[House Report 118-703]
[From the U.S. Government Publishing Office]
118th Congress } { Report
HOUSE OF REPRESENTATIVES
2d Session } { 118-703
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VETERANS AFFAIRS PEER REVIEW
NEUTRALITY ACT OF 2023
_______
September 23, 2024.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Bost, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany H.R. 5794]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 5794) to amend title 38, United States Code, to
eliminate conflicts of interest in conduct of quality
management and administrative investigations by the Veterans
Health Administration, and for other purposes, having
considered the same, reports favorably thereon without
amendment and recommends that the bill do pass.
CONTENTS
Page
Amendment........................................................
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 2
Hearings......................................................... 3
Subcommittee Consideration....................................... 3
Committee Consideration.......................................... 3
Committee Votes.................................................. 4
Committee Correspondence.........................................
Committee Oversight Findings..................................... 4
Statement of General Performance Goals and Objectives............ 4
Earmarks and Tax and Tariff Benefits............................. 4
Committee Cost Estimate.......................................... 4
Budget Authority and Congressional Budget Office Estimate........ 4
Federal Mandates Statement....................................... 5
Advisory Committee Statement..................................... 5
Applicability to Legislative Branch.............................. 5
Statement on Duplication of Federal Programs..................... 6
Section-by-Section Analysis of the Legislation................... 6
Changes in Existing Law Made by the Bill, as Reported............ 6
Purpose and Summary
Page H.R. 5794, the ``Veterans Affairs Peer Review
Neutrality Act of 2023,'' was introduced by Representative
Debbie Dingell of Michigan on September 28, 2023. The bill
would require the U.S. Department of Veterans Affairs (VA), to
require employees involved in a peer review for quality
management of care to recuse themselves if they have a conflict
of interest, and would require each medical facility to develop
procedures and guidelines for conducting final neutral review
on peer review done at VA facilities. This bill would also
prohibit individuals with certain peer review familiarity and
conflicts of interest from serving as an administrative
investigation board (AIB) member or as a factfinder.
Background and Need for Legislation
Section 1. Short Title
This Act may be cited as the ``Veterans Affairs Peer Review
Neutrality Act of 2023.''
Section 2. Elimination of Conflicts of Interest in Peer Review,
Administrative Investigation Boards, And Factfindings of
Veterans Health Administration
A 2022 VA Office of Medical Inspector (OMI)
investigation\1\ which uncovered misconduct at the Detroit,
Michigan John D. Dingell VA Medical Center (Detroit VAMC) made
clear the need for reforms in the VA peer review process. The
report uncovered quality of care and review of care issues at
the Detroit VAMC. The report concluded that quality assurance
and quality management processes were ``being manipulated,
preventing action from being taken to address quality
concerns.'' OMI found ``multiple instances where external peer
reviews were changed from a Level 3 Peer Review to a Level 1,
with little or no documented rationale.''\2\
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\1\Discussed in VA OIG Report, Review of VISN 10 and Facility
Leaders' Response to Recommendations from a VHA Office of the Medical
Inspector Report, John D. Dingell VA Medical Center in Detroit,
Michigan, July 18, 2023, https://www.vaoig.gov/sites/default/files/
reports/2023-07/VAOIG-22-04099-153.pdf.
\2\Per VHA Directive 1190, Peer Review For Quality Management, a
Level 3 Peer Review rating identifies care which may have deviated from
the standard of care, requiring further investigations, while a Level 1
signifies circumstances where no deviation occurred, requiring no
further investigation.
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OMI issued inspection findings that resulted in 12
recommendations regarding provider oversight, surgical
services, and quality reviews. One of the recommendations was
to develop local procedures and guidelines to establish that a
peer review committee member with a Level 3 review should be
reassessed by a neutral peer review committee at a separate
facility. This section would create a new section in Subchapter
II of chapter 73 of Title 38 United States Code (U.S.C.) that
would implement this recommendation for all VAMCs by
incorporating an elimination of conflicts of interests in peer
review, AIB, and fact-findings of the Veterans Health
Administration (VHA).
This section would also mandate that an individual withdraw
themself from participating in a peer review for quality
management if he or she has direct involvement with the care
under review or if the individual is unable to conduct an
objective, impartial, accurate, and informed review. In
addition, this section would develop procedures for these peer
review processes to be reviewed by an external VA facility to
improve oversight.
The Committee believes that this bill would be an important
step in improving quality control, procedures, and
investigations at VHA. These important processes are only able
to improve quality when they are fully trusted. The Committee
therefore believes that the bill would materially improve
trust, accountability, and ultimately contribute to the
minimization of adverse veteran patient outcomes within VHA.
