Witness Testimony of Hon. Michael J. Kussman, MD, MS, MACP, Veterans Health Administration, Under Secretary for Health, U.S. Department of Veterans Affairs
Good Morning Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here today to present the Administration’s views on nine bills that would affect Department of Veterans Affairs (VA) programs that provide veteran health care benefits and services. With me today is Walter A. Hall, Assistant General Counsel. Mr. Chairman, with the exception of section 2 of H.R. 2005, VA has not had sufficient time to prepare cost estimates for the bills on today’s agenda. As soon as these become available, we will supply them for the record. In addition, with the short time available to prepare for this hearing, we were not able to provide views on all of the bills reflected on the agenda. We can provide those views for the record.
H.R. 1448 — VA Hospital Quality Report Card Act of 2007
Mr. Chairman, I will begin by addressing H.R. 1448. This bill would require VA to establish a Hospital Quality Report Card Initiative (“Initiative”) to, among other things, help inform patients and consumers about the quality of care in VA hospitals. Under the Initiative, the Secretary would be required to publish, at least bi-annually, reports on the quality of VA’s hospitals that include quality-measures data that allow for an assessment of health care effectiveness, safety, timeliness, efficiency, patient-centeredness; and equity.
In collecting and reporting this data, the Secretary would have to include very extensive and detailed information (i.e., staffing levels of nurses and other health care professionals; rates of nosocomial infections; volume of various procedures performed, hospital sanctions and other violations; quality of care for specified patient populations; the availability of emergency rooms, intensive care units, maternity care, and specialty services; the quality of care in various hospital settings, including inpatient, outpatient, emergency, maternity, and intensive care unit settings; ongoing patient safety initiatives; and, other measures determined appropriate by the Secretary). VA would be allowed to make statistical adjustments to the data to account for differences relating to characteristics of the reporting hospital (e.g., size, geography, and teaching status) and patient characteristics (e.g., health status, severity of illness, and socioeconomic status). In the event VA makes such adjustments, there would be a concomitant obligation to establish procedures for making that data available to the public.
The bill would require the Secretary to disclose the entire methodology (for the reporting of the data) to all organizations and VA hospitals that are the subject of any information prior to making such information available to the public. Each report submitted under the Initiative would have to be available in electronic format, presented in an understandable manner to specified populations, and presented in a manner that allows for a comparison of VA’s hospital quality with local hospitals or regional hospitals. The Department would also need to establish procedures to make these reports available to the public, upon request, in a non-electronic format (such as through a toll-free telephone number).
In addition, H.R. 1448 would require the Secretary to identify and acknowledge the analytic methodologies and limitations on the data sources used to develop and disseminate the comparative data and to identify the appropriate and inappropriate uses of such data. The bill would further mandate the Secretary, on at least an annual basis, compare quality measures data submitted by each VA hospital with data submitted in the prior year or years by the same hospital to identify and report actions that would lead to false or artificial improvements in the hospital’s quality measurements.
This measure would further require the Secretary to develop and implement effective safeguards to: protect against the unauthorized use or disclosure of VA hospital data reported under this measure; protect against the dissemination of inconsistent, incomplete, invalid, inaccurate, or subjective VA hospital data; and ensure that identifiable patient data is not released to the public. In addition, the Secretary would need to evaluate and periodically report to Congress on the effectiveness of this initiative and its effectiveness in meeting the purposes of this Act. And such reports would have to be made available to the public. Finally, this legislation would direct the Secretary to use the results of the evaluations to increase the usefulness of this initiative.
H.R. 1448 would authorize to be appropriated to carry out this section such sums as may be necessary for each of Fiscal Years (FY) 2008 through 2017. The effective date for this bill and its requirements would be 18 months after the date of the bill’s enactment.
Mr. Chairman, VA supports the intent of this bill but opposes the bill as written. H.R. 1448 is too prescriptive in its requirements, and much of the information that would be required by H.R. 1448 is already available through other avenues, such as The Joint Commission’s (previously known as the Joint Commission on Accreditation for Healthcare Organizations) website that provides standardized comparative data in a form that has been tested for consumer understandability and usefulness. Moreover, VA is in the process of compliance with Executive Order 13410, which requires transparency of quality measures in Federal health care programs. We would welcome the opportunity to meet with the Committee members to help them understand what is available already, how the members might better access the information, and how we can help veterans and the public better access that information.
