Mr. Chairman, thank you for inviting me here today to present the Department of Veterans Affairs’ (VA) views on pending legislation.  Accompanying me this morning is Assistant General Counsel Walter A. Hall.  We appreciate the Committee’s support of Veterans and VA, and we appreciate being able to comment on these bills as we both work to improve the benefits provided to those who served.

H.R. 4062

H.R. 4062, the “Veterans’ Health and Radiation Safety Act,” would require VA to submit an annual report to Congress on low-volume programs (defined as programs that treat 100 patients or fewer annually) at VA medical facilities.  The report would have to include the Secretary’s evaluation and findings with respect to such programs.  Additionally, H.R. 4062 would require that employees working at VA hospitals where radioactive isotopes are used receive training on recognizing and reporting medical events.  Hospitals failing to provide this training would be prohibited from using radioactive isotopes for a period of time determined by the Secretary.  Lastly, VA would be required to evaluate non-government medical services contractors through weekly independent peer reviews, written evaluations, and other evaluations VA determines are appropriate.  A contracting officer must review and consider the results of these evaluations before VA renews any contracts with non-government medical service contractors. 

Mr. Chairman, we all are aware of a very unfortunate lapse that occurred at a brachytherapy program at one of our facilities.  We testified about this incident before this Committee on July 22, 2009.  On May 3, 2010, the Office of the Inspector General (OIG) issued a report on this incident with five recommendations.  Specifically, OIG recommended that the Veterans Health Administration (VHA) standardize, to a practical extent, the privileging, delivery of care, and quality controls for the procedures required to provide this treatment. This has been accomplished. Standardized procedures have been developed and site visits have verified they are uniformly in place at all facilities and steps have been taken to ensure that patients who received low radiation doses in the course of brachytherapy be evaluated to ensure that their cancer treatment plan is appropriate.  We have contacted all Veterans that were potentially impacted for follow-up testing and monitoring at other VA and private facilities and are reviewing the controls that are in place to ensure that VA contracts for health care comply with applicable laws and regulations, and where necessary, will make the required changes in organization and/or process to bring this contracting effort into compliance.  A template that outlines basics requirements for all contracts is currently in development. 

The report also recommended that senior VA leadership meet with senior Nuclear Regulatory Commission (NRC) leadership to determine if there is a way forward that will ensure the goals of both organizations are achieved.  VA is currently working to arrange this meeting. Finally, the report recommended that VHA should work with the OIG to develop a list of documents that should routinely be provided to the OIG when an outside agency is notified of a possible untoward medical event.  VHA will work closely with OIG to meet this recommendation.

We appreciate the intent of H.R. 4062 but for a number of reasons we do not support it.  First we note that section 2 requires the Secretary to submit annual reports to Congress on low volume programs.  However, the definition of a “program” is not clear.  Any treatment “program” could be defined so narrowly that no facility treats 100 patients or more a year in a particular program, or so broadly that almost every program includes more than 100 patients annually.  Moreover, treatment quality is not always related to patient volume or patient volume just within a given VA facility.  Many VA facilities have on staff specialist providers who also work elsewhere in the community.  When you combine all care provided by a specialist, the volume can be, and many times is, significantly more than can be accounted for just within VA workload.   In addition, standard credentialing, privileging, and review of quality of care are required at every facility regardless of the size of a program. 

All procedures that are performed and all medical care provided at all VA facilities involve quality assessment (QA) and oversight.  The first procedure each year has precisely the same QA requirements as the last, whether the annual procedure total is 5, 50 or 500.  Further, each procedure is performed by a fully credentialed and privileged physician. Instead of the requirement to provide an annual report on “low volume” programs, we would like to work with Congress to identify what information would be useful for Congress to receive on an annual basis.The mandatory training that would be required by section 3 would apply to all VHA staff and would not be limited to staff directly involved in the use of radioactive materials.  The NRC regulations already require all staff involved in the use of radioactive materials to have training and further require that facilities provide evidence of that training.  Competency and training requirements for staff are based upon their defined duties and risks associated with those duties.  In VHA, radiation safety training and education are provided annually, through the VA Learning Management System, to all staff involved in the use or handling of radioactive material.  This includes all contract staff or physicians working in VA Nuclear Medicine services as a condition of their authorization to practice at a VA medical center.  The definition of a medical event and reporting requirements are taught to and reviewed annually with all Nuclear Medicine technologists and physicians.  VA’s National Health Physics Program provides a mechanism to ensure that the training provided is completed as required by VA policy.  In addition, VA currently supports and trains all staff in reporting any untoward events or potential events consistent with guidance provided by the National Center for Patient Safety and the facility safety programs.  As a result, many of the requirements of section 3 are duplicative of current VA policy.

