[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041,
H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641,
H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220,
AND DRAFT LEGISLATION
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 29, 2010
__________
Serial No. 111-101
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
61-759 WASHINGTON : 2011
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida HENRY E. BROWN, Jr., South
VIC SNYDER, Arkansas Carolina, Ranking
HARRY TEAGUE, New Mexico CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas JERRY MORAN, Kansas
JOE DONNELLY, Indiana JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
September 29, 2010
Page
Legislative Hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R.
5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127,
H.R. 6220, and Draft Legislation............................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 25
Hon. Henry E. Brown, Jr., Ranking Republican Member.............. 1
Prepared statement of Congressman Brown...................... 25
WITNESSES
U.S. Department of Veterans Affairs, Robert L. Jesse, M.D.,
Ph.D., Principal Deputy Under Secretary for Health, Veterans
Health Administration.......................................... 18
Prepared statement of Dr. Jesse.............................. 71
______
American Legion, Jacob B. Gadd, Deputy Director, Veterans Affairs
and Rehabilitation Commission.................................. 10
Prepared statement of Mr. Gadd............................... 47
Barrow, Hon. John, a Representative in Congress from the State of
Georgia........................................................ 6
Prepared statement of Congressman Barrow..................... 28
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 13
Prepared statement of Mr. Atizado............................ 56
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 11
Prepared statement of Mr. Blake.............................. 52
Pingree, Hon. Chellie, a Representative in Congress from the
State of Maine................................................. 17
Prepared statement of Congresswoman Pingree.................. 71
Sestak, Hon. Joe, a Representative in Congress from the State of
Pennsylvania................................................... 2
Prepared statement of Congressman Sestak..................... 26
Stearns, Hon. Cliff, a Representative in Congress from the State
of Florida..................................................... 7
Prepared statement of Congressman Stearns.................... 34
Walz, Hon. Timothy J., a Representative in Congress from the
State of Minnesota............................................. 4
Prepared statement of Congressman Walz....................... 28
Wounded Warrior Project, Ralph Ibson, Senior Fellow for Policy... 15
Prepared statement of Mr. Ibson.............................. 67
SUBMISSIONS FOR THE RECORD
American Federation of Government Employees, AFL-CIO, and AFGE
National Veterans Affairs Council, statement................... 80
Buyer, Hon. Steve, Ranking Republican Member, Full Committee on
Veterans' Affairs, and a Representative in Congress from the
State of Indiana, statement.................................... 82
Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs,
and a Representative in Congress from the State of California,
statement...................................................... 84
Independence Through Enhancement of Medicare and Medicaid
Coalition, letter.............................................. 84
National Coalition for Homeless Veterans, statement.............. 85
National Association for the Advancement of Orthotics and
Prosthetics, Thomas Guth, C.P., President, letter.............. 87
National Nurses United, statement................................ 88
Veterans of Foreign Wars of the United States, Michael O'Rourke,
Assistant Director, National Veterans Service, statement....... 89
Vietnam Veterans of America, Richard F. Weidman, Executive
Director for Policy and Government Affairs, statement.......... 93
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Jacob B. Gadd, Deputy
Director, Veterans Affairs and Rehabilitation Commission,
America Legion, letter dated October 4, 2010, and response
letter dated November 15, 2010............................. 97
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Carl Blake, National
Legislative Director, Paralyzed Veterans of America, letter
dated October 4, 2010, and response letter dated November
15, 2010................................................... 101
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Adrian M. Atizado,
Assistant National Legislative Director, Disabled American
Veterans, letter dated October 4, 2010, and Mr. Atizado's
responses.................................................. 104
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Ralph Ibson, Senior
Fellow for Policy, Wounded Warrior Project, letter dated
October 4, 2010, and Mr. Ibson's responses................. 110
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs to Hon. Eric K. Shinseki,
Secretary, U.S. Department of Veterans Affairs, letter
dated October 4, 2010, and VA responses.................... 113
Hon. Cliff Stearns, Republican Member, Subcommittee on
Health, Committee on Veterans' Affairs, to Hon. Eric K.
Shinseki, Secretary, U.S. Department of Veterans Affairs,
letter dated November 16, 2010, and VA responses........... 120
LEGISLATIVE HEARING ON H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R.
