized
accreditation entity to provide incentives for those providers
to participate in a voluntary peer review program. In making
the adjustments in compensation, the Secretary would be
required to set such amounts as would be reasonably expected to
encourage participation in voluntary peer review.
Subsection (d) of new section 1703A would require VA to
provide for the voluntary peer review of health care providers
which provide health care services to VA on a fee basis and are
not accredited by a recognized accrediting entity.
The Chief Quality and Performance Officer (hereinafter,
``CQPO'') in each VISN would be responsible for the oversight
of this effort and would select a sample of patient records
from each participating entity to be peer reviewed by a
facility designated by the CQPO for such role.
Each Department facility conducting peer review of
community providers would be required to review the records in
accordance with policies and procedures established by the
Secretary, ensure that peer reviews are evaluated by the
facility's Peer Review Committee, and develop a mechanism for
notifying the Under Secretary for Health of any problems
identified through peer review.
The Under Secretary for Health would be required to develop
a mechanism to terminate the use of fee-basis providers when
quality of care concerns are identified through the peer review
process.
At the Committee's April 22, 2009, health legislation
hearing, AFGE, DAV, NRHA and PVA testified in support of these
provisions. These provisions are also consistent with the
recommendations contained in the Independent Budget.
Sec. 211. Enhancement of Vet Centers to Meet Needs of Veterans of
Operation Iraqi Freedom and Operation Enduring Freedom.
Section 211 of the Committee bill, which is derived from
S. 734, would allow VA to use volunteers and other individuals
to provide readjustment counseling, and to expedite the
credentialing and privileging of licensed independent health
care providers working on a volunteer basis in readjustment
counseling centers.
Background. In recognition that a significant number of
Vietnam-era veterans were experiencing readjustment problems,
in 1979, VA established the readjustment counseling service
which created readjustment counseling centers, or ``Vet
Centers.'' Congress has since made readjustment counseling
services available to veterans serving during other periods of
armed hostilities.
Section 1712A of title 38 requires the Secretary to furnish
readjustment counseling, which may include mental and
psychological assessments, upon the request of veterans who
served on active duty in a theater of combat operations or in
any area in which a period of hostilities occurred. If an
assessment completed by a physician or psychologist determines
that mental health services are necessary to facilitate the
successful readjustment of veterans to civilian life, services
will be provided by the Department.
Currently, clinical professionals who work in Vet Centers
are required to undergo credentialing and privileging
procedures in accordance with policies of VA. There is no
distinction between paid and volunteer counselors. As
previously noted, there is a national and VA-specific shortage
of mental health care providers.
Committee Bill. Section 211 of the Committee bill would
amend Subsection (c) of section 1712A of title 38, relating to
VA's readjustment counseling authority, to allow VA to use
volunteer counselors in the provision of readjustment
counseling and related mental health services.
To serve as a volunteer counselor at a Vet Center, an
individual would have to be a licensed psychologist or social
worker who had never been named in a tort claim arising from
professional activities and also had never had or have pending
against them, any disciplinary action taken with respect to any
license or certification qualifying the individual to provide
counseling services.
Eligible volunteer counselors would be issued credentials
and privileges for the provision of counseling and related
mental health services on an expedited basis, not later than 60
days from the date the application is submitted.
Subsection (b) of section 211 of the Committee bill would
amend subsection (e) of section 1712A so as to require each Vet
Center to develop an outreach plan to ensure that the community
served by the center is made aware of the services offered by
the center.
The Committee is committed to ensuring that every attempt
is made to add more providers to the VA health care system.
Those individuals who provide high quality health care services
and who voluntarily give their time and professional talents to
care for veterans should not be unduly burdened by cumbersome
bureaucratic processes. By streamlining the credentialing and
privileging processes for those select providers, the Committee
hopes to attract more high quality health care professionals to
VA's health care
system.
Sec. 212. Centers of Excellence for Rural Health Research, Education,
and Clinical Activities.
Section 212, which is derived from S. 658, would create VA
Rural Health Centers of Excellence.
Background. Veterans who reside in rural areas often have
worse health outcomes than veterans residing in urban areas.
For example, in FY 2005 and FY 2006, the rate of suicide for
veterans last utilizing a rural VA facility was 39.7/100,000
persons per year compared to 35.0/100,000 persons per year for
urban veterans. Research sponsored by VA's Health Services
Research and Development division has cited worse health
outcomes and health quality of life scores among rural veterans
compared to urban veterans, and favorably recommended
innovative approaches to improve access to care and quality of
care in those areas.
Committee Bill. The Committee bill would amend subchapter
II of chapter 73, as amended by section 214, to add a new
section 7330C, entitled ``Centers of excellence for rural
health research, education, and clinical activities.''
Under new section 7330C, the Secretary, through the
Director of the Office of Rural Health, would be required to
establish and operate at least one but not more than five
centers of excellence for the conduct of research, education,
and clinical activities relating to health services in rural
areas.
These centers would be required to develop specific models
to be used in furnishing health services to veterans in rural
areas, provide education and training for health care
professionals on the furnishing of health services to veterans
in rural areas, and develop and implement innovative clinical
activities and systems of care for VA for the furnishing of
health services to veterans in rural areas.
VA would be permitted to designate an existing rural health
resource center as a center of excellence. These centers of
excellence would be required to be geographically dispersed
throughout the United States.
Subsection (d) of new section 7330C would authorize the
appropriation of such sums as may be necessary to support the
research and education activities of the centers of excellence
and would authorize the Under Secretary for Health to allot to
the centers funds appropriated to VA's Medical Care and Medical
and Prosthetic Research accounts.
This subsection would also specify that clinical and
scientific investigation activities at each center would be
eligible to compete for awards of funding from the Medical and
Prosthetics Research Account, and would receive priority for
funds awarded to projects for research in the care of rural
veterans.
The Committee believes that creating these centers will
significantly enhance VA's ongoing efforts to meet the health
care needs of veterans residing in rural areas.
Sec. 213. Pilot Program on Incentives for Physicians Who Assume
Inpatient Responsibilities at Community Hospitals in Health
Professional Shortage Areas.
Section 213, which is derived from S. 734, would create a
pilot program allowing VA physicians to provide care to
veterans admitted to community hospitals, and providing
financial incentives for them to do so.
Background. The Census Bureau estimates that 8 percent of
the population as a whole are veterans. The DOD does not track
whether its veterans return to rural or urban areas, and there
are no consistent Federal-wide definitions of a ``rural''
population. VA uses the Census Bureau's definition of rural.
Using this definition, about 39 percent of current veterans
enrolled in the VA health care system reside in rural areas and
1.6 percent reside in highly rural areas.
The high number of veterans returning to rural areas will
likely continue with the newest generation. According to the
National Rural Health Association's February 2007 Issue Paper,
44 percent of new military recruits came from rural areas. In
contrast, just 25 percent of the U.S. population is considered
rural.
As a result, there are far fewer VA inpatient facilities
located in rural areas. For example, in FY 2008, VA had 633
mental health beds in facilities operating in rural areas,
compared to 4,088 mental health beds in facilities operating in
urban areas. Building additional facilities in rural areas is
problematic because rural veterans are, by definition,
dispersed over a wide area. VA stated in a February 26, 2009,
response to questions posed at the Committee's rural health
hearing:
Although the cumulative number of veterans living in
rural areas is high, the number living in any specific
rural area is relatively low. The need for high
intensity, low frequency health care services such as
admission to an inpatient mental health unit is likely
to be variable.
VA must obtain care for veterans in many of these areas by
paying community hospitals on a contractual or fee-for-service
basis. This means that veterans treated and monitored by VA
doctors in VA community based outpatient clinics must be
treated by a non-VA doctor when admitted to a community
hospital. This is because VA doctors do not have privileges at
community hospitals because such facilities require that a
physician occasionally accept responsibility for caring for
patients needing hospital admission that do not otherwise have
a doctor. Currently, VA doctors are not clearly authorized to
see non-veteran patients, even if it is a condition of their
ability to treat veterans in community hospitals.
Committee Bill. Section 213 of the Committee bill, in a
freestanding provision, would require VA to carry out a pilot
program to assess the feasibility and advisability of (1)
providing financial incentives to VA physicians who obtain and
maintain inpatient privileges at certain community hospitals,
and (2) the collection of payments from third parties for care
provided by any such physicians to nonveterans while carrying
out their responsibilities at the community hospital where they
are privileged.
The community hospitals that would be involved in the pilot
program would be in health professional shortage areas where
the number of physicians willing to assume inpatient
responsibilities at the hospital is sufficient for the purposes
of the pilot program. Eligible physicians would be primary care
or mental health physicians employed by VA on a full-time basis
who are in good standing with the Department, and who have
primarily clinical responsibilities with the Department.
Participation in the pilot program would be voluntary.
The pilot program would be carried out during the 3-year
period beginning on the date of the commencement of the pilot
program in not less than five community hospitals in each of
not less than two VISNs. The locations would be selected by the
Secretary based on the results of a survey of eligible
physicians to determine the extent of interest of such
physicians in participating in the pilot program.
The survey, which would be conducted not later than 120
days after the date of enactment of this Act, would be required
to disclose the type, amount and nature of the financial
incentives to be provided to physicians participating in the
pilot program.
Physicians selected for the program would be required to
assume and maintain inpatient responsibilities at one or more
community hospitals selected by the Secretary for participation
in the pilot.
Any physician participating in the pilot program who would
be required to see non-veteran patients as a condition of
obtaining privileges would be deemed to be acting in the scope
of the physician's office or employment for purposes of the
Federal Torts Claim Act.
The Secretary would be required to compensate eligible
physicians participating in the pilot program with additional
compensation as the Secretary considers appropriate for the
discharge of inpatient responsibilities by such physician at a
community hospital. The amount of such compensation would be
set forth in a written agreement between VA and the physician.
The Secretary would be required to consult with the
Director of the Office of Personnel Management regarding how
any additional compensation would be treated for the purposes
of retirement and other purposes under the civil service laws.
Subsection (i) of section 213 of the Committee bill would
require VA to implement mechanisms to collect from third party
payers for services provided by VA physicians to non-veterans
as part of the pilot program.
Subsection (j) of section 213 of the Committee bill would
define inpatient responsibilities as on-call responsibilities
required by a community hospital as a condition of granting
privileges to the physician to practice in the hospital.
Beginning not less than 1 year after the date of enactment
of the Committee bill and annually thereafter, VA would be
required to submit to Congress a report on the pilot program,
including the Secretary's findings with regard thereto, the
number of veterans and non-veterans provided inpatient care,
and the amounts collected and payable.
NRHA, PVA and AFGE testified in support of this specific
pilot program at the Committee's April 22, 2009, health
legislation hearing.
The Committee's goal for this pilot program is to foster
improved coordination between VA and community health
organizations, as well as to ensure that veterans receive good
continuity of care in the community. By allowing VA doctors to
treat their VA patients admitted to community hospitals, the
community and VA profit from the wise utilization of available
health care resources.
Sec. 214. Annual Report on Matters Related to Care for Veterans Who
Live in Rural Areas.
Background. According to VA, in FY 2008, contractual
purchasing authority on outpatient care, including emergency
room costs and inpatient ancillary costs, totaled $244,330,834.
In FY 2008, VA also spent $1.27 billion on care provided on a
fee-for- service basis.
Information on how and under what circumstances these
expenditures are made is not readily available. As this portion
of VA's budget continues to expand, improving oversight becomes
very important. In the FY 2010 Independent Budget, the IB VSOs
expressed concern regarding VA's inability to monitor quality
of care provided by contract providers.
Committee Bill. Section 214 of the Committee bill, in a
free standing provision, would require VA to submit an annual
report on the implementation of the provisions in sections 209
through 213 of the Committee bill and on the establishment and
functions of the Office of Rural Health. In the first such
report, VA would be required to include assessment of the fee-
basis health-care program required by section 212(b) of Public
Law 109-461 and the outreach program required by section 213 of
that Act.
Sec. 215. Transportation Grants for Rural Veterans Service
Organizations.
Section 215, as derived from S. 658, would authorize grants
to state veterans' service agencies and veterans' service
organizations for the purposes of providing certain
transportation services to veterans.