H.R. 1853 — Jose Medina Veterans Affairs Police Training Act of 2007
H.R. 1853 would require the Secretary to ensure, not later than eight months after the date of enactment, all VA police officers receive training on how to interact with visitors and patients at VA medical facilities who have, or who exhibit symptoms of, mental illness. The purpose for this mandate is the bill’s express finding that there has been, and will continue to be, an increase in the incidence of post-traumatic stress disorder (PTSD) among veterans who served in past and present combat theaters and thus in their concomitant need for VA mental health treatment and services.
We do not support H.R. 1853 because it is unnecessary. By statute, the Secretary is already required to provide VA Police Officers with training that emphasizes effective management of situations involving patients. To carry out that mandate, VA provides specialized training to VA Police Officers in dealing with disruptive and other unusual behaviors. VA officers also must successfully complete an 80 hour basic entry level training course at their medical centers as well as a 200 hour residential basic police officer training course at the VA Law Enforcement Training Center. Included in the residential course is a 17.5 hour block of training in Behavioral Science that includes such topics as introduction to mental illness, communications/conflict management, verbal judo, crisis intervention/conflict resolution and the dynamics of the suicidal individual. Much of this training is taught by VA psychologists. Moreover, VA officers must also complete a biannual refresher training program.
H.R. 1925 — VISN for the Gulf Coast Region
H.R. 1925 would require the Secretary to establish, not later than one year after enactment, a separate “Veterans Integrated Services Network (“VISN”) for the Gulf Coast region of the United States. This new VISN would be comprised of specified counties located in Florida, Alabama, and Mississippi.
VA does not support H.R. 1925. We find no justification for establishing a separate VISN for a service area that does not have the workload needed to make that organizational change cost-effective or to require that level of management. The current facilities and referral patterns in this area provide the best access for the veterans. VISNs were originally created around referral patterns and geographic boundaries. In addition, VISNs work together along their borders to ensure access to health care for veterans in those areas. The Gulf Coast region is one area where VISNs 7, 8 and 16 have worked very well together in managing care for veterans in the area. Therefore, VA sees no reason to add an additional Network for this region.
H.R. 2005 — Rural Veterans Health Care Improvement Act of 2007
H.R. 2005 is intended to improve VA’s ability to meet the health care needs of rural veterans. Section 2 of this bill would amend VA’s beneficiary travel program by requiring VA to pay or reimburse eligible veterans at the same per diem rates and mileage rates that apply to Federal employees using privately owned vehicles for official travel.
Section 3 would require the Secretary, through the Director of the Office of Rural Health, to establish up to five Rural Health Research, Education, and Clinical Centers of Excellence (“Centers”). The bill sets forth detailed requirements that would govern the Secretary’s designation and placement of such Centers. It also would limit designation of Centers to those facilities found by a peer review panel to meet the highest competitive standards of scientific and clinical merit and also found by the Secretary to have met the requirements specified in the legislation.
Section 4 would require the Secretary to establish a grant program for State Veterans’ Service Agencies and Veterans’ Service Organizations for purposes of providing veterans living in remote rural areas with innovative means of travel to VA medical centers (and to assist them with their other medical care needs). A grant awarded under this section could not exceed $50,000. Grant recipients would not be required to provide matching funds as a condition for receiving a grant. This section would require the Secretary to prescribe regulations to implement this program and also authorize to be appropriated $3 million for each of FYs 2008 through 2012 to carry out this program.
Section 5 would require the Secretary, through the Director of the Office of Rural Health, to carry out demonstration projects to examine alternatives for expanding care to veterans in rural areas. In so doing, the Secretary would be required to establish partnerships with the Department of Health and Human Services (HHS) to coordinate care for veterans in rural areas at both critical access hospitals and community health centers. VA would also be obliged to coordinate with HHS’ Indian Health Service to expand care for Native American veterans.
The bill would institute annual reporting requirements, the first of which would have to include the results of the statutorily mandated assessment of VA’s fee-basis program on the delivery of care to veterans residing in rural areas, along with the results of VA’s extensive outreach program to OEF/OIF veterans living in rural veterans.
Mr. Chairman, while we appreciate the impetus for H.R. 2005, we do not support the bill. In accordance with Congress’ mandate in the “Veterans Benefits, Health Care, and Information Technology Act of 2006,” VA recently established the Office of Rural Health (ORH) within the Veterans Health Administration. Part of that office’s charge is to determine how we can best continue to expand access to care for rural veterans. Presently, ORH is developing a strategic plan for operations and is considering a proposal to create new research centers. We would request the Congress wait until these assessments are complete before requiring action in this area. We will keep the Committee abreast of ORH’s activities and findings as available.
