Good Morning Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me here today to present the Administration’s views on five bills that would affect Department of Veterans Affairs (VA) programs that provide veteran health care benefits and services.  With me today is Walter Hall, Assistant General Counsel. 

H.R. 5729.  “Spina Bifida Health Care Program Expansion Act”

H.R. 5729 would authorize the Secretary to provide an eligible child of a Vietnam veteran who suffers from spina bifida with any needed health care.  It would also authorize the Secretary to provide these beneficiaries with domiciliary care.  As you know, the law currently limits the provision of health care services to those needed to treat the condition of spina bifida or an associated disability. 

VA has no objection to H.R. 5729.  Providing a total health management program to this needy beneficiary population would provide needed relief for the families seeking a complete spectrum of fully-integrated care.  Spina bifida is a devastating birth defect resulting from the failure of the spine to close.  Depending on the extent of spinal damage, problems resulting from spina bifida may include:  permanent paralysis, orthopedic deformities, cognitive disabilities, breathing problems, or impaired basic bodily functions.  Even with appropriate medical treatment, these children will have numerous secondary health conditions, such as decubitus ulcers (bed sores), lung infections, depression, and fractured bones.  Due to the wide range of neurological damage and mobility impairments that can be caused by spina bifida, it can be difficult to identify the secondary disabilities that are either directly or indirectly associated with the condition. 

We offer one caveat, however.  Providing such services in a VA domiciliary treatment setting could prove problematic.  Services provided under the spina bifida program are currently furnished under contract.  Domiciliary care is unique to the VA health care system and is used mainly for veteran-populations needing intensive rehabilitative outpatient care in a residential setting, such as veterans receiving treatment for substance use disorders, seriously mentally ill veterans, and homeless veterans.  The domiciliary program is managed by Mental Health Services and is intended as a transitional program to return veterans to the community, not as a long-term residential care arrangement.  Given the nature of the distinct clinical needs of the spina bifida beneficiary population and the traditional users of domiciliary services, we do not believe VA’s domiciliaries would be suitable residential treatment settings for spina bifida beneficiaries.  Instead, those beneficiaries would benefit from the services in VA's continuum of extended care services, e.g. home telehealth, homemaker/home health aide, adult day health care, and nursing home care. 

As a technical matter, we note that this bill amends only 38 U.S.C. §1803 [related to children of Vietnam veterans].  However, a separate authority (38 U.S.C. §1821(a)) authorizes VA to furnish certain Korean conflict veterans' children born with spina bifida the same health care benefits that are available and furnished to Vietnam veterans' children born with spina bifida.  Thus, by operation of law, the amendments included in H.R. 5729 would extend to those other beneficiaries as well.

We estimate that enactment of this bill will result cost $8.4 million in FY 2010 and $142 million from FY 2010-2019.

H.R. 2818.  Epilepsy Centers of Excellence

H.R. 2818 would require the Secretary, not later than 120 days after the date of the bill’s enactment, to designate not less than six VA facilities as Epilepsy Centers of Excellence (“Centers”).  Subject to the availability of appropriations for this specific purpose, the Secretary would be required to establish and operate these Centers.  H.R. 2818 includes general procedures to be followed by the Secretary when designating a facility as a Center as well as qualification criteria for facilities seeking such designation.  For instance, one criterion would require a facility to have (or develop in the foreseeable future) an affiliation with an accredited medical school that provides education and training in neurology, plus have an arrangement under which medical residents would receive education and training in the diagnosis and treatment of epilepsy.  Other criteria would require a facility to be able to attract the participation of scientists who are capable of ingenuity and creativity in health-care research efforts and to also possess the capability to evaluate effectively the Center’s activities in the areas of education, clinical care, and research. 

H.R. 2818 would also establish a national coordinator for epilepsy programs, who would report to the official responsible for neurology within the Veterans Health Administration (VHA).  This individual would be responsible for supervising the operation of the Centers, coordinating and supporting the national consortium of providers with interest in treating epilepsy at VA medical facilities without a Center, and regularly evaluating the Centers to ensure their compliance with the bill’s requirements.

VA does not support H.R. 2818, because it is unnecessary.  VA already has seven sites that have the following capabilities:  1) an epilepsy monitoring unit; 2) capacity to perform invasive monitoring; 3) ability to implant vagus nerve stimulators; and 4) ability to perform resection of epileptic foci.  Five additional sites have the capacity to perform epilepsy surgery but not all of the other components listed above. 

Moreover, it is increasingly VA’s goal to have each of its medical facilities capable of providing state-of-the-art epilepsy care.  Thus, the trend is to establish expertise and capacity on a system-wide basis, as opposed to creating a few centers of excellence across the country. 