5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, AND DRAFT
LEGISLATION
----------
WEDNESDAY, SEPTEMBER 29, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Perriello, Brown of South
Carolina, and Stearns.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call the hearing to order, and
thank everyone for coming today.
Today's legislative hearing is an opportunity for Members
of Congress, veterans, the U.S. Department of Veterans Affairs
(VA), and other interested parties to provide their views and
discussion on legislation that has been introduced within the
Subcommittee's jurisdiction.
This is an important part of the legislative process that
will encourage a frank discussion of ideas. We have 12
important bills before us today.
We have been hearing that votes might be called between
11:00 and 12:00, so I would ask unanimous consent that my full
remarks be submitted for the record so we can try to speed up
the hearing process. Hearing no objection, so ordered.
Mr. Michaud. So I now would recognize Mr. Brown, our
distinguished Ranking Member, for any opening statement that he
may have.
[The prepared statement of Chairman Michaud appears on
p. 25.]
OPENING STATEMENT OF HON. HENRY E. BROWN, JR.
Mr. Brown of South Carolina. Thank you, Mr. Chairman.
I, too, would like to submit my opening statement for the
record. And I would like unanimous consent to also offer
Ranking Member of the full Committee, Steve Buyer's statement
for the record.
Mr. Michaud. Without objection, so ordered.
[The prepared statement of Congressman Brown appears on
p. 25.]
[The prepared statement of Congressman Buyer appears on
p. 82.]
Mr. Michaud. We will now go to our first panel. And I would
recognize Mr. Sestak, to introduce his bill to the Committee.
And I want to thank you very much, first of all for your
service to our great Nation and also for your willingness to
come today.
STATEMENTS OF HON. JOE SESTAK, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF PENNSYLVANIA; HON. TIMOTHY J. WALZ, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF MINNESOTA; HON.
JOHN BARROW, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
GEORGIA; AND HON. CLIFF STEARNS, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF FLORIDA
STATEMENT OF HON. JOE SESTAK
Mr. Sestak. Thank you, Mr. Chairman and Ranking Member
Brown.
First I would like to acknowledge the great work that this
Subcommittee has done in the recent Congress. It is providing
unprecedented ways and means to care for our veterans, those
who have gone into harm's way on our behalf.
However, with these additional resources, the VA has a
responsibility to Congress, the American public, and most
especially our veterans to see that it operates the highest
possible standards of care.
In support of that goal, I am here to discuss my bill, H.R.
3843, the ``Transparency for America's Heroes Act.''
This legislation directs the Secretary of Veterans Affairs
to make available on the VA Web site redacted records and
documents, but not personal identifying information, created by
the VA as part of a medical quality assurance program.
It would also require the Secretary to ensure that such
records created during the 2-year period prior to the enactment
of this Act are also made available in a similar manner.
I authored this bill because I have grown increasingly
troubled by reports that give rise to concern of a lingering
lack of consistent care and accountability within the VA.
I must be very clear that I hold in highest regard the
thousands of dedicated professionals of the VA, many who have
spent their entire careers in the service of our veterans.
However, for the past 24 months, there have been too many
revelations of substandard care for our vets.
Congress, and the American public, have been belatedly
informed of prostate cancer victims who received insufficient
treatment, the possible exposure of more than 1,800 veterans to
serious diseases including hepatitis and human immunodeficiency
virus (HIV) while undergoing routine dental procedures,
deficiency in thoracic care.
And last September, we learned only after a Freedom of
Information Act (FOIA) request was filed that some elderly
veterans were being subjected to substandard, potentially
neglectful care in the Philadelphia Community Living Center at
Philadelphia VA Medical Center.
The nursing home, according to the Long-Term Care
Institute's report, ``Failed to provide a sanitary and safe
environment for the residents. And there was a significant
failure to promote and protect the residents' rights to
autonomy and to be treated with respect and dignity.''
Some of the examples cited shock the conscious. For
example, one patient with an open foot wound was left
unattended for so long that live maggots were found falling out
of the wound. Additionally, the floor was found to be covered
with dried blood and feeding tubes.
Another diabetic patient complained of chronic failure on
the staff's part to administer his insulin shots on schedule.
After hearing these reports, it came to my attention that
there were two other recent inspections, one by the Office of
Inspector General (OIG) of the VA and one by the Joint
Commission on Accreditation of Healthcare Organizations, both
of which concluded the facility met quality standards based on
the metrics used.