Background. Transportation is often a problem for many
veterans when making and keeping health care appointments.
Cancellation rates for outpatient appointments have
historically been high within VA, and transportation issues are
commonly cited as a contributing factor.
Veterans service organizations organize and offer van
transportation services to veterans traveling to and from
health care appointments. Their ability to offer these
services, however, is often limited by the availability of
funding. This is particularly true in areas where the distances
between veterans' residences and VA facilities are great, such
as in highly rural areas.
Committee Bill. Section 215, in a freestanding provision,
would require VA to establish a grant program to provide
innovative transportation options to veterans in highly rural
areas. The recipients of grants under the program would be
state veterans' service agencies and veterans' service
organizations. Entities receiving a grant would be required to
use the funds to assist veterans in highly rural areas with
transportation to and from VA medical centers and to otherwise
assist in providing medical care to veterans residing in highly
rural areas.
The maximum amount of a grant under this program would be
$50,000 and a recipient of a grant under this program would not
be required to provide matching funds as a condition of
receiving the grant.
The provision would authorize the appropriation of $3
million for each of the fiscal years 2010 through 2014 to carry
out this grant program.
TITLE III--OTHER HEALTH CARE MATTERS
Sec. 301. Veterans' Emergency Care Fairness Act of 2009.
Section 301, which is derived from S. 404, would allow
veterans who meet certain criteria to be reimbursed for the
difference between the maximum amount payable for emergency
medical services and any amount paid by an existing insurance
policy.
Background. Under Public Law 110-387, originally enacted on
November 30, 1999, a veteran who is enrolled in VA's health
care system can be reimbursed for emergency treatment received
at a non-VA hospital. However, the statute only permits such VA
reimbursement if the veteran has no other outside health
insurance, no matter how limited that other coverage might be.
This sole payer provision means that a veteran who has any
insurance is not entitled to reimbursement from VA for
emergency medical treatment received at a non-VA facility, even
if the veteran's insurance policy does not cover the full
amount owed.
Committee Bill. Section 301 of the Committee bill would
amend Section 1725(b)(3)(C) of title 38, relating to VA
reimbursement to veterans enrolled for VA care who receive
emergency care from outside providers. Subsection (a) of
section 301 of the Committee bill would amend section
1725(b)(3)(C) of title 38 so as to strike the phrase ``in whole
or in part,'' in order to authorize VA to provide reimbursement
for emergency care when the veteran has some insurance coverage
but that coverage is not sufficient to cover the cost of the
care. Under this change VA would be authorized to cover the
difference between the amount a veteran's insurance will pay
for emergency care and the total cost of care, thus becoming
the payer of last resort in such cases.
Section 1725 is further amended by adding a new paragraph
(4) to subsection (c) to specify that VA is to be a secondary
payer, that payment by VA along with any insurance payment
shall be payment in full, and that VA may not reimburse a
veteran for any copayment the veterans owes a third party.
These amendments would take effect on the date of enactment of
this Act. In addition to amending current law in a prospective
manner, Section 301 of the Committee bill, in a freestanding
provision, would authorize VA to reimburse the cost of
emergency care dating back to the effective date of the current
law if the Secretary determines that it is appropriate to do
so.
Sec. 302. Prohibition on Collection of Copayments from Veterans Who Are
Catastrophically Disabled.
Section 302 of the Committee bill, derived from S. 821,
would waive the collection of copayments from veterans who are
catastrophically disabled.
Background. In 1996, when Congress passed legislation
establishing the priority for enrolling veterans in VA's health
care system, it designated catastrophically disabled veterans
as Category 4. If these veterans' income would otherwise place
them in Categories 7 or 8, they are required to pay all fees
and copayments for the care of their non-service-connected
disabilities. The IB VSOs recommend that copayments for
catastrophically disabled veterans be eliminated in light of
the unique health care needs of this population. The veterans
who would be affected by this change, such as those with spinal
cord injury, require ongoing care and services.
Private insurers often do not cover these kinds of
services, and most other health programs do not offer the level
of care provided by VA. These veterans should not be required
to pay fees and copayments for their care, as they utilize and
rely on VA health care at a much higher rate than many other
veterans.
Committee Bill. Section 302 of the Committee bill would
amend subchapter III of chapter 17 by adding a new section
1730A. New section 1730A--entitled, ``Prohibition on collection
of copayments from veterans who are catastrophically
disabled''--would prohibit VA from collecting any copayment for
the receipt of hospital care or medical services from a veteran
who is catastrophically disabled, even if due to a non-service-
connected injury.
The Committee intends that this provision eliminate all
copayments for medical care, including prescriptions and
nursing home care, for catastrophically disabled veterans.
DAV, PVA, and the National Multiple Sclerosis Society
support this provision.
In a letter dated April 23, 2009, Blinded Veterans wrote
the following:
[This] legislation will eliminate these co-payments for
severely disabled veterans who are blind, paralyzed, or
suffered amputations, who often as non-service
connected veterans live on small social security
disability SSDI payments, and unable to pay for these
admissions. With this change these disabled veterans
will be able to access daily living blind or other
rehabilitation training that will improve their ability
to live independently at home.
TITLE IV--CONSTRUCTION AND NAMING MATTERS
Sec. 401. Major Medical Facility Project Department of Veterans Affairs
Medical Center, Walla Walla, Washington.
Section 401, in a freestanding provision which is derived
from S. 509, would authorize VA to design and construct a new
multiple specialty outpatient facility, perform campus
renovation and upgrades, and provide additional parking at the
VA Medical Center, Walla Walla, Washington. According to VA,
the project will serve nearly 50,000 enrolled veterans, and
will be carried out in an amount not to exceed $71,400,000.
These funds were already appropriated for this project in VA's
fiscal year 2009 major construction budget.
Sec. 402. Merril Lundman Department of Veterans Affairs Outpatient
Clinic.
Section 402, in a freestanding provision which is derived
from S. 226, would allow for the VA outpatient clinic in Havre,
Montana to be designated as the ``Merril Lundman Department of
Veterans Affairs Outpatient Clinic.''
In 2007, Merril Lundman, a veteran from Havre, Montana,
started a petition drive to ask for a clinic in Havre. Merril
Lundman died in December 2007, about a month before VA
announced it would open a clinic in Havre. As required by the
Committee's rules, the full Montana Congressional delegation,
and the Montana State Veterans' Organizations with national
membership of 500,000 or more, endorse this facility being
named in honor of Merril Lundman.
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 $6.7 billion over the 2010-
2014 period, assuming appropriation of the necessary amounts.
Enacting the bill would increase direct spending but those
effects would not be significant. Enactment of the Committee
bill would minimally affect receipts and would not affect the
budget of state and local governments. Tribal governments would
see minimal impact from enactment.
The cost estimate provided by CBO, setting forth a detailed
breakdown of costs, follows:
Congressional Budget Office,
Washington, DC, August 31, 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. 801, the Caregiver
and Veterans Health Services 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. 801--Caregiver and Veterans Health Services Act of 2009
Summary: S. 801 would authorize new programs for caregivers
of disabled veterans and make several changes to existing
veterans' health care programs. In total, CBO estimates that
implementing the bill would cost about $6.7 billion over the
2010-2014 period, assuming appropriation of the specified and
estimated amounts. Enacting the bill would increase direct
spending, but CBO estimates those effects would not be
significant. Enacting the bill would not affect revenues.
S. 801 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act
(hereinafter, ``UMRA'').
Estimated cost to the Federal government: The estimated
budgetary impact of S. 801 is shown in Table 1. The costs of
this legislation fall within budget function 700 (veterans
benefits and services).
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 existing or similar programs.
Table 1.--Budgetary Impact of S.801, the Caregiver and Veterans Health Services Act of 2009
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------
2010 2011 2012 2013 2014 2010-2014
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATIONa
Assistance for Caregivers
Estimated Authorization Level............. 125 249 913 1,509 2,154 4,950
Estimated Outlays......................... 113 234 845 1,441 2,076 4,709
Rural Demonstration Projects
Estimated Authorization Level............. 255 258 263 268 274 1,318
Estimated Outlays......................... 230 255 261 266 272 1,284
Travel Reimbursements
Estimated Authorization Level............. 22 45 91 92 93 343
Estimated Outlays......................... 20 43 86 91 92 332
Education Assistance
Estimated Authorization Level............. 22 30 41 51 62 206
Estimated Outlays......................... 20 29 40 50 61 200
Medical Construction
Authorization Level....................... 71 0 0 0 0 71
Estimated Outlays......................... 3 19 23 17 6 68
Copayments from Certain Disabled Veterans
Estimated Authorization Level............. 8 8 8 8 8 40
Estimated Outlays......................... 7 8 8 8 8 39
Transportation Grants
Authorization Level....................... 3 3 3 3 3 15
Estimated Outlays......................... 3 3 3 3 3 15
Rural Centers of Excellence
Estimated Authorization Level............. 2 2 2 2 2 10
Estimated Outlays......................... 2 2 2 2 2 10
Coordinators of Care for Native American
Veterans
Authorization Level....................... 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
Training for Mental Health Providers
Authorization Level....................... 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
Peer Reviews
Authorization Level....................... 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
Emergency Care
Authorization Level....................... 1 1 1 1 1 5
Estimated Outlays......................... 1 1 1 1 1 5
Other Provisions
Authorization Level....................... * * * * * 1
Estimated Outlays......................... * * * * * 1
-----------------------------------------------------------------
Total Changes
Estimated Authorization Level....... 512 599 1,325 1,937 2,600 6,974
Estimated Outlays................... 402 597 1,271 1,881 2,523 6,678
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.
aIn addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
enacting S.801 would increase direct spending by less than $500,000 over the 2010-2014 period and 2010-2019
period.
Spending subject to appropriation
CBO estimates that implementing S. 801 would cost $6.7
billion over the 2010-2014 period, assuming appropriation of
the specified and estimated amounts.
Assistance for Caregivers. Title I would require the
Department of Veterans Affairs (hereinafter, ``VA'') to provide
several benefits to caregivers of certain disabled veterans. In
total, CBO estimates that implementing those provisions would
cost $4.7 billion over the 2010-2014 period, assuming
appropriation of the necessary amounts (see Table 2).
Table 2.--Components of the Estimated Changes in Spending Subject to Appropriation Under Title I of S.801
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------
2010 2011 2012 2013 2014 2010-2014
----------------------------------------------------------------------------------------------------------------
Stipends
Estimated Authorization Level............. 14 33 401 838 1,313 2,599
Estimated Outlays......................... 13 31 364 791 1,258 2,457
Travel Benefits
Estimated Authorization Level............. 77 159 332 346 361 1,275
Estimated Outlays......................... 69 150 314 342 357 1,232
Oversight of Caregivers
Estimated Authorization Level............. 2 5 56 116 182 361
Estimated Outlays......................... 2 4 50 110 174 340
Personnel and Other Costs
Estimated Authorization Level............. 28 45 58 88 119 338
Estimated Outlays......................... 26 43 56 84 115 324
Benefits During Caregiver Training
Estimated Authorization Level............. 1 3 39 64 89 196
Estimated Outlays......................... 1 2 36 61 86 186
Medical Care
Estimated Authorization Level............. 1 3 21 44 69 138
Estimated Outlays......................... 1 3 19 41 66 130
Respite Care
Estimated Authorization Level............. * 1 6 13 21 41
Estimated Outlays......................... * * 6 12 20 38
Survey
Estimated Authorization Level............. 2 0 0 0 0 2
Estimated Outlays......................... 1 1 0 0 0 2
-----------------------------------------------------------------
Total Changes in Title I
Estimated Authorization Level....... 125 249 913 1,509 2,154 4,950
Estimated Outlays................... 113 234 844 1,441 2,076 4,709
----------------------------------------------------------------------------------------------------------------
Note: * = less than $500,000.
Stipends. Section 102 of the bill would require VA to pay a
monthly stipend to caregivers of severely injured veterans. CBO
estimates that implementing the provision would cost about $2.5
billion over the 2010-2014 period.