VA is working closely with other organizations in a variety of areas, including outreach, clinical care, education, expanded services, care coordination, and telemedicine, to improve the quality of health care available to those living in rural areas. The Department of Health and Human Services (HHS) and the Department of Veterans Affairs (VA) signed a Memorandum of Understanding (MOU) in February 2003 to encourage cooperation and resource sharing between the Indian Health Service (IHS) and the Veterans Health Administration (VHA) to deliver quality health care services and enhance the health status of American Indian and Alaska Native (AI/AN) veterans. VHA’s Office of Rural Health (ORH) has also established a working relationship with and sought consultation from HHS’s Office of Rural Health. As the office matures, VHA’s plan is to work closely with HHS to maximize the opportunities in a range of areas including education, training, research, and access. Therefore, a Congressional mandate to encourage cooperation with HHS and IHS is not necessary.
Moreover, while we acknowledge there has been a significant increase in fuel prices, beneficiary travel payments are paid out of funds appropriated for health care treatment and services. In our view, VA should use medical care funds for furnishing direct patient care in the manner that best serves the most veterans. It is also important to note that increasing the beneficiary travel payment and reimbursement rates would benefit only the limited categories of veterans who are eligible for those benefits e.g., veterans whose travel is in connection with treatment for a service-connected disability. For that reason, the amendments to the beneficiary travel program that are set forth in H.R. 2005 may not advance the Congress’ general objective of improving access to care for rural veterans.
We further note that the travel benefits program for Federal employees is distinct and on the whole inapposite to VA’s beneficiary travel benefits program. It is unclear, based upon the text of the bill, if the limitations and conditions on Federal employee eligibility for travel pay would be applied to veterans. Federal employees do not automatically qualify for reimbursement of expenses they incur while on official travel. They must meet certain criteria to be eligible for such reimbursement, particularly in connection with the use of a privately owned vehicle. The criteria and conditions for reimbursement that apply to Federal employees (e.g., travel order) would not be appropriate to patients traveling to VA facilities for care and treatment, and transposing such a system would prove to be very complex and difficult to manage. VA estimates the cost of section 2 of H.R. 2005 to be $253 million for FY 2008 and $7 billion over a 10-year period.
H.R. 2172 — Amputee Veteran Assistance Act
Mr. Chairman, the next bill on today’s agenda is H.R. 2172. This bill would require the Secretary to ensure, not later than five years after enactment, that all VA orthotic-prosthetic laboratories and clinics are certified by either the American Board for Certification in Orthotics and Prosthetics or the Board of Orthotics and Prosthetic Certification.
This bill would also require the Secretary to seek to enter into a contract with a non-VA entity for the service and repair of a prosthetic device for a veteran in the following situations:
- If the Secretary determines that VA facilities are unable to perform the necessary service or repair due to a lack of technology or for any other reason that the Secretary determines prevents such service or repair in a timely manner; or
- The veteran in need of such service or repair resides at a distance greater than 55 miles from the nearest suitable VA facility capable of furnishing the service or repair.
The bill would further require the Secretary to develop and carry out a plan to inform disabled veterans at least twice a year of the technological advances made in the field of prosthetics. The above-discussed contracting and information related requirements would both have to be implemented not later than six months after the date of the bill’s enactment.
Additionally, H.R. 2172 would require the Secretary to conduct and complete a review of all VA orthotic-prosthetic laboratories and clinics to ensure that the Department is capable of serving and repairing the most technologically advanced prosthetic devices. Such review would need to be conducted and completed not later than one year after the bill’s enactment. No later than six months after completion of that review, the Secretary would need to submit a report to Congress on the Secretary’s findings and any recommendations to address deficiencies in capability that were identified during the mandated review.
Finally, no later than one year after the bill’s enactment, this bill would require the Secretary to conduct and complete a review of VA’s prosthetists and orthotists to determine what level and kinds of training and education will be needed to ensure they are qualified to service and repair the most technologically advanced prosthetic devices. No later than six months after that review is completed, the Secretary would be required to submit a report to Congress on the Department’s findings and any recommendations to address identified deficiencies in education, training, or qualification.