However, it took this separate external investigation of
the Long-Term Care Institute, using a different set of
inspection criteria to find the maggots, to identify the
serious problems at the facility under its older leadership.
What concerns me is the two VA conducted reviews failed to
discover these deficiencies and that a Freedom of Information
Act request was required to bring this latest revelation, this
known latest revelation of poor care to light.
In fact, the report should not have even been released
after the FOIA petition was filed under the current law because
the third-party inspection was conducted on the VA's quality
assurance authority. And in this case, the report was
inadvertently leaked by a VA official who did not follow the
normal protocol.
This leads me to believe that there may be numerous of
other cases of deficient care, which will never see the light
of day because of the inspections in question like the one
conducted by the Long-Term Care Institute that were conducted
under the VA quality assurance authority.
Under current law, records and documents created by the VA
as part of a designated quality assurance program are
confidential and privileged and as a result cannot be disclosed
to any person or entity except when specifically authorized by
statute.
And, yet, in Pennsylvania, similar facilities' reports for
citizens of America that are not veterans are placed on Web
sites.
The standard rationale for this practice is according to
the VA to, ``Create a proactive culture of quality improvement
allowing for early identification and resolution of quality
issues.'' Obviously that was not done.
The VA also states that, ``Elimination of protected
document status for quality management activity documents would
possibly have a chilling effect on the level of objectivity
reflected within these improvement activities.''
As a former Admiral who led men and women into battle, I
disagree with this assessment. I am convinced there is a need
for a cultural and procedural sea change in the way the VA
medical system operates and that the best way to ensure quality
care in the VA is through a stringent, transparent oversight.
I certainly learned in the Navy to expect what you inspect
and to know what you have found. This entails vigilance on the
part of both Congress and the general public. If there are
other instances of inadequate VA care, they should be revealed
immediately along with a confirmation that appropriate
corrective actions have been taken like they were not in this
case.
My bill, as I conclude, would accomplish this without
releasing sensitive information, which could be used to
identify patients and health care professionals. After all,
even my personal service record can be given out in public,
redacted obviously.
If we fail to ensure this kind of accountability, the goals
of the current Administration, the hard work of the recent
Congress to finally provide our veterans the care and resources
they have been denied for so long will be compromised. At issue
is the very credibility and accountability of one of our
Nation's most important health care providers and that of the
government itself.
I am reminded of the long-term consequences for us, the
Executive Branch, to treat veterans and their families in
responsible kind of ways we have tried to do after a failure
for too long, particularly after Vietnam.
As our troops continue to return from Iraq and Afghanistan,
we can and must do better. Thank you, Mr. Chairman.
[The prepared statement of Congressman Sestak appears on
p. 26.]
Mr. Michaud. Thank you very much, Mr. Sestak, for that
description of your piece of legislation.
Are there any questions of the Subcommittee for Mr. Sestak?
Hearing none, thank you very much.
Mr. Sestak. Thank you, Mr. Chairman.
Thank you, Mr. Brown.
Mr. Michaud. I would like to recognize Mr. Walz, who is
also a Member of the Veterans' Affairs Committee who serves his
country with distinction, to introduce his legislation.
Mr. Walz.
STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Well, thank you, Chairman Michaud and Ranking
Member Brown, for this opportunity to be here.
I also want to thank you and tell you what a privilege it
is to serve with you on the full Committee. The two of you put
veterans first and foremost in everything you do. And for that,
I am incredibly grateful.
I am here today to testify on a bipartisan bill introduced
by myself, Mr. Bilirakis, Mr. Miller, and Mr. Pascrell, H.R.
6123, the ``Veterans Traumatic Brain Injury and Rehabilitative
Services Improvement Act.''
First and foremost, the care that our soldiers are getting
at our VA hospitals is top quality. I think all of us in this
room have recognized the incredible efforts that have been
made, especially dealing with traumatic brain injury (TBI). But
one of the things that I think we see missing is a cohesive,
holistic approach to this care.
And this bill does a couple of things that are critically
important for these veterans to achieve the quality of life we
want to have them achieve.
We are doing a great job of the VA doing on the health
professional side of things, but it would cover other VA
support services that contribute to the maximum quality of
life, things like helping with reemployment, helping with other
things as far as adaptive types of things, and then doing a
second thing that is not clarified in the current provisions,
and this makes it a little broader. We are asking them to not
simply improve lost functioning but to maintain that
improvement once it is gained.