Hearings
On March 21, 2024, the Health Subcommittee held a
legislative hearing on H.R. 5794. The following witnesses
testified:
The Honorable Chairman Mike Bost, U.S. House of
Representatives, 12th Congressional District, Illinois;
The Honorable Chris Deluzio, U.S. House of
Representatives, 17th Congressional District,
Pennsylvania; The Honorable Jack Bergman, U.S. House of
Representatives, 1st Congressional District, Michigan;
The Honorable Greg Murphy, U.S. House of
Representatives, 3rd Congressional District, North
Carolina; The Honorable Derrick Van Orden, U.S. House
of Representatives, 3rd Congressional District,
Wisconsin; The Honorable Nick LaLota, U.S. House of
Representatives, 1st Congressional District, New York;
The Honorable Debbie, Dingell, U.S. House of
Representatives, 6th Congressional District, Michigan;
The Honorable Lauren Underwood, U.S. House of
Representatives, 14th Congressional District, Illinois;
Dr. Ajit Pai, Executive Director, Office of
Rehabilitation and Prosthetics Services, Veterans
Health Administration; Dr. Michael Brenna, Executive
Director, Office of Construction and Facilities
Management, Veterans Affairs; Dr. Wendy Tenhula, Deputy
Chief Research and Development Officer, Office of
Research and Development, Veterans Health
Administration; Dr. David Perry, Chief Officer,
Workforce Management and Consulting, Veterans Health
Administration; Mr. Jon Retzer, Assistant National
Legislative Director, Disabled Americans Veterans; Mr.
Roscoe Butler, Senior Health Policy Advisor, Paralyzed
Veterans of America; Ms. Brittany Elliot, Veteran
(USMC), Advocate; Ms. Melissa Bryant, Chair, Board of
Directors, Minority Veterans of America.
The following individuals and organizations submitted
statements for the record:
Wounded Warrior Project, Treat Now, Superior
Ambulance.
Subcommittee Consideration
On April 16, 2024, the Health subcommittee met in an open
markup session, a quorum being present, and ordered H.R. 5794
to be reported favorably to the Full Committee by voice vote.
Committee Consideration
On May 1, 2024, the Full Committee met in open markup
session, a quorum being present, and ordered H.R. 5794, be
reported favorably to the House of Representatives by voice
vote.
A motion by Ranking Member Takano of California to report
H.R. 5794 favorably to the House of Representatives was agreed
to by voice vote.
Committee Votes
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, no recorded votes were taken with
ordering H.R. 5794 to the House.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
(2)(b)(1) of rule X of the Rules of the House of
Representatives, the Committee's oversight findings and
recommendations are reflected in the descriptive portions of
this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives of H.R. 5794 are to establish unbiased
peer review, AIB, and factfinding procedures at VHA.
Earmarks and Tax and Tariff Benefits
H.R. 5794 does not contain any Congressional earmarks,
limited tax benefits, or limited tariff benefits as defined in
clause 9 of rule XXI of the Rules of the House of
Representatives.
Committee Cost Estimate
The Committee adopts as its own the cost estimate of H.R.
5794 prepared by the Director of the Congressional Budget
Office.
Budget Authority and Congressional Budget Office Cost Estimate
Pursuant to clause (3)(c)(3) of rule XIII of the Rules of
the House of Representatives, the following is the cost
estimate for H.R. 5794 provided by the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974:
No H.R. 5794 would require the Department of Veterans
Affairs (VA) to reduce conflicts of interest during internal
investigations conducted by the Veterans Health Administration.
In particular, the bill would require VA employees to recuse
themselves from investigations if they have a conflict of
interest or cannot otherwise conduct an impartial review. It
also would require that final reviews of investigations that
involve members of a peer-review committee at a medical
facility be conducted by a committee composed of members at a
different facility.
According to VA, many of the requirements of H.R. 5794 are
being satisfied under current VA guidelines and any changes to
current VA administrative procedures would have no cost. On
that basis, CBO estimates that implementing H.R. 5794 would not
affect the federal budget.
The CBO staff contact for this estimate is Matt Schmit. The
estimate was reviewed by Christina Hawley Anthony, Deputy
Director of Budget Analysis.
Phillip L. Swagel,
Director, Congressional Budget Office.
Federal Mandates Statement
Section 423 of the Congressional Budget and Impoundment
Control Act (as amended by Section 101(a)(2) of the Unfunded
Mandate Reform Act, P.L. 104-4), is inapplicable to H.R. 5794.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
5794.
Applicability to Legislative Branch
The Committee finds that H.R. 5794 does not relate to the
terms and conditions of employment or access to public services
or accommodation within the meaning of section 102(b)(3) of the
Congressional Accountability Act.