VA does not support H.R. 2172 because it is unnecessary. VA’s policies already meet or exceed the requirements in the bill. In 2003 VA mandated all prosthetic and orthotic laboratories be accredited by the American Board for Certification in Orthotics and Prosthetics or the Board of Orthotics and Prosthetic Certification. Today, all 58 of our laboratories are accredited and we require all contractors be accredited by these organizations as well. As a prerequisite of attaining accreditation, each facility had to employ at least one certified Prosthetist/Orthotist to oversee all work. Today, 131 out of our 186 prosthetists/orthotists are certified and we are actively encouraging all staff to attain this certification. Both ABC and BOC require all certified practitioners maintain certification through 5-year cycles of continuing education units, including education in new and emerging technology. VA will continue to conduct site visits to all prosthetic and orthotic laboratories to ensure they meet quality standards and maintain their accreditation.
VA uses over 600 non-department entities for fabrication, service and repair of prosthetic devices. Veterans will continue to have their choice of contracted providers, including the VA. VA is informing veterans of new developments with Open Forums, routine newsletters and press releases, and a dedicated web link devoted to the care and treatment of amputees.
As a technical matter we point out that H.R. 2172 would amend chapter 31 of title 38, United States Code, which governs vocational rehabilitation benefits administered by the Veterans Benefits Administration, not chapter 17 of the same title, which governs the provision of health care benefits, including prosthetic care and services.
H.R. 2173 — Authorization for Vet Centers to contract for Mental Health Services
I will now discuss H.R. 2173. This bill would amend VA’s readjustment counseling authority in 38 U.S.C. §1712A to permit the Secretary to enter into contracts with community mental health centers (deemed qualified by the Secretary) for the provision of mental health services as part of VA’s readjustment counseling program.
VA does not support H.R. 2173. Currently, VA’s authority to provide mental health services to veterans receiving readjustment counseling services under section 1712A of title 38, United States Code, is limited to mental health services that are necessary to facilitate the successful readjustment of a veteran to civilian life and limited to the provision of counseling, training and mental health services described in 38 U.S.C. §§1782 and 1783 (bereavement counseling) for the veteran’s immediate family members. It is not clear if the bill, in creating a new subsection wholly unrelated to the existing provisions governing VA’s contracting authority under section 1712A, means to encompass mental health services beyond those currently authorized and those which have traditionally been provided under VA’s readjustment counseling mission (in contrast to VA’s clinical mission).
As already alluded to, Vet Centers currently have authority to contract with private sector community mental health agencies for the provision of readjustment counseling services and related mental health services. For more complex mental health needs, Vet Centers readily refer patients to VA medical facilities. Furthermore, H.R. 2173 would obfuscate and blur the special service mission of the Vet Centers as defined by law. These services are deliberatively set apart from medical facilities to promote more than medical readjustment services for combat veterans in an easy to access, community-based setting.
H.R. 2192 — Establishment of Office of Ombudsman within the Department
H.R. 2192 would establish an Office of the Ombudsman (herein referred to as the “Office”) within the Department and require the Secretary to designate an Ombudsman to carry out the duties of the Office. The Ombudsman would act as a liaison for veterans and their family members with respect to the receipt of health care and benefits administered by VA.
This measure would also require the Secretary to ensure the services of the Office are available to all veterans and their family members and would further direct the Secretary to make available to each veteran, and to the family members of all veterans, information on contacting and using the services of the Office. Lastly, H.R. 2192 would authorize the disclosure of information provided by veterans or their family members only to the extent necessary to carry out the duties of the Office.
VA does not support H.R. 2192. Of particular concern is the provision that would authorize the Ombudsman to act as a liaison for veterans and their family members with respect to the receipt of health care. VHA has instituted a variety of measures to support our patients and their families, including appointing patient advocates in our Medical Centers, benefits counselors, OEF/OIF Coordinators, and Transition Patient Advocates for those seriously injured in combat. Vet Center counselors also contribute to resolving situations on behalf of veterans. VSO representatives, likewise, serve ably as counselors and mentors and many State Departments of Veterans Affairs contribute in this area. VBA has also has extensive initiatives and programs aimed at assisting claimants with respect to receipt of benefits, including the Transition Assistance Program (TAP), the Benefits Delivery at Discharge (BDD) Program, and expanded outreach to veterans, dependents, and survivors. Adding another layer of oversight and involvement could create a confusing situation for patients and families, who might become unsure whom to consult. A new Office of the Ombudsman could also produce confusion within VA in terms of assignments and responsibilities, since the bill, as written, does not delineate between the role the new Office would fill vis-à-vis other offices within VA.