Some of the brain-based research and the things we are
seeing show that we can continue to get improvement or at least
hold those achievements that we have gotten for these veterans.
And I want to make sure that that gets there.
The ambiguities in the law make the TBI treatment very
narrow. It is incredibly good quality of care on the physical
side of things. We are not encompassing the whole range of
things that we could do. So we need to make sure that there is
a comprehensive approach. That is what this bill ensures. It
provides comprehensive care instead of just physical care.
And I want to be very clear with our VA folks who are here,
and we get great input from them on this. This is not creating
any new programs. It is integrating existing programs for the
quality of life improvement of the veterans. It is just a
better way of defining how we care for these TBI patients. It
is a better way of making sure that it is veteran and family
centered in how that care goes across the spectrum of things.
This bill has the full support of the Wounded Warrior
Project, the Disabled American Veterans, the Blinded Veterans,
and the Enlisted Association of the National Guard.
And I want to take special time to thank Ralph Ibson and
Christine Hill at the Wounded Warrior Project for bringing
this. These are folks that are out there every day with our
heroes. They are out there trying to understand what it is
going to take to bring them back to a quality of life that get
as close to approximation as we can to a normal existence for
these folks. And that is what we want to try and do.
So I am appreciative of the work that has been done on
this. I want to be very clear. I am appreciative of the
incredible care that is given to these wounded warriors through
the VA. I think we can define with this bill a little broader
on what the VA can go ahead and deliver in terms of
comprehensive, holistic care to these veterans.
And I think at the end of the day, the American people want
to see us do everything possible to take these wounded warriors
back home, to give them all the care possible, and to improve
their quality of life to allow them to function both in the
workplace, in social settings, and beyond just physical
functioning.
So with that, I would be happy to take any question and,
again, thank both of you for the work you are doing.
[The prepared statement of Congressman Walz appears on p.
28.]
Mr. Michaud. Thank you very much, Mr. Walz, and also thank
you very much for your hard work and dedication on the
Veterans' Affairs Committee. We value your opinion and
appreciate all the hard work that you have been doing. So,
thank you.
Mr. Walz. Thank you, Mr. Chairman.
Mr. Michaud. Are there any questions?
Seeing none, thank you very much.
Mr. Walz. Thank you.
Mr. Michaud. Mr. Barrow, I also want to thank you for
coming today to bring forward H.R. 4041 and I look forward to
hearing your testimony. Mr. Barrow.
STATEMENT OF HON. JOHN BARROW
Mr. Barrow. Well, thank you, Mr. Chairman. It is an honor
to be with you and thank you for allowing me to testify today.
I want to thank you and my South Carolina neighbor, Mr.
Brown, for the tremendous leadership you all are showing in
closing the gap that has existed for too long now between the
promises that have been made to our veterans and the resources
we have committed toward meeting those needs and fulfilling
those promises.
The most consistent and frustrating feedback that I get
from people I represent is from veterans having problems with
the VA. I suspect it is the same for some of you in your
districts as well.
The initial disability determination can take too long.
Communication with the VA can be weak. Once they are in the
system, it is hard to navigate. Facilities can be too far away.
Well, I can see how major programs in the VA could benefit
from a major overhaul and I realize that is not going to happen
any time soon. For better or for worse, the system works well
enough for enough folks that the demand for a major overhaul
will be a long time coming. But I do not think any of us really
believes that the current system works as well as it could or
should.
The problem with today's VA is its complexity. The medical
needs of returning veterans are more complex than they have
ever been. We design very intricate treatments and benefits and
services to meet those needs. Unfortunately, it has become so
complex that you need specialized training just to wade through
the bureaucracy of it all.
My purpose in coming today is to promote a bill I have
introduced, H.R. 4041, which will give veterans the tools they
need to navigate this maze.
We all agree that every wounded warrior should have an
individualized plan for recovery coordinated by a professional
who is trained to successfully navigate the VA system of
services and benefits.
The Dole-Shalala Commission calls these professionals
Federal Recovery Coordinators (FRCs) and made them a major
component of their comprehensive recommendations to improve the
VA. The Federal Recovery Coordinator Program has been
authorized by Congress since 2008, but today there are only 20
Federal Recovery Coordinators spread across the entire country
coordinating the care of only around 500 wounded veterans.