Under section 102, caregivers of veterans whose severe
service-connected injuries were incurred or aggravated on or
after September 11, 2001, would be eligible for monthly
stipends and other benefits. (The other benefits are discussed
below.) Based on information from the Department of Defense
(hereinafter, ``DOD'') on military retirees, CBO estimates that
in 2010 caregivers to about 2,000 veterans would be eligible
for VA benefits. Starting in 2012, the bill would widen the
eligible population to include caregivers of other veterans
with severe service-connected injuries. Based on information
from VA on how they would implement the bill, CBO estimates
that caregivers to 52,500 veterans would become eligible for VA
benefits. CBO further estimates that the program would be
implemented gradually, with only 475 caregivers receiving
stipends in 2010 and full implementation in 2015.
Based on data from the Bureau of Labor Statistics on
average hourly pay for home health care aides, CBO estimates
that in 2010, VA would pay 475 family caregivers a stipend of
$2,350 a month (an hourly rate of $10.50 for an average of 225
hours a month), for a cost of $13 million in 2010. After
adjusting for gradual implementation of the program over the
2010-2014 period and for inflation, CBO estimates that number
of family caregivers receiving stipends would grow to 39,400 in
2014, at a cost of $1.3 billion that year.
Travel Benefits. Section 103 would authorize VA to pay
transportation, lodging, and subsistence expenses of family
members and other caregivers of veterans. Over the 2010-2014
period, CBO estimates that implementing this provision would
cost $1.2 billion, assuming appropriation of the necessary
amounts.
Lodging and subsistence expenses of nonveterans are not
reimbursable under current law. Based on information from VA
about veterans who have received travel benefits in 2009, CBO
estimates that in 2010 VA would reimburse $1,950 each to 34,000
nonveterans (an average per diem rate of $130 for 15 days a
year), for a cost of $66 million in 2010. After adjusting for
gradual implementation of the program over the 2010-2014 period
and for inflation, CBO estimates that the number of nonveterans
receiving per diems would grow to almost 150,000 a year by 2014
and VA would spend about $1.2 billion a year over the 2010-2014
period.
CBO estimates that under the bill almost all family members
or caregivers would either travel in the same vehicle with the
veteran or would be deemed medically necessary attendants (VA
is currently authorized to pay transportation expenses in those
instances), but that a few nonveterans would become newly
eligible for reimbursement of travel costs starting in 2010.
CBO further estimates that 6,000 nonveterans would receive
reimbursements worth $500 in 2010, for a total cost that year
of $3 million. After adjusting for gradual implementation of
the program over the 2010-2014 period and for inflation, CBO
estimates that VA would spend about $55 million on travel costs
for nonveterans over the 2010-2014 period.
Oversight of Caregivers. Section 102 also would require
regular oversight of caregivers, including home visits. CBO
estimates that implementing the provision would cost $340
million over the 2010-2014 period.
Based on information from VA, CBO estimates that VA would
contract with home-health agencies to conduct oversight of 500
caregivers at a cost of almost $325 a month per caregiver (an
hourly rate of $108 for an average of 3 hours a month), for a
cost of $2 million in 2010. After adjusting for gradual
implementation of the program over the 2010-2014 period and for
inflation, CBO estimates that the number of caregivers being
overseen would grow to 39,400 in 2014, at a cost of about $175
million that year.
Personnel and Other Costs. To implement the new caregiver
benefits under section 102 of the bill, VA would need
additional personnel at medical centers and at its headquarters
in Washington, DC. Those personnel would evaluate veterans and
their caregivers to determine the type of care veterans need
and the training their caregivers require, and provide
training, counseling, and support to caregivers. VA also would
be required to design an interactive Web site to provide
information on caregiver services, conduct outreach, and report
periodically to the Congress. CBO estimates that implementing
those provisions would cost about $325 million over the 2010-
2014 period.
Based on information from VA, CBO estimates that each of
the 153 medical centers would require a team consisting of a
nurse, a social worker, a psychologist, a physical therapist,
an occupational therapist, and a program support assistant. An
additional staff of three people would be required at VA
headquarters to monitor and coordinate implementation. Assuming
an average annual salary of $115,000 per person and after
adjusting for inflation, CBO estimates that about 25 percent of
the necessary staff would be hired in 2010 at an annual cost of
$26 million, and that all necessary staff would be hired by
2014, at a cost that year of $115 million.
Benefits During Caregiver Training. Section 102 would
provide respite care and travel benefits to caregivers while
they undergo training at VA facilities. CBO estimates that
implementing those provisions would cost about $185 million
over the 2010-2014 period.
The bill would require VA to provide training to family
members or other individuals to prepare them to provide care to
disabled veterans. Based on information from VA, CBO expects VA
would provide initial training for two weeks and refresher
training for one week each year. During those training periods,
VA also would provide respite care (if the veteran had no
substitute caregivers), reimbursement of travel costs, and per
diem expenses.
CBO estimates that in 2010 about 450 veterans would require
respite care during the two-week period of initial training--at
a daily cost of $210--for a total cost of $1 million that year.
The following year, CBO estimates that 1,000 veterans would
need respite care (550 during initial training and 450 during
refresher training) at a total cost of $2 million in 2011. By
2014, CBO estimates that almost 35,500 veterans would require
respite care during training, for a cost of $57 million that
year.
CBO further estimates that 550 caregivers would undergo
initial training and be eligible for travel benefits in 2010.
(That figure is higher than the number of veterans requiring
respite care because CBO assumes some veterans will have more
than one caregiver.) CBO estimates that half--or 275--live
close enough to the training site that they would commute daily
and be eligible for mileage reimbursements averaging $375 (90
miles round trip for 10 weekdays at a reimbursement rate of
$0.415 per mile). The other 275 would travel to the training
site and stay there for the duration of training. Those
caregivers would be eligible for reimbursement for travel costs
averaging $150 (two 180 mile round trips at $0.415 per mile) as
well as per diems averaging $130 a day. CBO estimates that
total costs for caregivers undergoing training in 2010 would be
less than $500,000. In 2011, 605 caregivers would commute for
training (330 for initial training and 275 for refresher
training), while another 605 would travel to the training site
and stay there for the duration of their training, for total
costs that year of about $1 million. By 2014, CBO estimates
that about 43,300 caregivers would undergo training and would
receive travel benefits and per diems worth about $30 million
that year.
Medical Care. Section 102 also would authorize VA to
provide medical care to caregivers, if such caregivers are not
covered under other health plans. CBO estimates that
implementing the provision would cost $130 million over the
2010-2014 period.
The population eligible for this benefit also is similar to
the population eligible for the monthly stipend; however, CBO
estimates that only one-quarter of the caregivers would be
eligible (i.e. would not be covered under other health plans)
and would seek medical care from VA. Based on information from
VA on the cost of health care it provides to non-veterans, CBO
estimates that in 2010 they would provide medical care to 250
family caregivers at an average cost of almost $6,000 each, for
a total cost of $1 million in 2010. After adjusting for
inflation and gradual implementation of the program, CBO
estimates that the number of family caregivers receiving
medical care would grow to 13,100 by 2014, at a cost of $66
million that year.
In addition, section 101 would prohibit VA from recovering
the cost of certain emergency care provided to family members
and caregivers of veterans whose severe service-connected
injuries were incurred or aggravated on or after September 11,
2001. The bill would only affect emergencies that occur while
the family member or caregiver accompanies a veteran who is
receiving care at a VA facility (or a non-VA facility VA has
contracted with). Based on information from VA, CBO estimates
that about 250 people each year would receive such care at an
average cost of $330 each, for total costs of less than
$500,000 over the 2010-2014 period.
Respite Care. Section 102 would expand VA's authority to
provide respite care to veterans. CBO estimates that
implementing that provision would cost $38 million over the
2010-2014 period.
Under current law, veterans who receive medical services,
hospital care, nursing home care, or domiciliary care from VA
are eligible for up to 30 days of respite care. The bill would
extend eligibility for that benefit to enrolled veterans who do
not receive such care. Based on information from VA, CBO
estimates that the majority of disabled, enrolled veterans who
require caregivers currently receive care from VA, and that
about 50 additional veterans would receive respite care in 2010
under this provision. CBO further estimates that VA would
provide an average of 21 days of respite care to each veteran--
at a daily cost of $210 in 2010--for a total cost of less than
$500,000 that year. After adjusting for inflation and gradual
implementation of the program, CBO estimates that by 2014 about
4,000 veterans would receive respite care at a total cost of
$20 million.
Survey. Section 104 would require VA and DOD to conduct a
national survey of family caregivers of seriously disabled
veterans and servicemembers (covering the size and
characteristics of the population and types of care provided),
and to report to the Congress on their findings. CBO estimates
that implementing this provision would cost $2 million over the
2010-2014 period.
Rural Demonstration Projects. Section 205 would authorize
VA to carry out demonstration projects, including by
establishing partnerships with the Department of Health and
Human Services and the Indian Health Service, to expand care
for veterans in rural areas. In 2009, VA received
appropriations of $250 million for similar purposes. After
adjusting that amount for inflation, CBO estimates that
implementing this provision would require additional
appropriations of $255 million in 2010 and $1.3 billion over
the 2010-2014 period.
Travel Reimbursements. Section 208 would authorize VA to
pay mileage reimbursements in excess of the cost of that travel
by public transportation; under current law, VA pays the lesser
of mileage reimbursements or the cost of public transportation.
CBO estimates that implementing this provision would cost $332
million over the 2010-2014 period, assuming appropriation of
the necessary amounts.
Based on VA's estimate that it expects to pay $300 million
in mileage reimbursements in 2009 and data on bus fares to
major VA medical facilities, CBO estimates that under the bill
those costs would increase by 25 percent starting in 2010.
After adjusting for gradual implementation of the program, CBO
estimates that VA would pay an additional $272 million in
travel reimbursements over the 2010-2014 period. Enacting this
provision also would increase spending on VA's vocational
rehabilitation program, however, CBO estimates those effects
would be insignificant (see discussion under ``Direct
Spending.'')
Section 208 also would allow VA to reimburse the cost of
air travel, if that mode of travel was the only practical way
to reach a VA medical facility; under current law, VA pays for
such travel in very few cases. VA was unable to provide data on
the number of veterans currently using air travel or the cost
of such travel. Assuming that 5 percent of the existing users
of the beneficiary travel program--about 30,000 people--would
each make one round trip a year at a cost of $500 and after
adjusting for gradual implementation of the program, CBO
estimates that VA would pay an additional $60 million over the
2010-2014 period.
Education Assistance. Two sections of the bill would
authorize VA to provide scholarships and assistance with
education loans to certain employees. Taken together, CBO
estimates that implementing those provisions would cost $200
million over the 2010-2014 period, assuming appropriation of
the necessary amounts.
Debt Reduction. Section 201 would amend the Education Debt
Reduction Program, which helps certain employees repay
education loans, by deleting the ceiling of $44,000 per
employee and allowing VA to pay up to the total principal and
interest owed. Section 201 also would require VA to inform
those job applicants who would be eligible for the program of
their eligibility when making job offers, and to accept into
the program any applicants who accept a job offer. 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.
CBO estimates that under the proposed program changes, 650
additional employees each year would become eligible and that
the average payment per new employee in 2010 would be $8,500.
(Existing participants would receive an additional payment of
$2,500 each in 2010.) After adjusting for inflation, CBO
estimates that implementing this provision would cost $197
million over the 2010-2014 period, assuming appropriation of
the necessary amounts.
Scholarship Program. Section 202 would authorize a new
scholarship program for individuals studying to rehabilitate
the visually impaired. Under the bill, VA would pay such
individuals up to $15,000 a year for tuition and fees (each
recipient could receive a maximum of $45,000), in exchange for
the participant's agreement to work at VA for at least three
years after graduation. Based on information from VA, CBO
estimates that the department would offer 20 scholarships each
year (each for a three-year period) to interns in occupations
working with the visually impaired, and that the average
payment would be $11,250 in 2010. After adjusting for
inflation, CBO estimates that implementing this provision would
cost $3 million over the 2010-2014 period, assuming
appropriation of the necessary amounts.
Medical Construction. Section 401 would authorize the
appropriation of $71 million to construct a new outpatient
facility and renovate existing facilities in Walla Walla,
Washington. CBO estimates that implementing that provision
would cost $68 million over the 2010-2014 period, assuming
appropriation of the authorized amounts. (The remaining $3
million would be spent after 2014.)