The requirement in section 4 to obtain weekly independent peer review of all medical services provided pursuant to a contract, and written evaluations of the services carried out by the supervisor or manager of the employee providing the services, are excessive and would add unwarranted cost in staff time spent procuring and developing the reports.  The requirement to undertake peer reviews each week may be ineffective if there are an insufficient number of procedures to carry out a statistically valid review.  The requirement for additional reporting and oversight of all medical services provided by contract, most of which have not reported adverse events, would be a waste of resources.  Given current VA procedures related to peer review and reporting, some of the provisions in this bill are not necessary.  We are available to meet with Committee staff to discuss these issues in more detail.

While VA appreciates the Committee’s focus on this issue, we believe with the above regulatory requirements, safeguards, and training, these additional measures are not necessary.  We are still developing costs for this bill and will provide them for the record. 

H.R. 4465

This bill would amend 38 U.S.C. 1722, which describes how VA determines that Veterans are considered unable to defray the expenses of necessary care for purposes of determining eligibility for health care under 38 U.S.C. 1705 and 1710.  Section 1722 states that the term “attributable income” is determined in the same manner that eligibility for pension is determined under 38 U.S.C. 1521.  H.R. 4465 would amend section 1722 to provide that the term “attributable income” is determined in the same manner that eligibility for pension is determined under section 1521 except that the Secretary shall treat as a child an unmarried person who is placed in the legal custody of the Veteran for a period of at least 12 consecutive months; either has not attained the age of 21, has not attained the age of 23 and is enrolled in a full time course of study at an institution of higher learning approved by the Secretary, or is incapable of self support because of a mental or physical incapacity that occurred while the person was considered a child of the Veteran; is dependent on the Veteran for over one-half of the person’s support; and resides with the Veteran unless separated to receive institutional care as a result of disability or incapacitation or under such other circumstances as the Secretary may prescribe by regulation.

VA would like to work with the Committee to better understand the intent of this legislation.  On its face it would affect only a person placed in the legal custody of a Veteran as a result of an order of a court and would count the person as a child of a Veteran until age of 21 unless he or she is a full-time student or incapacitated.  Currently all other persons (other than full-time students or those who are incapacitated) are not considered children once they reach 18 years of age.  Thus, the effect of the bill would be that persons placed in the legal custody of a Veteran by a court would be considered children under more generous criteria than the Veteran’s natural children.  The purpose of this differentiation is unclear.

If the intention is to extend the broader criteria (the age 21 cut-off) to all children of Veterans, the language should be clarified.  Moreover, all conditions in the bill as it is drafted are conjunctive so that it may also be read to provide that only persons placed in the custody of a Veteran by a court shall be treated as a child.

VA currently neither tracks nor has access to databases that would provide numbers of individuals, or Veterans (either currently enrolled or potential users of VA health care) with a child (or children) as defined in the proposed legislation.  Thus, we are unable to determine the potential financial impact the passage of this legislation would have upon VA health care enrollment, expenditures, and first and third party collections.

H.R. 4505

Pursuant to VA regulations (38 C.F.R. 51.210), state homes constructed with VA grants are required to maintain an occupancy rate of 75 percent Veterans to be eligible to receive VA per diem payments.  The only non-Veterans who are authorized to reside at state homes are either spouses of Veterans or parents of Veterans if all of their children have died while serving in the armed forces of the United States.  H.R. 4505 would require that in administering section 51.210, VA permit a State home to provide services to the parents of Veterans if any of the parents’ children died while serving in the armed forces.

VA supports this bill.  There should be no additional costs to VA.