My bill will increase the number of Federal Recovery
Coordinators, formalize their training, and establish
guidelines and best practices for successful care coordination.
As envisioned and designed by the Dole-Shalala Commission,
a Federal Recovery Coordinator would be a nurse or a social
worker with a Master's Degree who has excellent communication,
leadership, and resource navigation skills. Today's wounded
warrior might have a unique combination of traumatic physical
injury, post-traumatic stress disorder (PTSD), substance abuse,
or marital problems, trouble finding a job, or trouble
reintegrating back into the community. A recovery coordinator
acts as an air traffic controller to guide veterans to the
proper treatment and benefit options.
I have submitted for the record personal testimonies from a
few returnees that I represent whose Federal Recovery
Coordinators have been a Godsend. I commend them to you.
Despite its obvious benefits and successes, the program is
in its infancy and needs some help in order to be all that it
can be. My bill will help in three specific ways.
First and foremost, the bill authorizes formal training for
45 new Federal Recovery Coordinators in the next 3 years. It is
obvious that we have too many veterans who desperately need
these services and we do not have nearly enough coordinators to
meet the demand.
Second, my bill authorizes the development of specialized
case management software to complement the work of trained care
coordinators.
Third, my bill authorizes the development of uniform best
practices for recovery coordination. The coordinators out there
today are blazing valuable new trails, but they work out of
sight of each other. We need to develop and promote what works
best so that all of our wounded veterans will get the best
chance at getting what they need.
Our goal here has to be helping the veterans who need it
and to do it as fast and effectively as we possibly can. I have
seen the Federal Recovery Coordinator Program in action and I
am convinced this really is the best way forward.
I appreciate the opportunity to testify before you. I
appreciate the Committee's willingness to take a deeper look at
this legislation. And I will be happy to answer any questions.
[The prepared statement of Congressman Barrow appears on
p. 28.]
Mr. Michaud. Thank you very much, Mr. Barrow, for your
description of the legislation you presented today. I really
appreciate your advocacy on behalf of our veterans as well.
Are there any questions for Mr. Barrow?
Thank you very much, Mr. Barrow. I appreciate your coming.
Mr. Barrow. Thank you, Mr. Chairman.
Mr. Michaud. I would like to recognize Mr. Stearns who also
sits on the Veterans' Affairs Committee. I really appreciate
your efforts in helping us deal with veterans' issues. And Mr.
Stearns has two bills before us today, H.R. 5516 and H.R. 5996.
So, Mr. Stearns.
STATEMENT OF HON. CLIFF STEARNS
Mr. Stearns. Good morning and thank you, Mr. Chairman.
And thank you, Ranking Member, Mr. Brown of South Carolina.
As you mentioned, I have two bills before the Committee
today, H.R. 5516, the ``Access to Appropriate Immunization for
Veterans,'' and H.R. 5996, a bill to help veterans with chronic
obstructive pulmonary disease, COPD.
The first bill is a bipartisan bill that I am proud to have
introduced as a co-founder of the COPD Caucus. COPD is the
fourth leading cause, of death in the United States. It is
predicted to be the third leading cause of death by the year
2020 beating both diabetes and stroke. And 126,000 Americans
die each year from this disease. That is about one death every
4 minutes.
My bill, Mr. Chairman, would increase the VA's ability to
diagnose, treat, and manage COPD. COPD is a chronic condition
that does not have a cure. Early detection and treatment is
important to slow or arrest the progression of the disease.
It is estimated that more than 12 million people are
diagnosed with COPD and, yet, this number is believed to be
small as COPD is often under-diagnosed. The Centers for Disease
Control and Prevention, CDC, estimates that over 24 million
Americans have symptoms of COPD.
Despite all this, there is a lack of awareness by patients
and doctors about this disease. It is a progressive disease.
Early detection is extremely important. Because there is no
cure, early treatment is vital. Because the COPD rate is three
times higher in the veterans' population, Mr. Chairman, than
the civilian population, how can the VA not be providing this
type of specialized care? COPD is the fourth most common
diagnoses among hospitalized veterans ages 65 to 74.