We estimate the cost for FY 2008 to be $6.4 million and $64.7 million over a ten-year period.

H.R. 5554.  “Veterans Substance Use Disorders Prevention and           Treatment Act of 2008”

Currently, VA is required to develop and carry out individual treatment plans for veterans receiving treatment for substance use disorders.  H.R. 5554 would further require that these treatment plans ensure VA medical centers provide a “full continuum of care” for substance use disorders.  The bill would define a “full continuum of care” as all of the following: 

• screening for substance use disorders in all settings;

• detoxification and stabilization services;

• intensive outpatient care services;

• relapse prevention services;

• outpatient counseling services;

• residential substance use disorder treatment in the case of veterans with severe recurring substance abuse or substance dependence;

• pharmacological treatment to reduce cravings and opioid substitution therapy;

• coordination with groups providing peer-to-peer counseling;

• short-term, early interventions for substance use disorders, such as motivation counseling, that are readily available and provided in a manner to overcome the stigma associated with the provision of such interventions and related care; and

• marital and family counseling. 

H.R. 5554 would also require the Secretary to provide outreach to veterans who served in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) to increase awareness of the availability of VA care, treatment, and services for substance use disorders.

This measure would further compel the Secretary to ensure that amounts available for care, treatment, and services for substance use disorders are allocated in such a manner that a full continuum of care is available to every veteran seeking such services without regard to the location of the veteran’s residence.  The Secretary would also have to submit a detailed report on the services furnished under this authority as part of the budget documents submitted annually to the Congress, and each such report would need to be reviewed and addressed by VA’s own Committee on Care of Severely Chronically Mentally Ill Veterans.  The amendments concerning the allocation of funding would be effective October 1, 2009.

H.R. 5554 would also require, not later than one year after the date of the bill’s enactment, that the Secretary carry out a two-year pilot program to test the feasibility and advisability of providing veterans who seek treatment for substance use disorders with access to a computer-based self-assessment, education, and specified treatment program through a secure Internet website operated by the Secretary.  Participation in the pilot would be voluntary and limited to veterans who served in OEF/OIF.  The bill specifies a number of requirements to be followed by the Secretary in establishing the pilot program.  For example, the Secretary would be required to ensure that access to the Internet website and the on-line treatment program does not involuntarily generate an identifiable medical record of that access in any medical database maintained by VA.  The Internet website would also need to be accessible from remote locations, including rural areas, as well as include a self-assessment tool for substance use disorders, self-guided treatment, and educational materials.  Plus, appropriate information for the veteran’s family members would need to be available on the website.  H.R. 5554 would limit pilot program sites to VA medical centers that have a Center for Excellence for Substance Abuse Treatment and Education or a Substance Abuse Program Evaluation and Research Center.

We support the goals of enhancing substance use services for veterans as described in H.R. 5554, but we cannot support the bill as written.  First, many of the bill’s provisions are unnecessary because those enhancements have been included in VHA’s Comprehensive Mental Health Strategic Plan, which is being funded under the Mental Health Enhancement Initiative. 

Second, the bill would provide for residential substance use disorder treatment only “in the case of veterans with severe recurring substance abuse or substance dependence.”  This implies that the choice between an outpatient and a residential treatment program should be based upon the severity and persistence of a substance use disorder.  There is no evidence that treatment-outcomes for persons with severe substance use disorder vary as a function of the setting in which the services are delivered.  Rather, the important factor is that patients be able to consistently attend treatment services.  Thus, availability of residential treatment is important for patients who could not reliably attend outpatient treatment programs because of their distance to care, unstable housing arrangements, or health or psychosocial factors that prevent consistent treatment attendance.  Simply put, the bill fails to correctly target the veterans in need of residential care: those with substance use disorders who cannot be managed effectively in intensive outpatient programs.

For these reasons, we recommend the Committee forbear in its consideration of this bill, and we would welcome the opportunity to work with the Committee and to brief the Committee on the Department’s on-going efforts in this area.  

We estimate the total cost of H.R. 5554 to be $72 million in FY 2009 and $725 million over a ten-year period. 

H.R. 5595.  “Make Our Veterans Smile Act of 2008”

Mr. Chairman, H.R. 5595 would make two significant changes to VA’s current authority to furnish outpatient dental services.  First, the bill would require VA to furnish needed outpatient dental services and treatment to any veteran who has a service-connected disability.  Second, it would authorize the Secretary to invoke our fee-basis authority to contract with a private provider for outpatient dental treatment and services for any veteran eligible to receive dental treatment and services through Department facilities.  Both of the amendments would be effective on or after January 1, 2009.