Copayments from Certain Disabled Veterans. Section 302
would prohibit the collection of copayments and other fees from
catastrophically disabled veterans who receive hospital care or
medical services from VA. In 2008, VA collected about $8
million in copayments for medical care and prescription drugs
from those veterans. CBO estimates that implementing this
provision would decrease collections by $8 million per year.
Such collections are offsets to discretionary appropriations.
As part of the annual appropriations process, the Congress
gives VA authority to spend those collections. Therefore,
maintaining the same level of health care services for veterans
would necessitate additional funding each year to make up for
the loss of copayments under this bill. Thus, CBO estimates
that implementing this provision would cost about $40 million
over the 2010-2014 period, assuming appropriation of the
necessary amounts.
Transportation Grants. Section 215 would authorize the
appropriation of $3 million each year over the 2010-2014
period. VA would use those amounts to make grants to
organizations that improve access to medical care for veterans
living in highly rural areas (counties with a population
density fewer than seven persons per square mile). CBO
estimates that implementing that provision would cost $15
million over the 2010-2014 period, assuming appropriation of
the authorized amounts.
Rural Centers of Excellence. Section 212 would require VA
to establish between one and five centers of excellence for
research, education, and clinical activities focused on rural
health services. VA has indicated that the proposed centers of
excellence would be similar to existing Rural Health Resource
Centers, and that under the bill it would establish one center
of excellence. Based on operating costs of the existing
resource centers, CBO estimates that implementing this
provision would cost $2 million a year over the 2010-2014
period, assuming appropriation of the necessary amounts.
Coordinators of Care for Native American Veterans. Section
207 would require VA to appoint a coordinator of care for
Native American veterans at each of the 10 medical centers that
serve the greatest number of such veterans. The coordinators
would improve outreach to and expand access to care for tribal
communities, coordinate the medical needs of veterans living on
reservations, act as an ombudsman for Native American veterans
using the VA health care system, and advocate for the use of
traditional medicine in VA treatments. CBO estimates that
implementing this provision would require VA to hire 10
employees at an annual cost of $1 million a year over the 2010-
2014 period, assuming appropriation of the necessary amounts.
Training for Mental Health Providers. Section 206 would
require VA to train veterans and clinicians to provide peer
support, readjustment counseling, and other mental health
services to veterans of Operation Iraqi Freedom and Operation
Enduring Freedom (hereinafter, ``OIF/OEF'') and to assist
family members of OIF/OEF veterans with their recovery and
readjustment to civilian life. Under current law, VA has the
authority to provide such services through Vet Centers and
existing mental health programs, and may also contract with
non-VA entities to provide services, especially in rural areas.
Based on information from VA, CBO estimates that about
20,000 veteran peer counselors and clinicians would undergo
initial training in 2010 at a cost of $1 million. Additional
training for new staff and refresher training for existing
staff also would average about $1 million each year over the
2011-2014 period. CBO estimates that implementing this
provision would cost $5 million over the 2010-2014 period,
assuming appropriation of the necessary amounts.
Peer Reviews. Section 210 would authorize VA to review the
quality of health care provided by non-VA contractors. Under
the bill, non-VA providers in each of VA's 21 regional networks
of medical facilities would provide a sample of patient records
to VA for review. Based on information from VA, CBO estimates
that VA would require 10 additional employees to analyze
records and prepare reports at a cost of $1 million a year over
the 2010-2014 period, assuming appropriation of the necessary
amounts.
Emergency Care. Section 301 would require VA to pay for the
emergency care that certain veterans receive at non-VA medical
facilities, or to reimburse veterans if they have paid for that
care. It also would permit VA, subject to the Secretary's
discretion, to reimburse veterans for emergency treatment that
was provided prior to the date of enactment. CBO estimates that
implementing those provisions would cost $5 million over the
2010-2014 period, assuming appropriation of the necessary
amounts.
Under current law, VA has the authority to reimburse
certain veterans or pay for emergency treatment of a
nonservice-connected condition, if VA is the payer of last
resort. Veterans who have recourse against a third party that
would partly cover those medical expenses are not eligible for
such reimbursement from VA. Section 301 would remove that
restriction.
Based on information from VA, CBO estimates that under the
bill VA would approve about 700 new claims a year over the
2010-2014 period and about 2,000 claims for emergency treatment
provided over the 2005-2009 period. (CBO assumes that few
veterans have retained records for emergency treatment provided
before 2005.) CBO estimates that VA would pay an average of
$730 per claim in 2010, rising to about $900 per claim in 2014,
for total costs of $1 million a year.
Other Provisions. Two sections of the bill, when taken
individually, would increase spending subject to appropriation
by less than $500,000 each year. Taken together, CBO estimates
that implementing the following provisions would have a total
cost of $1 million over the 2010-2014 period, assuming
availability of appropriated funds:
Section 209 would require the Office of Rural
Health to develop a five-year strategic plan. VA has indicated
that the office is developing a similar plan and that the
necessary modifications would have insignificant costs.
Section 214 would require annual reports to the
Congress on the implementation of several sections of the bill.
Direct Spending
Section 208 would increase mileage reimbursements paid to
veterans using VA's vocational rehabilitation program. However,
CBO estimates that few beneficiaries would be affected, that
the increased amounts paid per veteran would be quite low, and
thus, that enacting section 208 would increase direct spending
by less than $500,000 each year and over the 2010-2014 and
2010-2019 periods.
Intergovernmental and private-sector impact: S. 801
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
program activities authorized in the bill.
Previous CBO estimates: On July 23, 2009, CBO transmitted a
cost estimate for H.R. 3155, the Caregiver Assistance and
Resource Enhancement Act, as ordered reported by the House
Committee on Veterans' Affairs on July 15, 2009. H.R. 3155 is
similar to title I of S. 801, however H.R. 3155 affected a much
smaller population, and its estimated costs were
correspondingly lower.
On July 23, 2009, CBO transmitted a cost estimate for H.R.
3219, the Veterans' Insurance and Health Care Improvement Act
of 2009, as ordered reported by the House Committee on
Veterans' Affairs on July 15, 2009. Section 203 of H.R. 3219 is
similar to section 302 of S. 801, and their estimated costs are
identical.
On March 25, 2009, CBO transmitted a cost estimate for H.R.
1377, a bill to amend title38, United States Code, to expand
veteran eligibility for reimbursement by the Secretary of
Veterans Affairs for emergency treatment furnished in a non-
Department facility, and for other purposes, as ordered
reported by the House Committee on Veterans' Affairs on March
25, 2009. H.R. 1377 is similar to section 301 of S. 801, and
their estimated costs are identical.
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. 801 reported favorably to the Senate
by roll call vote, without dissent.
----------------------------------------------------------------------------------------------------------------
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
various bills incorporated into the Committee bill. In
addition, on May 14, 2009, VA provided views on S. 801.
Excerpts of both the testimony and Department views are
reprinted below:
STATEMENT OF GERALD M. CROSS, M.D., FAAFP, PRINCIPAL DEPUTY UNDER
SECRETARY FOR HEALTH, U.S. 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. Unfortunately, we do not yet have
views and estimates on several bills including S. 239, S. 498,
S. 699, S. 772, S. 793, subsection (f) of S. 252 and S. 821. We
will forward those as soon as they are available. Our support
for the bill provisions discussed below is contingent upon VA's
ability to fund such activities within the President's 2010
budget.
* * * * * * *
S. 801 ``FAMILY CAREGIVER PROGRAM ACT OF 2009''
S. 801 is divided into four separate sections. I will
address each section separately; however, VA has not yet
evaluated the costs of implementing the provisions of S. 801.
We will provide an estimate to the Committee as soon as it is
completed.
Section 2 would authorize VA to waive charges for
humanitarian care provided to caregivers accompanying certain
severely injured veterans as they receive medical care. VA does
not object to the concept of providing humanitarian medical
benefits to caregivers but we must oppose this section. As
currently written, Section 2 identifies an extensive list of
family members as potential caregivers and provides no criteria
regarding the extent or duration of their service to the
Veteran. Family caregivers could change frequently and we are
concerned that the provision of humanitarian care could become
a primary factor in designating a caregiver rather than that
person's ability to assist the veteran. Further, language that
has historically appeared in VA appropriation statutes
(requiring reimbursement for hospital care and medical services
provided to individuals who are not otherwise eligible for
these benefits) may restrict VA's ability to waive charges as
outlined in this provision of the bill. We are also considering
the impact of Section 2 on the implementation of the family
medical care provisions of the National Defense Authorization
Act of 2008 (Sec. 1672(b) of Public Law 110-181).
Section 3 of S. 801 addresses family caregiver assistance.
I have previously discussed the family caregiver provisions of
S. 252 and S. 543, which would require the Secretary to conduct
pilot programs to assess the feasibility of training family
caregivers as personal care attendants. While the eligibility
criteria for this section are very similar to those in S. 543,
S. 801 differs dramatically from S. 252 and S. 543 because it
would establish a program of instruction, preparation,
training, certification and ongoing support for designated
family caregivers across VA. The mechanics of the program under
S. 801 are also different as eligible veterans and their family
member (or other designated individual) would make a joint
application to VA which would then evaluate the veteran to
identify the personal care services needed by that individual
and determine if they could be provided by a family member. The
applicant family member is also evaluated to determine the
training they would need to provide those services. Unlike
S. 252 and S. 253, S. 801 does not address the development of
the training curriculum. However, it does distinguish between a
family member who provides personal care services and a family
member who is designated as the veteran's primary personal care
attendant. The agency would be required to provide training,
certification, technical support, and counseling to both;
however, a primary personal care attendant would also be
furnished mental health services, medical care under 38 U.S.C.
1781, respite care and a stipend.
VA strongly opposes Section 3. The same concerns identified
in conjunction with caregiver provisions of S. 252 and S. 543
apply here as well. VA currently contracts for caregiver
services with various providers and this arrangement is
preferable because it does not divert VA from its primary
mission of treating veterans and training clinicians. We also
would like to reiterate that S. 801 would establish the
caregiver program across the agency and we caution against
implementing a program of this magnitude without first
exploring its feasibility and effectiveness. Should the
Committee decide to proceed with a caregiver assistance
proposal, we urge you to opt for the program defined in section
209 of S. 252 which would allow VA to conduct a three-year
pilot providing assistance to caregivers of TBI patients.
Moreover, the concerns that I addressed in discussing Section 2
relative to the large cadre of eligible caregivers would make
this proposal challenging to administer and monitor for quality
and effectiveness. The administrative burden on VA to re-
identify and track caregivers could be considerable.
Finally, S. 801 in general, and Section 3 in particular,
would create preferential benefits for one generation of
Veterans that are not available to others. VA believes that
caregiver assistance would benefit veterans of all ages and
periods of service and any initiative to support caregivers
should not be limited to post-September 11 veterans.
Section 4 would amend VA's beneficiary travel statute (38
U.S.C. 111) to include lodging and subsistence as travel
expenses for attendants of certain veterans receiving VA health
care. This provision would also define the travel period to
include travel to and from the facility and the duration of the
treatment episode. We believe that the proposed amendments
would apply to all attendants eligible for beneficiary travel
under 38 U.S.C. 111, not just those attendants defined by
S. 801. VA opposes Section 4 as this benefit expansion would
divert resources from medical care. In addition, 38 U.S.C. 111
already provides travel benefit attendants for severely injured
veterans.
------
The Secretary of Veterans Affairs,
Washington, DC, May 14, 2009.
Hon. Daniel K. Akaka,
Chairman,
Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: This letter is in response to your
invitation to submit for the record the Department's views on
six bills, S. 239, S. 498, S. 699, S. 772, S. 793, and S. 821.
As you know, we received some of these legislative items too
late to address in testimony before the Committee on April 22,
2009. In addition, while our views remain the same, we are
submitting additional information and costs on four bills that
were addressed in the April 22 testimony, S. 252, S. 404,
S. 423, and S. 801. Thank you for giving us this valuable
opportunity to submit our views before the hearing record
closes.