H.R. 5996 would have the VA develop treatment protocols and
related tools for the diagnosis, treatment, and management of
chronic obstructive pulmonary disease. It would also have the
VA establish a pilot smoking cessation program targeted towards
individuals who have COPD.
While there are many ways that someone can develop this
type of disease, the most common is from smoking. However, it
should be noted that COPD has underlying genetic risk factors
and healthy nonsmokers can also develop COPD.
I think it is important to note that this is not giving VA
any new authority. VA already has the authority to do what I am
asking for. But for whatever reason, they have not aggressively
moved to develop these treatment protocols for the fourth
leading cause of death in the United States. My bill would have
the VA begin to develop these treatments for our veterans.
This bill has the support of the U.S. COPD Coalition, the
COPD Foundation, the American Thoracic Society, the American
Association for Respiratory Care, and the Alpha-1 Foundation
and the Alpha-1 Association.
And I would like to submit, Mr. Chairman, by unanimous
consent the letters of support for the record.
Mr. Michaud. Is there any objection? Hearing none, so
ordered.
Mr. Stearns. The other bill is the ``Access to Appropriate
Immunizations for Veterans Act of 2010,'' H.R. 5516. The VA
already has the authority to provide vaccines to veterans to
immunize them against preventable diseases.
However, the VA has only established performance measures
for two vaccines. For these two vaccines against the flu and
pneumonia, the vaccination rate increased from 27 percent to
almost 80 percent and hospitalization rates dropped in half.
My bill would extend all the Centers for Disease Control
and Prevention's recommended vaccines to the performance
measures.
It is important to note that the vaccines are not just for
children. In fact, just last week, the New York Times ran an
article on how important it is for adults to receive vaccines
and booster shots.
I would like to read a part of this article quickly.
``Adult immunizations are not just an important way to prevent
the spread of the disease, immunizations are also a
phenomenally cost-effective way to preserve health. When you
compare the cost of getting sick with these diseases to the
cost of a simple vaccine, it is a modest investment, said Dr.
Robert Hopkins, a professor of internal medicine and pediatrics
at the University of Arkansas for Medical Centers.''
According to the CDC, each year, approximately 70,000 adult
Americans die from vaccine preventable diseases. Influenza
alone is responsible for over one million ambulatory care
visits, 200,000 hospitalizations, and 30,000 deaths.
Only 7 percent of Americans over the age of 60 have
received the vaccine to protect them from shingles, a painful
nerve infection.
Just 11 percent of young women have received the vaccine
against HPV (human papillomavirus), the virus that causes 70
percent of cervical cancers.
Many of our veterans who are in a high-risk category of
contracting vaccine preventable diseases, including those with
HIV, hepatitis C, and substance abuse disorder, are enrolled in
the VA health care system and could simply benefit from
receiving these vaccines.
I want the VA to provide superior quality care to our
veterans. Adding vaccinations to the performance measure is a
simple common-sense idea that will increase the level of care
available and save money by stopping preventable diseases.
The bill would also require the VA to report back to
Congress on their progress of supporting vaccinations within
the veterans' populations.
And I would like in conclusion to enter the New York Times
article into the record and the CDC's recommended vaccination
schedule for adults by unanimous consent.
Mr. Michaud. Is there any objection?
Hearing none, so ordered.
Mr. Stearns. And thank you, Mr. Chairman, for allowing me
to testify.
[The prepared statement and attachments of Congressman
Stearns appears on p. 34.]
Mr. Michaud. Thank you very much, Mr. Stearns, for your
testimony on both bills.
Are there any questions from the Committee?
Hearing none, thank you very much.
I would like to call up the second panel. And while they
are coming up, I will introduce them. We have Jacob Gadd from
the American Legion; Carl Blake from the Paralyzed Veterans of
America (PVA); Adrian Atizado from the Disabled American
Veterans (DAV); and Ralph Ibson from the Wounded Warrior
Project (WWP).
We also heard from Mr. Filner and Ms. Pingree. They will be
here a little bit later to present their testimony on the bills
that they have introduced.
We will start with Mr. Gadd from the American Legion.