H.R. 2219 — Veterans Suicide Prevention Hotline Act of 2007
Mr. Chairman, H.R. 2219 would require the Secretary to award one grant for a period of not more than three years to an eligible entity to establish, publicize, and operate a national toll-free telephone number to serve as a suicide prevention hotline targeted to, and staffed predominately by, veterans of the Armed Forces.
Under H.R. 2219, the grantee would be required to perform the following functions:
- enter into a contract with a telecommunication carrier for the use of such a national toll-free number;
- select; train; and supervise personnel to answer incoming calls and to provide counseling and referral services to callers;
- ensure that sufficient staffing is provided so that the hotline services are available to callers at all times;
- assemble and maintain a current database of information to be used to refer callers to local service providers and of information about the availability of shelters for homeless callers;
- publicize the hotline to potential callers; and
- certify the capacity of, and provide supplemental training for, any local crisis center operating as a subcontractor of the grantee.
H.R. 2219 would further provide that to be eligible to receive the grant under this section, a private, nonprofit entity would have to prepare and submit a detailed application to the Secretary addressing a number of specified areas. The selected grant recipient would, in turn, be required to submit an annual report to the Secretary, in the form and with such information as the Secretary may require. The grantee would have to include in that report the volume of calls to the hotline, the demand for specific types of referrals, and the number of trained volunteers answering the hotline. Finally, payments awarded to the grantee would be subject to annual approval by the Secretary and to the availability of appropriations for each FY.
For purposes of the grant award, H.R. 2219 would authorize to be appropriated $2,500,000 each year for FYs 2008, 2009, and 2010.
VA does not support H.R. 2219. VA is already developing a comprehensive program for suicide prevention including a national 24 hour toll-free hotline. The services under development in VA are more comprehensive that those proposed in H.R. 2219. VA is proposing to administer the services with VA mental health professional staff, not outside contractors, to provide mechanisms for accessing the electronic health records of veteran-callers as part of the response to crisis calls, and to establish strong interactions between the national hotline and the suicide prevention coordinators in each medical center to provide for continuity of care. While we respect the idea of peer-to-peer counseling, which is employed with great effectiveness in our Vet Centers, VA believes it is more appropriate from a clinical standpoint to staff VA’s national hotline with trained health care professionals.
H.R. 2378 — Services to Prevent Veterans Homelessness Act
H.R. 2378 is a measure intended to prevent low income veterans transitioning to, or residing in, permanent housing from falling back into their former homeless condition. Subject to the availability of appropriations provided for the bill’s purpose, H.R. 2378 would require the Secretary to provide financial assistance to eligible entities to provide and coordinate the provision of supportive services for very low-income veteran-families occupying permanent housing or transitioning from homelessness to permanent housing. The bill would further require the Secretary to establish a formula for determining the rate of payments to be made to eligible entities providing supportive services under this section. The rate would have to be adjusted at least annually to reflect changes in the cost of living. In calculating the rate payment formula, the Secretary would be authorized to consider geographic cost of living variances, family size, and the cost of services provided.
To be eligible to receive funding, H.R. 2378 would require eligible entities to submit a detailed application to the Secretary. This bill would also authorize the Secretary to give preference to an entity providing or coordinating the provision of supportive services for very low-income veteran families who are transitioning from homelessness to permanent housing.
This measure would require the Secretary to provide training and technical assistance to entities receiving payments under this program on the planning, development, and provision of supportive services to the targeted families. Such assistance could be provided either directly, or through grants or contracts with appropriate public or nonprofit private entities.
As to funding, H.R. 2378 would make available out of the amounts appropriated for medical care $25 million for each of FYs 2008, 2009, and 2010, of which not more than $750,000 could be used to provide technical assistance.
VA generally supports H.R. 2378 but we strongly recommend that the bill be modified to allow VA to establish additional criteria, specifically clinical indicators, to ensure this program reaches veteran families requiring additional support to end their homelessness. H.R. 2378 would require additional staffing resources for VHA’s Homeless Program Office in the Office of Mental Health Services.
This concludes my prepared statement. I would be pleased to answer any questions you or any of the members of the Subcommittee may have.