* * * * * * *
S. 801 ``FAMILY CAREGIVER PROGRAM ACT OF 2009''
VA's opposition to S. 801 was detailed in the April 22,
2009, testimony. The costs for each section of the bill are
outlined below.
Section 2 would amend 38 U.S.C. Sec. 1784 to allow for
waiver of charges for hospital care or medical services
provided to certain family members of Veterans receiving VA
health care. We project that this provision would cost
approximately $330,000 in 2010, $2 million over five years, and
$5.3 million over ten years.
Section 3 addresses family caregiver assistance. VA has
identified 65,798 Veterans with a serious injury incurred on or
after September 11, 2001, that would be eligible for this
program during its first two years. It is expected that an
additional 1,440 Veterans would become eligible each subsequent
year. VA estimates that this provision would cost $5.056
billion in fiscal year 2010, $26.859 billion over five years,
and $62.8 billion over 10 years. Note that these costs do not
include Veterans severely injured prior to September 11, 2001,
that may become eligible for this program after the first two
years.
Section 4, Lodging and Subsistence for Attendants, would
amend 38 U.S.C. Sec. 111 to allow for travel, including lodging
and subsistence, for the period consisting of travel to and
from a treatment facility and the duration of the treatment
episode for certain family members of certain Veterans
receiving VA health care. We estimate the cost of this
provision to be $8.6 million in 2010, $57.7 million over five
years, and $163 million over ten years.
* * * * * * *
The Office of Management and Budget advises that there is
no objection to the submission of this letter from the
standpoint of the Administration.
Thank you again Mr. Chairman, for the opportunity to
provide VA's views on these bills.
Sincerely,
Eric K. Shinseki.
* * * * * * *
Excerpt from April 22, 2009, Hearing Record Regarding S. 801
Response to Written Questions Submitted by Hon. Daniel K. Akaka to
U.S. Department of Veterans Affairs
Question 1. In written testimony, the Department expressed
concern ``that the provision of humanitarian care could become
a primary factor in designating a caregiver rather than the
person's ability to assist the Veteran.'' Since the legislation
states that the designated caregiver receives waived charges
for emergency medical care in the sole instance he or she is
accompanying the Veteran, the likelihood of the caregiver
receiving health care benefits is very small. Please elaborate
as to why VA has a reservation with this provision?
Response. Given the extensive list of persons eligible to
be the Veteran's caregiver, the Veteran may elect to designate,
or be under pressure to designate, as their caregiver someone
who has need for medical care and would benefit greatly from
the Department of Veterans Affairs' (VA) providing that care.
This person may not be the best choice to assist the Veteran
with their daily needs. Moreover, the legislation does not
provide for limits on the number of times or how frequently the
Veteran may change caregivers. Potentially, a number of persons
could receive needed medical care by being designated as
caregiver.
Question 2. The Department objects to section 3 of S. 801
because of a concern that it will force VA to create
preferential benefits for one group of Veterans. Yet, the
legislation allows VA to extend this benefit to ``include the
largest number of Veterans possible.'' Please explain, in
detail, why the Department raises an objection to this
provision?
Response. The number of Veterans meeting the eligibility of
section 3 for the first 2 years of enactment is small compared
to eligible Veterans from previous generations. VA believes
that any program that would benefit one cadre of combat
Veterans over another is inequitable, whether for a 2-year
period or permanently.
VA has been working on the family caregiver issue for some
time and believes that the newly developed Veteran directed-
home and community-based service (VD-HCBS) creates a workable
infrastructure for family caregivers to be paid for the
relevant service they provide. The VD-HCBS program provides
Veterans of all ages the opportunity to receive home and
community based services in a consumer-directed fashion that
enables them to avoid nursing home placement and continue to
live in their homes. The VD-HCBS program addresses the home
care needs for Veterans of all ages, allowing services to be
provided to younger, seriously-injured and Traumatic Brain
Injury (TBI) Veterans. This program will also help address the
demand for paid family caregivers in a comprehensive and
structured manner.
We would be pleased to discuss this program and other
alternatives to section 3 of S. 801 with Members of the
Committee staff. VA is committed to working with the Congress
to create a viable family caregiver program.
Sincerely,
Eric K. Shinseki.
* * * * * * *
Changes in Existing Law
In compliance with paragraph 12 of Rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman).
TITLE 38. VETERANS' BENEFITS
* * * * * * *
PART I. GENERAL PROVISIONS
* * * * * * *
PART V. BOARDS, ADMINISTRATIONS, AND SERVICES
Chapter Sec.
Board of Veterans' Appeals....................................7101
United States Court of Appeals for Veterans Claims............7251
Veterans Health Administration--Organization and Functions....7301
Veterans Health Administration--Personnel.....................7401
Visual Impairment and Orientation and Mobility Professionals 75.
Education Assistance Program................................7501
7601Health Professionals Educational Assistance Program...............
* * * * * * *
PART I. GENERAL PROVISIONS
* * * * * * *
CHAPTER 1. GENERAL
SEC. 101. DEFINITIONS
* * * * * * *
SEC. 111. PAYMENTS OR ALLOWANCES FOR BENEFICIARY TRAVEL
(a) Under regulations prescribed by the President pursuant
to the provisions of this section, the Secretary may pay the
actual necessary expense of travel (including lodging and
subsistence), or in lieu thereof an allowance based upon
mileage [traveled,] (at a rate of 41.5 cents per mile) when not
traveling by air, of any person to or from a Department
facility or other place in connection with vocational
rehabilitation, counseling required by the Secretary pursuant
to chapter 34 or 35 of this title, or for the purpose of
examination, treatment, or care. Actual necessary expense of
travel includes the reasonable costs of airfare if travel by
air is the only practical way to reach a Department facility.
In addition to the mileage allowance authorized by this
section, there may be allowed reimbursement for the actual cost
of ferry fares, and bridge, road, and tunnel tolls.
(b)(1) * * *
* * * * * * *
(4) In determining for purposes of subsection (a) whether
travel by air is the only practical way for a veteran to reach
a Department facility, the Secretary shall consider the medical
condition of the veteran and any other impediments to the use
of ground transportation by the veteran.
* * * * * * *
(e) [When any] (1) When any person entitled to mileage
under this section requires an attendant (other than an
employee of the Department) in order to perform such travel,
the attendant may be allowed expenses of travel (including
lodging and subsistence) upon the same basis as such person for
the period consisting of travel to and from a treatment
facility and the duration of the treatment episode at that
facility.
(2) The Secretary may prescribe regulations to carry out
this subsection. Such regulations may include provisions--
(A) to limit the number of individuals that may
receive expenses of travel under paragraph (1) for a
single treatment episode of a person; and
(B) to require attendants to use certain travel
services.
(3) In this subsection:
(A) The term ``attendant'' includes, with respect to
a person described in paragraph (1), the following:
(i) A family member of the person.
(ii) An individual approved as a personal
care attendant under section 1717A(d)(3) of
this title.
(iii) Any other individual whom the Secretary
determines--
(I) has a preexisting relationship
with the person; and
(II) provides a significant portion
of the person's care.
(B) The term ``family member'' shall have such
meaning as the Secretary shall determine by policy or
regulation.
* * * * * * *
[(g)(1) Subject to paragraph (3), in determining the amount
of allowances or reimbursement to be paid under this section,
the Secretary shall use the mileage reimbursement rate for the
use of privately owned vehicles by Government employees on
official business (when a Government vehicle is available), as
prescribed by the Administrator of General Services under
section 5707(b) of title 5.
[(2) In no event shall payment be provided under this
section--
[(A) unless the person claiming reimbursement has
been determined, pursuant to regulations which the
Secretary shall prescribe, to be unable to defray the
expenses of such travel (except with respect to a
person receiving benefits for or in connection with a
service-connected disability under this title, a
veteran receiving or eligible to receive pension under
section 1521 of this title, or a person whose annual
income, determined in accordance with section 1503 of
this title, does not exceed the maximum annual rate of
pension which would be payable to such person if such
person were eligible for pension under section 1521 of
this title;
[(B) to reimburse for the cost of travel by privately
owned vehicle in any amount in excess of the cost of
such travel by public transportation unless (i) public
transportation is not reasonably accessible or would be
medically inadvisable, or (ii) the cost of such travel
is not greater than the cost of public transportation;
and
[(C) in excess of the actual expense incurred by such
person as certified in writing by such person.
[(3) Subject to the availability of appropriations, the
Secretary may modify the amount of allowances or reimbursement
to be paid under this section using a mileage reimbursement
rate in excess of that prescribed under paragraph (1).]
(g)(1) Beginning one year after the date of the enactment
of the Caregiver and Veterans Health Services Act of 2009, the
Secretary may adjust the mileage rate described in subsection
(a) to be equal to the mileage reimbursement rate for the use
of privately owned vehicles by Government employees on official
business (when a Government vehicle is available), as
prescribed by the Administrator of General Services under
section 5707(b) of title 5.
(2) If an adjustment in the mileage rate under paragraph
(1) results in a lower mileage rate than the mileage rate
otherwise specified in subsection (a), the Secretary shall, not
later than 60 days before the date of the implementation of the
mileage rate as so adjusted, submit to Congress a written
report setting forth the adjustment in the mileage rate under
this subsection, together with a justification for the decision
to make the adjustment in the mileage rate under this
subsection.
* * * * * * *
PART II. GENERAL BENEFITS
* * * * * * *
CHAPTER 11. COMPENSATION FOR SERVICE-CONNECTED DISABILITY OR DEATH
* * * * * * *
CHAPTER 17. HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
SUBCHAPTER I. GENERAL
SEC.
1701. DEFINITIONS.
1702. PRESUMPTIONS: PSYCHOSIS AFTER SERVICE IN WORLD WAR II AND
FOLLOWING PERIODS OF WAR; MENTAL ILLNESS FOLLOWING
SERVICE IN THE PERSIAN GULF WAR.
1703. CONTRACTS FOR HOSPITAL CARE AND MEDICAL SERVICES IN NON-
DEPARTMENT FACILITIES.
1703A. OVERSIGHT OF CONTRACT AND FEE-BASIS CARE.
* * * * * * *
1709. TELECONSULTATION AND TELERETINAL IMAGING.
* * * * * * *
SUBCHAPTER II. HOSPITAL, NURSING HOME, OR DOMICILIARY CARE AND MEDICAL
TREATMENT
1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE.
* * * * * * *
1717. HOME HEALTH SERVICES; INVALID LIFTS AND OTHER DEVICES.
1717A. FAMILY CAREGIVER ASSISTANCE.
* * * * * * *
SUBCHAPTER III. MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS
1721. POWER TO MAKE RULES AND REGULATIONS.
* * * * * * *
1730. COMMUNITY RESIDENTIAL CARE.
1730A. PROHIBITION ON COLLECTION OF COPAYMENTS FROM CATASTROPHICALLY
DISABLED VETERANS.
* * * * * * *
Subchapter I. General
SEC. 1701. DEFINITIONS
* * * * * * *
SEC. 1703A. OVERSIGHT OF CONTRACT AND FEE-BASIS CARE
(a) Rural Outreach Coordinators.--The Secretary shall
designate a rural outreach coordinator at each Department
community based outpatient clinic at which not less than 50
percent of the veterans enrolled at such clinic reside in a
highly rural area. The coordinator at a clinic shall be
responsible for coordinating care and collaborating with
community contract and fee-basis providers with respect to the
clinic.
(b) Incentives To Obtain Accreditation of Medical
Practice.--(1) The Secretary shall adjust the fee-basis
compensation of providers of health care services under the
Department to encourage such providers to obtain accreditation
of their medical practice from recognized accrediting entities.
(2) In making adjustments under paragraph (1), the
Secretary shall consider the increased overhead costs of
accreditation described in paragraph (1) and the costs of
achieving and maintaining such accreditation.
(c) Incentives for Participation in Peer Review.--(1) The
Secretary shall adjust the fee-basis compensation of providers
of health care services under the Department that do not
provide such services as part of a medical practice accredited
by a recognized accrediting entity to encourage such providers
to participate in peer review under subsection (e).
(2) The Secretary shall provide incentives under paragraph
(1) to a provider of health care services under the Department
in an amount which may reasonably be expected (as determined by
the Secretary) to encourage participation in the voluntary peer
review under subsection (d).