STATEMENTS OF JACOB B. GADD, DEPUTY DIRECTOR, VETERANS AFFAIRS
AND REHABILITATION COMMISSION, AMERICAN LEGION; CARL BLAKE,
NATIONAL LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA;
ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS; AND RALPH IBSON, SENIOR FELLOW FOR
POLICY, WOUNDED WARRIOR PROJECT
STATEMENT OF JACOB B. GADD
Mr. Gadd. Mr. Chairman and Members of the Subcommittee,
thank you for this opportunity today for the American Legion to
present our views on today's pending legislation.
As this legislation covers many different pieces of
legislation, I will highlight a few of the bills and draft
legislation beginning with H.R. 4041, to authorize certain
improvements in the Federal Recovery Coordinator Program.
In 2007, the American Legion approved Resolution 29,
Improvements to Implement a Seamless Transition, where we
recommended a single recovery coordinator to ensure efficient
rehabilitation and transition from military to civilian life
and eliminate the delays and gaps in treatment and services.
The program was designed and created an individualized care
coordination plan for severely injured servicemembers in order
to ensure a warm handoff for severely wounded servicemembers
transitioning between the U.S. Department of Defense and VA.
With close to two million servicemembers having deployed in
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF),
and now New Dawn, VA has only reported to date that less than
1,000 servicemembers have been assisted through this program.
The American Legion, therefore, recommends expanding the
program areas of the FRC Program to include program
eligibility, increasing the FRC staff to one individual
coordinator per State, and improving communication at the
national, State, and local levels.
First, the American Legion believes that coordination of
care, especially those who are severely wounded, is essential
to ensure they receive the education and benefits that they
need and have earned.
However, the American Legion believes efforts to improve
care coordination must be directed at not only the severely
wounded but any veteran transitioning and to ensure they do not
fall through the cracks.
Second, VA reported in 2010 that five new FRCs are in the
process of being hired, which brings the total number to 25
across the country.
The American Legion recommends having an FRC within each
State to ensure all active-duty Reserve and Guard units receive
the same education, outreach, and benefits assistance.
Third, in some cases, the American Legion has had
difficulty contacting the FRCs through phone, e-mail, or
mailing address. In addition, the program should increase its
outreach through use of a dedicated Web page to update current
contact information.
Finally, in regards to development of a computerized
tracking program, the American Legion applauds VA's new
application, the care management and tracking and reporting
application, CMTRA. This tracking tool allows VA to coordinate
care amongst a wide variety of providers such as the OEF/OIF
care management team.
However, the American Legion recommends that consolidation
of a new software tool be compatible with the CMTRA tool to
prevent redundancy or to have any veterans that may fall
through the cracks.
Next, H.R. 5641, VA's authorized under title 38, Code of
Federal Regulations to provide a comprehensive array of
medically necessary in-home services. VA defines a medical
foster home as a noninstitutional long-term care setting for
veterans.
The Medical Foster (MF) Program is owned or rented by the
medical foster home caregiver. Each VA medical center facility
appoints an MF coordinator and ensures quality assurance,
inspections, maintaining of files and patients.
The American Legion would like to take additional time to
contact some veterans within this program to see their safety
and get feedback from them on this program.
Draft legislation to amend title 38 to ensure that the
Secretary provides veterans with information concerning
service-connected disabilities, several Department service
officers for the American Legion have identified that the
Veterans Health Administration (VHA) providers are not
assisting veterans with questions a provider interprets as
claims related.
The American Legion is working with Central Office to
understand the reasons for this disconnect between VHA and the
Veterans Benefits Administration (VBA) and we intend to
recommend a Fast Letter or new VHA directive be sent to the
field to clarify this policy on VA treating physicians in the
case where medical evidence on the veteran's behalf is there
and the provider from VHA is not helping with the VBA side on
the claims process.
As always, the American Legion thanks this Committee for
the opportunity to testify and represent the positions of over
2.4 million veteran members. Thank you.
[The prepared statement of Mr. Gadd appears on p. 47.]
Mr. Michaud. Thank you very much.
Mr. Blake.
STATEMENT OF CARL BLAKE
Mr. Blake. Chairman Michaud, Members of the Subcommittee,
on behalf of Paralyzed Veterans of America, I would like to
thank you for the opportunity to be here to testify today.
Since you have my full written statement for the record, I
will limit my comments to just a select few bills.
PVA cautiously supports H.R. 3843, the ``Transparency for
America's Heroes Act.'' Transparency is critical for the public
to be able to see and understand what its government is doing.