Draft Legislation – Improve VA Outreach Act of 2010

Section 2 of the draft outreach bill would require VA to establish and maintain procedures to effectively coordinate outreach activities of VA between internal departments, Federal, state and local agencies, and Veterans Service Organizations (VSOs).  This bill would require VA to annually review the procedures in place to conduct these activities and modify them as needed.  Section 3 would require VA to consult with the Department of Health and Human Services (HHS) regarding outreach to Veterans who receive medical care through HHS community health centers or facilities of the Indian Health Service (IHS).  Section 4 would establish an advisory committee on outreach comprised of representatives from VSOs, individuals with expertise in Veterans’ issues, marketing, branding, advertising, and communication, and representatives from State and county Veterans agencies.  The committee would also include representatives from the Center for Minority Veterans, Center for Women Veterans, VHA, Veterans Benefits Administration (VBA) and National Cemetery Administration (NCA) to serve as ex-officio members.  Terms of service and pay for the committee members would be decided by the Secretary.  The committee’s responsibilities would include providing advice to the Secretary on outreach matters, reviewing the strategic plan for outreach, preparing biennial reports for the Secretary, and providing the Secretary with any other reports that the committee considers appropriate.  The Federal Advisory Committee Act would apply to this committee.

Section 5 would require the Secretary to submit to Congress a biennial strategic plan for outreach activities, including plans to identify and inform Veterans and dependents of available benefits and services; plans to enroll or register eligible Veterans; and goals, objectives, tasks, and performance measures for the above-mentioned plans.  The strategic plan would be sent to the Advisory Committee on Outreach for recommendations prior to being submitted to Congress.

Because the bill would require duplication of existing programs, VA does not support it.  We note that the requirements set forth in section 2 are already being met.  VA recently created the National Outreach Office in the Office of Intergovernmental Affairs, Office of Public and Intergovernmental Affairs.  This new office is responsible for ensuring the effective coordination of the outreach activities of the Department between and among the Office of the Secretary, the Office of Public and Intergovernmental Affairs, VHA, VBA, NCA, staff offices, and external stakeholders.  Further, VA already has a workgroup established to better coordinate services between IHS and VA and is working on a memorandum of agreement to improve collaboration.

We believe Section 4, while well-intended, would be redundant.  There are currently five advisory committees that provide outreach direction in their annual reports to the Secretary and Congress.  These committees include the Advisory Committee on Homeless Veterans, the Advisory Committee on Minority Veterans, the Advisory Committee on the Readjustment of Veterans, the Veterans’ Rural Health Advisory Committee, and the Advisory Committee on Women Veterans.  Finally, pursuant to 38 U.S.C. 6302, VA is already required to develop a biennial plan on outreach activities. 

The annual discretionary cost of this bill would be approximately $400,000.

Draft Legislation- World War II Hearing Aid Treatment Act

VA currently has authority to provide hearing aids to certain Veterans receiving VA health care.  Specifically, 38 U.S.C section 1717(c) authorizes VA to provide them to any Veteran who is profoundly deaf and is entitled to compensation on account of hearing impairment.  This draft bill would extend eligibility for hearing aids to all Veterans of active-duty service in World War II, even if those Veterans are not otherwise entitled to compensation under title 38, United States Code.

Hearing loss can be frustrating and dangerous, especially for older adults.  Further, the added effects of hearing loss and aging can combine to create a significant communication handicap and negatively impact the ability to communicate effectively.  The negative effect of stress and communication difficulties can contribute to poor quality of life.  In addition, untreated hearing loss among the older adult population is linked to emotional and social consequences such as depression and social isolation.  Use of hearing aids has been shown to be effective for hearing loss remediation and is an important element of life quality for all of our Veterans with hearing loss.

VA does not support the draft legislation because we currently have authority to provide hearing aids to Veterans with service-connected hearing loss.  In addition to the statutory authority found section 1717(c), 38 USC 1707(b) authorizes the Secretary to provide sensori-neural aids in accordance with guidelines prescribed by the Secretary.  These guidelines are found in 38 CFR 17.149 and list a number of different categories of Veterans who are eligible for hearing aids, including Veterans with significant functional or cognitive impairment evidenced by deficiencies in activities of daily living and Veterans with hearing impairments resulting from the existence of another medical condition for which the Veteran is receiving VA care.  VA also believes the legislation would cause inequitable treatments of non-World War II Veterans with hearing loss.  Furthermore, the legislation would create unequal benefits for hearing aids in relation to other prosthetic appliances that are also crucial to Veterans’ well-being and quality of life.  

The discretionary cost of this legislation would be approximately $14.8 million in the first year, $350 million over 5-years and $509.7 million over 10 years. This concludes my statement, Mr. Chairman.  I would be happy to entertain any questions you or the other members of the Committee may have.