(d) Peer Review.--(1) The Secretary shall provide for the
voluntary peer review of providers of health care services
under the Department who provide such services on a fee basis
as part of a medical practice that is not accredited by a
recognized accrediting entity.
(2) Each year, beginning with the first fiscal year
beginning after the date of the enactment of this section, the
Chief Quality and Performance Officer in each Veterans
Integrated Services Network (VISN) shall select a sample of
patient records from each participating provider in the
Officer's Veterans Integrated Services Network to be peer
reviewed by a facility designated under paragraph (3).
(3) The Chief Quality and Performance Officer in each
Veterans Integrated Services Network shall designate Department
facilities in such network for the peer review of patient
records submitted under this subsection.
(4) Each year, beginning with the first fiscal year
beginning after the date of the enactment of this section, each
provider who elects to participate in the program shall submit
the patient records selected under paragraph (2) to a facility
selected under paragraph (3) to be peer reviewed by such
facility.
(5) Each Department facility designated under paragraph (3)
that receives patient records under paragraph (4) shall--
(A) peer review such records in accordance with
policies and procedures established by the Secretary;
(B) ensure that peer reviews are evaluated by the
Peer Review Committee; and
(C) develop a mechanism for notifying the Under
Secretary for Health of problems identified through
such peer review.
(6) The Under Secretary for Health shall develop a
mechanism by which the use of fee-basis providers of health
care are terminated when quality of care concerns are
identified with respect to such providers.
(7) The Chief Quality and Performance Officer in each
Veterans Integrated Services Network shall be responsible for
the oversight of the program of peer review under this
subsection in that network.
* * * * * * *
SEC. 1709. TELECONSULTATION AND TELERETINAL IMAGING
(a) Teleconsultation.--(1) The Secretary shall carry out a
program of teleconsultation for the provision of remote mental
health and traumatic brain injury assessments in facilities of
the Department that are not otherwise able to provide such
assessments without contracting with third party providers or
reimbursing providers through a fee-basis system.
(2) The Secretary shall, in consultation with appropriate
professional societies, promulgate technical and clinical care
standards for the use of teleconsultation services within
facilities of the Department.
(b) Teleretinal Imaging.--The Secretary shall carry out a
program of teleretinal imaging in each Veterans Integrated
Services Network (VISN).
(c) Annual Reports.--In each fiscal year beginning with
fiscal year 2010 and ending with fiscal year 2015, the
Secretary shall submit to Congress a report on the programs
required by subsections (a) and (b). Such report shall include
the following:
(1) A description of the efforts made by the
Secretary to make teleconsultation available in rural
areas and to utilize teleconsultation in rural areas.
(2) The rates of utilization of teleconsultation by
Veterans Integrated Services Network disaggregated by
each fiscal year for which a report is submitted under
this subsection.
(d) Definitions.--In this section:
(1) The term ``teleconsultation'' means the use by a
health care specialist of telecommunications to assist
another health care provider in rendering a diagnosis
or treatment.
(2) The term ``teleretinal imaging'' means the use by
a health care specialist of telecommunications, digital
retinal imaging, and remote image interpretation to
provide eye care.
Subchapter II. Hospital, Nursing Home, or Domiciliary Care and Medical
Treatment
SEC. 1710. ELIGIBILITY FOR HOSPITAL, NURSING HOME, AND DOMICILIARY CARE
* * * * * * *
SEC. 1712A. ELIGIBILITY FOR READJUSTMENT COUNSELING AND RELATED MENTAL
HEALTH SERVICES
(a) * * *
* * * * * * *
(c) [The Under Secretary] (1) 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].
(2) In carrying out this section, the Under Secretary may
utilize the services of the following:
(A) 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.
(B) Eligible volunteer counselors in the provision of
counseling and related mental health services.
(3) For purposes of this subsection, an eligible volunteer
counselor is an individual--
(A) who--
(i) provides counseling services without
compensation at a center;
(ii) is a licensed psychologist or social
worker;
(iii) has never been named in a tort claim
arising from professional activities; and
(iv) has never had, and has no pending,
disciplinary action taken with respect to any
license or certification qualifying that
individual to provide counseling services; or
(B) who is otherwise credentialed and privileged to
perform counseling services by the Secretary.
(4) Eligible volunteer counselors shall be issued
credentials and privileges for the provision of counseling and
related mental health services under this section on an
expedited basis in accordance with such procedures as the
Secretary shall establish. Such procedures shall provide for
the completion by the Secretary of the processing of an
application for such credentials and privileges not later than
60 days after receipt of the application.
(d) * * *
(e) [The Secretary] (1) 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.
(2) Each center shall develop an outreach plan to ensure
that the community served by the center is aware of the
services offered by the center.
* * * * * * *
SEC. 1717A. FAMILY CAREGIVER ASSISTANCE
(a) In General.--(1) As part of home health services
provided under section 1717 of this title, the Secretary shall,
upon the joint application of an eligible veteran and a family
member of such veteran (or other individual designated by such
veteran), furnish to such family member (or designee) family
caregiver assistance in accordance with this section. The
purpose of providing family caregiver assistance under this
section is--
(A) to reduce the number of veterans who are
receiving institutional care, or who are in need of
institutional care, whose personal care service needs
could be substantially satisfied with the provision of
such services by a family member (or designee); and
(B) to provide eligible veterans with additional
options so that they can choose the setting for the
receipt of personal care services that best suits their
needs.
(2) The Secretary shall only furnish family caregiver
assistance under this section to a family member of an eligible
veteran (or other individual designated by such veteran) if the
Secretary determines it is in the best interest of the eligible
veteran to do so.
(b) Eligible Veterans.--(1) For purposes of this section,
an eligible veteran is a veteran (or member of the Armed Forces
undergoing medical discharge from the Armed Forces)--
(A) who has a serious injury (including traumatic
brain injury, psychological trauma, or other mental
disorder) incurred or aggravated in the line of duty in
the active military, naval, or air service on or after
the date described in paragraph (2); and
(B) whom the Secretary determines, in consultation
with the Secretary of Defense as necessary, is in need
of personal care services because of--
(i) an inability to perform one or more
independent activities of daily living;
(ii) a need for supervision or protection
based on symptoms or residuals of neurological
or other impairment or injury; or
(iii) such other matters as the Secretary
shall establish in consultation with the
Secretary of Defense as appropriate.
(2) The date described in this paragraph--
(A) during the period beginning on the date of the
enactment of the Caregiver and Veterans Health Services
Act of 2009 and ending two years after the date of the
enactment of that Act, is September 11, 2001; and
(B) beginning on the first day after the date that is
two years after the date of the enactment of the
Caregiver and Veterans Health Services Act of 2009, is
the earliest date the Secretary determines is
appropriate to include the largest number of veterans
(and members of the Armed Forces) possible under this
section without reducing the quality of care provided
to such veterans (and members).
(c) Evaluation of Eligible Veterans and Family
Caregivers.--(1) The Secretary shall evaluate each eligible
veteran who makes a joint application under subsection (a)(1)--
(A) to identify the personal care services required
by such veteran; and
(B) to determine whether such requirements could be
significantly or substantially satisfied with the
provision of personal care services from a family
member (or other individual designated by the veteran).
(2) The Secretary shall evaluate each family member of an
eligible veteran (or other individual designated by the
veteran) who makes a joint application under subsection (a)(1)
to determine--
(A) the basic amount of instruction, preparation, and
training such family member (or designee) requires, if
any, to provide the personal care services required by
such veteran; and
(B) the amount of additional instruction,
preparation, and training such family member (or
designee) requires, if any, to be the primary personal
care attendant designated for such veteran under
subsection (e).
(3) An evaluation carried out under paragraph (1) may be
carried out--
(A) at a Department facility;
(B) at a non-Department facility determined
appropriate by the Secretary for purposes of such
evaluation; and
(C) at such other locations as the Secretary
considers appropriate.
(d) Training and Approval.--(1) Except as provided in
subsection (a)(2), the Secretary shall provide each family
member of an eligible veteran (or other individual designated
by the veteran) who makes a joint application under subsection
(a)(1) the basic instruction, preparation, and training
determined to be required by such family member (or designee)
under subsection (c)(2)(A).
(2) The Secretary may provide to a family member of an
eligible veteran (or other individual designated by the
veteran) the additional instruction, preparation, and training
determined to be required by such family member (or designee)
under subsection (c)(2)(B) if such family member (or
designee)--
(A) is approved as a personal care attendant for the
veteran under paragraph (3); and
(B) requests, with concurrence of the veteran, such
additional instruction, preparation, and training.
(3) Upon the successful completion by a family member of an
eligible veteran (or other individual designated by the
veteran) of basic instruction, preparation, and training
provided under paragraph (1), the Secretary shall approve the
family member as a personal care attendant for the veteran.
(4) If the Secretary determines that a primary personal
care attendant designated under subsection (e) requires
additional training to maintain such designation, the Secretary
shall make such training available to the primary personal care
attendant.
(5) The Secretary shall, subject to regulations the
Secretary shall prescribe, provide for necessary travel,
lodging, and per diem expenses incurred by a family member of
an eligible veteran (or other individual designated by the
veteran) in undergoing training under this subsection.
(6) If the participation of a family member of an eligible
veteran (or other individual designated by the veteran) in
training under this subsection would interfere with the
provision of personal care services to the veteran, the
Secretary shall, subject to regulations as the Secretary shall
prescribe and in consultation with the veteran, provide respite
care to the veteran during the provision of such training to
the family member so that such family caregiver (or designee)
can participate in such training without interfering with the
provision of such services.
(e) Designation of Primary Personal Care Attendant.--(1)
For each eligible veteran with at least one family member (or
other individual designated by the veteran) who is described by
subparagraphs (A) through (E) of paragraph (2), the Secretary
shall designate one family member of such veteran (or other
individual designated by the veteran) as the primary personal
care attendant for such veteran to be the primary provider of
personal care services for such veteran.
(2) A primary personal care attendant designated for an
eligible veteran under paragraph (1) shall be selected from
among family members of such veteran (or other individuals
designated by such veteran) who--
(A) are approved under subsection (d)(3) as a
personal care attendant for such veteran;
(B) complete all additional instruction, preparation,
and training, if any, provided under subsection (d)(2);
(C) elect to provide the personal care services to
such veteran that the Secretary determines such veteran
requires under subsection (c)(1);
(D) has the consent of such veteran to be the primary
provider of such services for such veteran; and
(E) the Secretary considers competent to be the
primary provider of such services for such veteran.
(3) An eligible veteran receiving personal care services
from a family member (or other individual designated by the
veteran) designated as the primary personal care attendant for
the veteran under paragraph (1) may revoke consent with respect
to such family member (or designee) under paragraph (2)(D) at
any time.
(4) If an individual designated as the primary personal
care attendant of an eligible veteran under paragraph (1)
subsequently fails to meet the requirements set forth in
paragraph (2), the Secretary--
(A) shall immediately revoke the individual's
designation under paragraph (1); and
(B) may designate, in consultation with the eligible
veteran or the eligible veteran's surrogate appointed
under subsection (g), a new primary personal care
attendant for the veteran under such paragraph.
(5) The Secretary shall take such actions as may be
necessary to ensure that the revocation of a designation under
paragraph (1) does not interfere with the provision of personal
care services required by a veteran.
(f) Ongoing Family Caregiver Assistance.--(1) Except as
provided in subsection (a)(2) and subject to the provisions of
this subsection, the Secretary shall provide ongoing family
caregiver assistance to family members of eligible veterans (or
other individuals designated by such veterans) as follows:
(A) To each family member of an eligible veteran (or
designee) who is approved under subsection (d)(3) as a
personal care attendant for the veteran the following:
(i) Direct technical support consisting of
information and assistance to timely address
routine, emergency, and specialized caregiving
needs.
(ii) Counseling.
(iii) Access to an interactive Internet
website on caregiver services that addresses
all aspects of the provision of personal care
services under this section.
(B) To each family member of an eligible veteran (or
designee) who is designated as the primary personal
care attendant for the veteran under subsection (e) the
following:
(i) The ongoing family caregiver assistance
described in subparagraph (A).