Statement on Duplication of Federal Programs
Pursuant to clause 3(c)(5) of rule XIII of the Rules of the
House of Representatives, the Committee finds that no provision
of H.R. 5794 establishes or reauthorizes a program of the
Federal Government known to be duplicative of another Federal
program, a program that was included in any report from the
Government Accountability Office to Congress pursuant to
section 21 of Public Law 111-139, or a program related to a
program identified in the most recent Catalog of Federal
Domestic Assistance.
Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 would establish the short title as the ``Veterans
Affairs Peer Review Neutrality Act of 2023''.
Section 2. Elimination of conflicts of interest in peer review,
administrative investigation boards, and factfindings of
Veterans Health Administration
Section 2 would amend Subchapter II of Chapter 73 of Title
38 United States Code by inserting a new section: 7311B,
Elimination of conflicts of interest in peer review,
administrative investigation boards, and factfindings of
Veteran Health Administration. This section would require
individuals who are responsible for quality management of the
care that is provided by VA, as well as each member of a peer
review committee regarding quality management of care, to
withdraw themselves from participation in a case review if the
individual has direct involvement with the care under review or
if the individual is unable to conduct an objective, impartial,
accurate, and informed review.
This section would also require each VA medical facility to
develop procedures and guidelines to require that any initial
peer review for quality management that is conducted, with
respect to care provided by a provider who is part of a peer
review committee for that facility, be evaluated, discussed,
and assigned a final level review by a neutral peer review
committee at another VA facility.
Additionally, this section would clarify that individuals
with knowledge of confidential quality assurance information
specific to a matter under investigation by an AIB board, with
respect to quality management of care provided by a health care
provider at a VA facility, would not serve on the AIB board, or
as fact finder, or disclose such information to an AIB board or
factfinder. Each member of an AIB board or factfinder would not
have any personal interest or other bias concerning the
investigation being conducted or have any direct involvement in
maters being investigated, or have a supervisory, or personal
relationships with the subject being investigated. If a member
of an AIB board or factfinder is found to have the above-
mentioned relationships, the member would be required to inform
the authority responsible for the investigation and recuse
themselves from such matters.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italics, existing law in which no change
is proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (new matter is
printed in italics and existing law in which no change is
proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
PART V--BOARDS, ADMINISTRATIONS, AND SERVICES
* * * * * * *
CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
SUBCHAPTER I--ORGANIZATION
Sec.
7301. Functions of Veterans Health Administration: in general.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
7311B. Elimination of conflicts of interest in peer review,
administrative investigation boards, and factfindings of
Veterans Health Administration.
* * * * * * *
SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION
* * * * * * *
Sec. 7311B. Elimination of conflicts of interest in peer review,
administrative investigation boards, and
factfindings of Veterans Health Administration
(a) Peer Review.--
(1) In general.--Each individual responsible for
conducting peer review for quality management of care
provided by a health care provider at a medical
facility of the Department and each member of a peer
review committee with respect to quality management of
such care shall withdraw from participation in a case
review if--
(A) the individual has direct involvement
with the care under review; or
(B) the individual is unable to conduct an
objective, impartial, accurate, and informed
review.
(2) Neutral assessment of conduct of committee
members.--Each medical facility of the Department shall
develop procedures and guidelines for that facility to
require that any initial peer review for quality
management that is conducted with respect to care
provided by a health care provider who is a member of
the peer review committee for that facility be
evaluated, discussed, and assigned a final level review
by a neutral peer review committee at another facility
of the Department.
(b) Administrative Investigation Boards and Factfindings.--
(1) Knowledge of confidential information.--
Individuals with knowledge of confidential quality
assurance information specific to a matter under
investigation by an administrative investigation board
or factfinder with respect to quality management of
care provided by a health care provider at a medical
facility of the Department may not--
(A) serve on the administrative investigation
board or as a factfinder; or
(B) disclose such information to an
administrative investigation board or a
factfinder.
(2) Personal interest, involvement, or
relationship.--
(A) In general.--The Secretary shall ensure
that each member of an administrative
investigative board or factfinder does not
have--
(i) any personal interest or other
bias concerning the investigation being
conducted;
(ii) direct involvement in matters
being investigated; or
(iii) a supervisory or personal
relationship with the subject of the
investigation.
(B) Recusal.--If a potential member of an
administrative investigative board or
factfinder has a personal interest or other
bias concerning the investigation being
conducted, direct involvement in matters being
investigated, or a supervisory or personal
relationship with the subject of the
investigation, the potential member shall
inform the authority responsible for the
investigation and recuse themselves from such
matter.
* * * * * * *
[all]