VA does not support H.R. 5595.  Although the concept of providing life-long comprehensive dental services to veterans with a service-connected disability is laudable and in concert with our general mission of improving the oral health of all veterans, it is not feasible.  Enactment of this legislation would make an additional 1,075,000 veterans eligible for VA dental care.  This increased workload would overwhelm VA’s capacity to provide these services in-house (both in terms of staffing and the number of physical dental clinics and labs).  In fact, VA is already operating at full capacity and must now purchase dental services for those veterans we cannot treat. 

Of chief concern to us is the estimated cost of this bill.  Expanding VA’s contracting authority would result in a thirteen-fold increase in the amount VA expends for fee-basis dental care, i.e., over $817 million in FY 2008 alone.  The total cost for the next ten years would be almost $11.3 billion.

H.R. 5622  “Veterans Timely Access to Health Care Act”

Mr. Chairman, the last bill on the agenda is H.R. 5622, which would establish a five-year pilot program under which the Secretary would be required to ensure that a veteran seeking primary care from a VA medical facility in Veterans Integrated Service Network 8 is given access to care in 30 days.  The standard would be measured from the date on which the veteran contacts VA seeking an appointment until the date on which a visit with a primary-care provider is completed.  H.R. 5622 would also require the Secretary to periodically review the performance of covered medical facilities in meeting the 30-day standard.  When unable to meet the 30-day standard, the bill would require VA to contract for the needed care and services.

When purchasing those services, H.R. 5622 would prohibit the Secretary from paying the non-VA provider more than the rate that would be applicable under part B of the Medicare Program.  It would also prohibit the non-VA provider from billing the veteran for any difference between the billed charges and the amount paid by VA.  The Secretary would also be required to develop a form to be used by veterans to authorize VA to obtain any records created in connection with the veterans’ receipt of care from a non-VA facility. 

Once a veteran has received care for 30 days from a non-VA provider under this section, the veteran could choose to receive his or her primary care at a VA facility, if available.  The veteran would need to notify VA in writing of this choice.  

VA does not support H.R. 5622, because it is overly prescriptive and to a large degree unnecessary.  Although we agree with the imposition of a 30-day standard for the scheduling of patients, such a standard should only apply to new patients.  New patients need to be tracked to determine if there are difficulties accessing the VA system of care. 

VA already complies with and exceeds the 30-day standard.  Almost all VA facilities currently comply with the 30-day standard 90 percent or more of the time and improvement continues.  In FY 2007, the percent of primary care appointments provided within 30 days of the patient’s desired date for new patients was 83 percent and 98 percent for established patients (established patients are those already being seen; the majority of their appointments are for follow-up care in the future and they do not need to be seen within 30 days).

VA is making significant strides to eliminate the waiting list for primary care and believes based upon our recent progress and planned future efforts that we will reduce the list of primary care patients waiting more than 30 days of the desired appointment date to zero by the end of FY 2009. 

In those situations where VA would be required by H.R. 5622 to contract for care, restricting payment to no more than the Medicare rate could make it difficult for VA to obtain that care in the private sector.  The bill would not require contractors, even if they are Medicare providers, to agree to accept the Medicare rate from VA.  The result could be that VA may not be able to purchase needed services in the community, and VA would have to limit the contract services available to veterans participating in the pilot program.

Another fundamental problem with H.R. 5622 is its requirement to contract for care for certain veterans.  This essentially sends these veterans outside the VA system for a 30-day period before they can choose to resume care at a VA facility.  This would result in their care being interrupted and fragmented, lessening the quality of care they receive.  Also, requiring the veterans to request in writing their desire to return to care in a VA facility places an undue responsibility on the patients.  Lastly, this contracting-requirement assumes that all private care providers in the community can meet the 30-day standard, but there are no measures available to support this assumption.

Finally, contracted care would not necessarily include the comprehensive screenings, case management services, documented quality, and expertise in veteran-specific conditions that are available in the VA health care system.

We estimate that H.R. 5622, if enacted, would cost $26.2 million for the remainder of FY 2008.  We are still developing out-year projections based on anticipated changes in the demographics of VISN 8, but we will supply those for the record as soon as they are available.

H.R. 5730.  Injured and Amputee Veterans Bill of Rights

Mr. Chairman, H.R. 5730, which would direct the Secretary to display in each VA prosthetic and orthotic clinic an Injured and Amputee Veterans Bill of Rights, was only recently added to today’s agenda.  We are still in the process of developing views on the bill.  Once completed, we will forward it to the Committee. 

This concludes my prepared statement.  I would be pleased to answer any questions you or any of the members of the Subcommittee may have.

[A second handout from the Department of Veterans Affairs entitled, "Risk Adjustment Mortality as an Indicator of Outcomes:  Comparison of the Medicare Advantage Program with the Veterans Health Administration," will be retained in the Committee files.]