(ii) Mental health services.
(iii) Respite care of not less than 30 days
annually, including 24-hour per day care of the
veteran commensurate with the care provided by
the family caregiver to permit extended
respite.
(iv) Medical care under section 1781 of this
title if such family member (or designee) is
not entitled to care or services under a
health-plan contract (as defined in section
1725(f) of this title).
(v) A monthly personal caregiver stipend.
(2)(A) The Secretary shall provide respite care under
paragraph (1)(B)(iii), at the election of the Secretary--
(i) through facilities of the Department that are
appropriate for the veteran; or
(ii) through contracts under section 1720B(c) of this
title.
(B) If the primary personal care attendant of an eligible
veteran designated under subsection (e)(1) determines in
consultation with the veteran or the veteran's surrogate
appointed under subsection (g), and the Secretary concurs, that
the needs of the veteran cannot be accommodated through the
facilities and contracts described in subparagraph (A), the
Secretary shall, in consultation with the primary personal care
attendant and the veteran (or the veteran's surrogate), provide
respite care through other facilities or arrangements that are
medically and age appropriate.
(3) If the Secretary determines that the Department lacks
the capacity to furnish medical care under clause (iv) of
paragraph (1)(B), the Secretary may contract, in accordance
with such regulations as the Secretary shall prescribe, for
such insurance, medical services, or health plans as the
Secretary considers appropriate to furnish such medical care.
(4)(A) The Secretary shall provide monthly personal
caregiver stipends under paragraph (1)(B)(v) in accordance with
a schedule established by the Secretary that specifies stipends
provided based upon the amount and degree of personal care
services provided.
(B) The Secretary shall ensure, to the extent practicable,
that the schedule required by subparagraph (A) specifies that
the amount of the personal caregiver stipend provided to a
primary personal care attendant designated under subsection
(e)(1) for the provision of personal care services to an
eligible veteran is not less than the amount a commercial home
health care entity would pay an individual in the geographic
area of the veteran to provide equivalent personal care
services to the veteran.
(C) If personal care services are not available from a
commercial provider in the geographic area of an eligible
veteran, the Secretary may establish the schedule required by
subparagraph (A) with respect to the veteran by considering the
costs of commercial providers of personal care services in
geographic areas other than the geographic area of the veteran
with similar costs of living.
(5) Provision of ongoing family caregiver assistance under
this subsection for provision of personal care services to an
eligible veteran shall terminate if the veteran no longer
requires the personal care services.
(g) Surrogates.--If an eligible veteran lacks the capacity
to submit an application, provide consent, make a request, or
concur with a request under this section, the Secretary may, in
accordance with regulations and policies of the Department
regarding the appointment of guardians or the use of powers of
attorney, appoint a surrogate for the veteran who may submit
applications, provide consent, make requests, or concur with
requests on behalf of the veteran under this section.
(h) Oversight.--(1) The Secretary shall enter into
contracts with appropriate entities to provide oversight of the
provision of personal care services under this section by
primary personal care attendants designated under subsection
(e)(1).
(2) The Secretary shall ensure that each eligible veteran
receiving personal care services under this section from a
primary personal care attendant designated under subsection
(e)(1) is visited in the veteran's home by an entity providing
oversight under paragraph (1) at such frequency as the
Secretary shall determine under paragraph (3).
(3)(A) Except as provided in subparagraph (B), the
Secretary shall determine the manner of oversight provided
under paragraph (1) and the frequency of visits under paragraph
(2) for an eligible veteran as the Secretary considers
commensurate with the needs of such veteran.
(B) The frequency of visits under paragraph (2) for an
eligible veteran shall be not less frequent than once every six
months.
(4)(A) An entity visiting an eligible veteran under
paragraph (2) shall submit to the Secretary the findings of the
entity with respect to each visit, including whether the
veteran is receiving the care the veteran requires.
(B) If an entity finds under subparagraph (A) that an
eligible veteran is not receiving the care the veteran
requires, the entity shall submit to the Secretary a
recommendation on the corrective actions that should be taken
to ensure that the veteran receives the care the veteran
requires, including, if the entity considers appropriate, a
recommendation for revocation of a caregiver's approval under
subsection (d)(3) or revocation of the designation of an
individual under subsection (e)(1).
(5) After receiving findings and recommendations, if any,
under paragraph (4) with respect to an eligible veteran, the
Secretary may take such actions as the Secretary considers
appropriate to ensure that the veteran receives the care the
veteran requires, including the following:
(A) Revocation of a caregiver's approval under
subsection (d)(3).
(B) Revocation of the designation of an individual
under subsection (e)(1).
(6) If the Secretary terminates the provision of ongoing
family caregiver assistance under subsection (f) to a family
member of an eligible veteran (or other individual designated
by the veteran) because of findings of an entity submitted to
the Secretary under paragraph (4), the Secretary may not
provide compensation to such entity for the provision of
personal care services to such veteran, unless the Secretary
determines it would be in the best interest of such veteran to
provide compensation to such entity to provide such services.
(i) Outreach.--The Secretary shall carry out a program of
outreach to inform eligible veterans and their family members
of the availability and nature of family caregiver assistance
under this section.
(j) Construction.--(1) A decision by the Secretary under
this section affecting the furnishing of family caregiver
assistance shall be considered a medical determination.
(2) Nothing in this section shall be construed to create an
employment relationship between the Secretary and an individual
in receipt of family caregiver assistance under this section.
(3) Nothing in this section shall be construed to create
any entitlement to any services or stipends provided under this
section.
(k) Definitions.--In this section:
(1) The term ``family caregiver assistance'' includes
the instruction, preparation, training, and approval
provided under subsection (d) and the ongoing family
caregiver assistance provided under subsection (f).
(2) The term ``family member'' shall have such
meaning as the Secretary shall determine by policy or
regulation.
(3) The term ``personal care services'', with respect
to a veteran, includes the following:
(A) Supervision of the veteran.
(B) Protection of the veteran.
(C) Services to assist the veteran with one
or more independent activities of daily living.
(D) Such other services as the Secretary
considers appropriate.
* * * * * * *
Subchapter III. Miscellaneous Provisions Relating to Hospital and
Nursing Home Care and Medical Treatment of Veterans
SEC. 1725. REIMBURSEMENT FOR EMERGENCY TREATMENT
* * * * * * *
(b) Eligibility.
* * * * * * *
(3) * * *
* * * * * * *
(C) has no other contractual or legal
recourse against a third party that would[, in
whole or in part,] extinguish such liability to
the provider; and
* * * * * * *
(c) Limitations on reimbursement.
* * * * * * *
(4)(A) If the veteran has contractual or legal
recourse against a third party that would, in part,
extinguish the veteran's liability to the provider of
the emergency treatment and payment for the treatment
may be made both under subsection (a) and by the third
party, the amount payable for such treatment under such
subsection shall be the amount by which the costs for
the emergency treatment exceed the amount payable or
paid by the third party, except that the amount payable
may not exceed the maximum amount payable established
under paragraph (1)(A).
(B) In any case in which a third party is financially
responsible for part of the veteran's emergency
treatment expenses, the Secretary shall be the
secondary payer.
(C) A payment in the amount payable under
subparagraph (A) shall be considered payment in full
and shall extinguish the veteran's liability to the
provider.
(D) The Secretary may not reimburse a veteran under
this section for any copayment or similar payment that
the veteran owes the third party or for which the
veteran is responsible under a health-plan contract.
* * * * * * *
(f) Definitions.--For purposes of this section:
* * * * * * *
(3) The term ``third party'' means any of the
following:
(A) A Federal entity, including the Secretary
of Health and Human Services with respect to
the Medicare program under title XVIII of the
Social Security Act (42 U.S.C. 1395 et seq.)
and the Medicaid program under title XIX of
such Act (42 U.S.C. 1396 et seq.).
(B) A State or political subdivision of a
State, including a State Medicaid agency with
respect to payments made under a State plan for
medical assistance approved under title XIX of
such Act (42 U.S.C. 1396 et seq.).
* * * * * * *
SEC. 1730A. PROHIBITION ON COLLECTION OF COPAYMENTS FROM
CATASTROPHICALLY DISABLED VETERANS
Notwithstanding subsections (f) and (g) of section 1710 and
section 1722A(a) of this title or any other provision of law,
the Secretary may not require a veteran who is catastrophically
disabled to make any copayment for the receipt of hospital care
or medical services under the laws administered by the
Secretary.
Subchapter VIII. Health Care of Persons Other Than Veterans
SEC. 1781. MEDICAL CARE FOR SURVIVORS AND DEPENDENTS OF CERTAIN
VETERANS
(a) The Secretary is authorized to provide medical care, in
accordance with the provisions of subsection (b) of this
section, for--
(1) the spouse or child of a veteran who has a total
disability, permanent in nature, resulting from a
service-connected disability,
(2) a family member of a veteran (or other individual
designated by the veteran) designated as the primary
personal care attendant for such veteran under section
1717A(e) of this title who is not entitled to care or
services under a health-plan contract (as defined in
section 1725(f) of this title),
[(2)] (3) the surviving spouse or child of a veteran
who (A) died as a result of a service-connected
disability, or (B) at the time of death had a total
disability permanent in nature, and
[(3)] (4) the surviving spouse or child of a person
who died in the active military, naval, or air service
in the line of duty and not due to such person's own
misconduct,
who are not otherwise eligible for medical care under chapter
55 of title 10 (CHAMPUS).
* * * * * * *
SEC. 1784. HUMANITARIAN CARE
[The Secretary may furnish hospital care or medical
services as a humanitarian service in emergency cases, but the
Secretary shall charge for such care and services at rates
prescribed by the Secretary.]
(a) In General.--The Secretary may furnish hospital care or
medical services as a humanitarian service in emergency cases.
(b) Reimbursement.--Except as provided in subsection (c),
the Secretary shall charge for care and services provided under
subsection (a) at rates prescribed by the Secretary.
(c) Waiver of Charges.--(1) Except as provided in paragraph
(2), the Secretary shall waive the charges required by
subsection (b) for care or services provided under subsection
(a) to an attendant of a covered veteran if such care or
services are provided to such attendant for an emergency that
occurs while such attendant is accompanying such veteran while
such veteran is receiving approved inpatient or outpatient
treatment at--
(A) a Department facility; or
(B) a non-Department facility--
(i) that is under contract with the
Department; or
(ii) at which the veteran is receiving fee-
basis care.
(2) If an attendant is entitled to care or services under a
health-plan contract (as that term is defined in section
1725(f) of this title) or other contractual or legal recourse
against a third party that would, in part, extinguish liability
for charges described by subsection (b), the amount of such
charges waived under paragraph (1) shall be the amount by which
such charges exceed the amount of such charges covered by the
health-plan contract or other contractual or legal recourse
against the third party.
(d) Definitions.--In this section:
(1) The term ``attendant'', with respect to a
veteran, includes the following:
(A) A family member of the veteran.
(B) An individual eligible to receive ongoing
family caregiver assistance under section
1717A(e)(1) of this title for the provision of
personal care services to the veteran.
(C) Any other individual whom the Secretary
determines--
(i) has a relationship with the
veteran sufficient to demonstrate a
close affinity with the veteran; and
(ii) provides a significant portion
of the veteran's care.
(2) The term ``covered veteran'' means any veteran
with a severe injury incurred or aggravated in the line
of duty in the active military, naval, or air service
on or after September 11, 2001.
(3) The term ``family member'' shall have such
meaning as the Secretary shall determine by policy or
regulation.
(4) The term ``severe injury'', in the case of a
covered veteran, means any physiological,
psychological, or neurological condition that renders a
veteran unable to live independently as determined by
the Secretary.
* * * * * * *
PART V. BOARDS, ADMINISTRATIONS,
AND SERVICES
Chapter Sec.
Board of Veterans' Appeals....................................7101
United States Court of Appeals for Veterans Claims............7251
Veterans Health Administration--Organization and Functions....7301
Veterans Health Administration--Personnel.....................7401
Visual Impairment and Orientation and Mobility Professionals 75.
Education Assistance Program................................7501
7601Health Professionals Educational Assistance Program...............
* * * * * * *
CHAPTER 73. VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
* * * * * * *
SUBCHAPTER II. GENERAL AUTHORITY AND ADMINISTRATION
SEC.
7311. QUALITY ASSURANCE.
* * * * * * *
7330A. EPILEPSY CENTERS OF EXCELLENCE
7330B. INDIAN VETERANS HEALTH CARE COORDINATORS.
7330C. CENTERS OF EXCELLENCE FOR RURAL HEALTH RESEARCH, EDUCATION, AND
CLINICAL ACTIVITIES.
* * * * * * *
Subchapter II. General Authority and Administration
* * * * * * *
SEC. 7330A. EPILEPSY CENTERS OF EXCELLENCE
* * * * * * *
SEC. 7330B. INDIAN VETERANS HEALTH CARE COORDINATORS
(a) In General.--(1) The Secretary shall assign at each of
the 10 Department Medical Centers that serve communities with
the greatest number of Indian veterans per capita an official
or employee of the Department to act as the coordinator of
health care for Indian veterans at such Medical Center. The
official or employee so assigned at a Department Medical Center
shall be known as the ``Indian Veterans Health Care
Coordinator'' for the Medical Center.
(2) The Secretary shall, from time to time--
(A) survey the Department Medical Centers for
purposes of identifying the 10 Department Medical
Centers that currently serve communities with the
greatest number of Indian veterans per capita; and
(B) utilizing the results of the most recent survey
conducted under subparagraph (A), revise the assignment
of Indian Veterans Health Care Coordinators in order to
assure the assignment of such coordinators to
appropriate Department Medical Centers as required by
paragraph (1).
(b) Duties.--The duties of an Indian Veterans Health Care
Coordinator shall include the following:
(1) Improving outreach to tribal communities.
(2) Coordinating the medical needs of Indian veterans
on Indian reservations with the Veterans Health
Administration and the Indian Health Service.
(3) Expanding the access and participation of the
Department of Veterans Affairs, the Indian Health
Service, and tribal members in the Department of
Veterans Affairs Tribal Veterans Representative
program.
(4) Acting as an ombudsman for Indian veterans
enrolled in the health care system of the Veterans
Health Administration.
(5) Advocating for the incorporation of traditional
medicine and healing in Department treatment plans for
Indian veterans in need of care and services provided
by the Department.
(c) Indian Defined.--In this section, the term ``Indian''
has the meaning given the term in section 4 of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450b).
SEC. 7330C. CENTERS OF EXCELLENCE FOR RURAL HEALTH RESEARCH, EDUCATION,
AND CLINICAL ACTIVITIES
(a) Establishment of Centers.--The Secretary, through the
Director of the Office of Rural Health, shall establish and
operate at least one and not more than five centers of
excellence for rural health research, education, and clinical
activities, which shall--
(1) conduct research on the furnishing of health
services in rural areas;
(2) develop specific models to be used by the
Department in furnishing health services to veterans in
rural areas;
(3) provide education and training for health care
professionals of the Department on the furnishing of
health services to veterans in rural areas; and
(4) develop and implement innovative clinical
activities and systems of care for the Department for
the furnishing of health services to veterans in rural
areas.
(b) Use of Rural Health Resource Centers.--In selecting
locations for the establishment of centers of excellence under
subsection (a), the Secretary may select a rural health
resource center that meets the requirements of subsection (a).
(c) Geographic Dispersion.--The Secretary shall ensure that
the centers established under this section are located at
health care facilities that are geographically dispersed
throughout the United States.
(d) Funding.--(1) There are authorized to be appropriated
to the Medical Care Account and the Medical and Prosthetics
Research Account of the Department of Veterans Affairs such
sums as may be necessary for the support of the research and
education activities of the centers operated under this
section.
(2) There shall be allocated to the centers operated under
this section, from amounts authorized to be appropriated to the
Medical Care Account and the Medical and Prosthetics Research
Account by paragraph (1), such amounts as the Under Secretary
of health considers appropriate for such centers. Such amounts
shall be allocated through the Director of the Office of Rural
Health.
(3) Activities of clinical and scientific investigation at
each center operated under this section--
(A) shall be eligible to compete for the award of
funding from funds appropriated for the Medical and
Prosthetics Research Account; and
(B) shall receive priority in the award of funding
from such account to the extent that funds are awarded
to projects for research in the care of rural veterans.
* * * * * * *
CHAPTER 74. VETERANS HEALTH ADMINISTRATION--PERSONNEL
* * * * * * *
CHAPTER 75. VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY
PROFESSIONALS EDUCATION ASSISTANCE PROGRAM
SEC.
7501. ESTABLISHMENT OF SCHOLARSHIP PROGRAM; PURPOSE.
7502. APPLICATION AND ACCEPTANCE.
7503. AMOUNT OF ASSISTANCE; DURATION.
7504. AGREEMENT.
7505. REPAYMENT FOR FAILURE TO SATISFY REQUIREMENTS OF AGREEMENT.
SEC. 7501. ESTABLISHMENT OF SCHOLARSHIP PROGRAM; PURPOSE
(a) Establishment.--Subject to the availability of
appropriations, the Secretary shall establish and carry out a
scholarship program to provide financial assistance in
accordance with this chapter to an individual--
(1) who is accepted for enrollment or currently
enrolled in a program of study leading to a degree or
certificate in visual impairment or orientation and
mobility, or a dual degree or certification in both
such areas, at an accredited (as determined by the
Secretary) educational institution that is in a State;
and
(2) who enters into an agreement with the Secretary
as described in section 7504 of this chapter.
(b) Purpose.--The purpose of the scholarship program
established under this chapter is to increase the supply of
qualified blind rehabilitation specialists for the Department
and the Nation.
(c) Outreach.--The Secretary shall publicize the
scholarship program established under this chapter to
educational institutions throughout the United States, with an
emphasis on disseminating information to such institutions with
high numbers of Hispanic students and to Historically Black
Colleges and Universities.
SEC. 7502. APPLICATION AND ACCEPTANCE
(a) Application.--(1) To apply and participate in the
scholarship program under this chapter, an individual shall
submit to the Secretary an application for such participation
together with an agreement described in section 7504 of this
chapter under which the participant agrees to serve a period of
obligated service in the Department as provided in the
agreement in return for payment of educational assistance as
provided in the agreement.
(2) In distributing application forms and agreement forms
to individuals desiring to participate in the scholarship
program, the Secretary shall include with such forms the
following:
(A) A fair summary of the rights and liabilities of
an individual whose application is approved (and whose
agreement is accepted) by the Secretary.
(B) A full description of the terms and conditions
that apply to participation in the scholarship program
and service in the Department.
(b) Approval.--(1) Upon the Secretary's approval of an
individual's participation in the scholarship program, the
Secretary shall, in writing, promptly notify the individual of
that acceptance.
(2) An individual becomes a participant in the scholarship
program upon such approval by the Secretary.
SEC. 7503. AMOUNT OF ASSISTANCE; DURATION
(a) Amount of Assistance.--The amount of the financial
assistance provided for an individual under this chapter shall
be the amount determined by the Secretary as being necessary to
pay the tuition and fees of the individual. In the case of an
individual enrolled in a program of study leading to a dual
degree or certification in both the areas of study described in
section 7501(a)(1) of this chapter, the tuition and fees shall
not exceed the amounts necessary for the minimum number of
credit hours to achieve such dual certification or degree.
(b) Relationship to Other Assistance.--Financial assistance
may be provided to an individual under this chapter to
supplement other educational assistance to the extent that the
total amount of educational assistance received by the
individual during an academic year does not exceed the total
tuition and fees for such academic year.
(c) Maximum Amount of Assistance.--(1) In no case may the
total amount of assistance provided under this chapter for an
academic year to an individual who is a full-time student
exceed $15,000.
(2) In the case of an individual who is a part-time
student, the total amount of assistance provided under this
chapter shall bear the same ratio to the amount that would be
paid under paragraph (1) if the participant were a full-time
student in the program of study being pursued by the individual
as the coursework carried by the individual to full-time
coursework in that program of study.
(3) In no case may the total amount of assistance provided
to an individual under this chapter exceed $45,000.
(d) Maximum Duration of Assistance.--The Secretary may
provide financial assistance to an individual under this
chapter for not more than six years.
SEC. 7504. AGREEMENT
An agreement between the Secretary and a participant in the
scholarship program under this chapter shall be in writing,
shall be signed by the participant, and shall include--
(1) the Secretary's agreement to provide the
participant with financial assistance as authorized
under this chapter;
(2) the participant's agreement--
(A) to accept such financial assistance;
(B) to maintain enrollment and attendance in
the program of study described in section
7501(a)(1) of this chapter;
(C) while enrolled in such program, to
maintain an acceptable level of academic
standing (as determined by the educational
institution offering such program under
regulations prescribed by the Secretary); and
(D) after completion of the program, to serve
as a full-time employee in the Department for a
period of three years, to be served within the
first six years after the participant has
completed such program and received a degree or
certificate described in section 7501(a)(1) of
this chapter; and
(3) any other terms and conditions that the Secretary
determines appropriate for carrying out this chapter.
SEC. 7505. REPAYMENT FOR FAILURE TO SATISFY REQUIREMENTS OF AGREEMENT
(a) In General.--An individual who receives educational
assistance under this chapter shall repay to the Secretary an
amount equal to the unearned portion of such assistance if the
individual fails to satisfy the requirements of the agreement
entered into under section 7504 of this chapter, except in
circumstances authorized by the Secretary.
(b) Amount of Repayment.--The Secretary shall establish, by
regulations, procedures for determining the amount of the
repayment required under this subsection and the circumstances
under which an exception to the required repayment may be
granted.
(c) Waiver or Suspension of Compliance.--The Secretary
shall prescribe regulations providing for the waiver or
suspension of any obligation of an individual for service or
payment under this chapter (or an agreement under this chapter)
whenever noncompliance by the individual is due to
circumstances beyond the control of the individual or whenever
the Secretary determines that the waiver or suspension of
compliance is in the best interest of the United States.
(d) Obligation as Debt to United States.--An obligation to
repay the Secretary under this section is, for all purposes, a
debt owed the United States. A discharge in bankruptcy under
title 11 does not discharge a person from such debt if the
discharge order is entered less than five years after the date
of the termination of the agreement or contract on which the
debt is based.
CHAPTER 76. HEALTH PROFESSIONALS EDUCATIONAL ASSISTANCE PROGRAM
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Subchapter VII. Education Debt Reduction Program
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SEC. 7682. ELIGIBILITY
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(d) Notice to Potential Employees.--In each offer of
employment made by the Secretary to an individual who, upon
acceptance of such offer would be treated as eligible to
participate in the Education Debt Reduction Program, the
Secretary shall, to the maximum extent practicable, include the
following:
(1) A notice that the individual will be treated as
eligible to participate in the Education Debt Reduction
Program upon the individual's acceptance of such offer.
(2) A notice of the determination of the Secretary
whether or not the individual will be selected as a
participant in the Education Debt Reduction Program as
of the individual's acceptance of such offer.
SEC. 7683. EDUCATION DEBT REDUCTION
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(d) Maximum annual amount.--(1) Subject to paragraph (2),
the amount of education debt reduction payments made to a
participant under the Education Debt Reduction Program may not
exceed [$44,000 over a total of five years of participation in
the Program, of which not more than $10,000 of such payments
may be made in each of the fourth and fifth years of
participation in the Program] the total amount of principle and
interest owed by the participant on loans referred to in
subsection (a).
(2) * * *
(e) Selection of Participants.--(1) The Secretary shall
select for participation in the Education Debt Reduction
Program each individual eligible for participation in the
Education Debt Reduction Program who--
(A) the Secretary provided notice with an offer of
employment under section 7682(d) of this title that
indicated the individual would, upon the individual's
acceptance of such offer of employment, be--
(i) eligible to participate in the Education
Debt Reduction Program; and
(ii) selected to participate in the Education
Debt Reduction Program; and
(B) accepts such offer of employment.
(2) The Secretary may select for participation in the
Education Debt Reduction Program an individual eligible for
participation in the Education Debt Reduction Program who is
not described by subparagraphs (A) and (B) of paragraph (1).
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