Requiring VA to publish redacted medical quality assurance
records on the VA's Web site will provide users of the VA a
better understanding of the successes or failures of the VA and
the quality of care delivered to veterans.
This may encourage greater efforts on the part of VA
employee staff and leadership to ensure that the best care is
provided to veterans while ensuring openness.
However, PVA's concern stems from the need for privacy with
these health care records. And the comments of Congressman
Sestak notwithstanding, it is important that sufficient
safeguards be put in place to prevent the unintended release of
personal health information that may be detrimental to a VA
patient.
PVA supports H.R. 5428, to better educate injured and
amputee veterans on their rights and the requirement that VA
staff who work at prosthetics and orthotics clinics or who work
as patient advocates for veterans understand these rights as
well.
This bill would ensure that VA prosthetics clinics around
the country prominently display the Injured and Amputee
Veterans' Bill of Rights and that VA employees fully understand
it.
This reaffirms the idea that a veteran in need of an
assistive device or prosthetic gets the highest quality item
available and in a timely manner.
As expressed in previous testimony on this topic, PVA is
concerned, however, that this legislation's language seems to
ignore veterans who may be in need of special equipment who
suffer from a specific disease and not just a physical injury.
PVA supports H.R. 5543, to repeal the prohibition on
collective bargaining with respect to compensation for VA
employees which may improve the collective bargaining rights
and procedures for certain health care professionals in the VA.
AS PVA testified in March of this year, these changes would
be a positive step in addressing the recruitment and retention
challenges the VA faces to hire key health care professionals,
particularly registered nurses, physicians, physician
assistants, and other selected specialists.
PVA generally supports H.R. 5641, the ``Heroes at Home
Act.'' However, it is essential that proper protections are put
in place to ensure that it is the desire of the veteran to be
transferred to a non-VA nursing home and only in the case that
the foster home meets VA standards at the time of transfer.
PVA generally supports H.R. 6127. However, we do have some
concerns with the issues surrounding this bill. While we see no
real argument with granting these men and women who experienced
the exposures outlined by this bill, Access to the VA health
care system, we question why this is the only group singled out
for enrollment.
Given the long-standing discussions about Operation Iraqi
Freedom, veterans being exposed to burn pits or servicemembers
exposed to other hazardous materials in any number of settings,
we believe proper consideration needs to be given to a broader
spectrum of veterans and servicemembers.
PVA generally supports the provisions of the discussion
draft on improvements to VA homeless programs. Too many
veterans continue to live on the streets due to drug, mental
health, financial, and employment challenges.
Expansion of grant programs for improvements to facilities
and increased outreach to more homeless veterans may help them
receive services and rehabilitation and achieve the Secretary's
goal to end veterans' homelessness.
But as PVA testified last October, we do have some concerns
about the long-term effects of the legislation. By adjusting
the payments for geographic areas, we believe it is aimed at
providing greater funding to higher cost localities. This may
actually reduce the total number of homeless veterans that can
be served if future increases in overall program funding are
insufficient.
While the argument could be made that reductions in funding
for low cost areas may offset increases to high cost areas, the
funding levels provided for homeless programs are seldom
sufficient anyway to provide for all the veterans who may need
to take advantage of these critical services.
PVA would recommend a very cautious approach on this
legislation to ensure that the most vulnerable veterans are not
inadvertently hurt in efforts to provide greater funds for some
of them.
PVA would like to thank the Subcommittee once again for the
opportunity to testify and I would be happy to answer any
questions that you might have. Thank you.
[The prepared statement of Mr. Blake appears on p. 52.]
Mr. Michaud. Thank you very much, Mr. Blake.
Mr. Atizado.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee,
thank you for inviting DAV to testify at this important hearing
of the Subcommittee on Health.
DAV is an organization of 1.2 million service-disabled
veterans and devote our energies to rebuilding the lives of
disabled veterans and their families.
For the sake of brevity, I will only present a number of
bills and would refer the Subcommittee to our written
testimony.
DAV is pleased to support H.R. 5516 based on our National
Resolution No. 36. Our Resolution calls for VA to maintain a
comprehensive high-quality health care system specifically
including preventative health services. Preventative health
services are an important component of the maintenance of
general health, especially in elderly and disabled populations.
This bill could contribute to significant cost avoidance by
reducing the spread of infectious diseases and by obviating the
need for health interventions in acute illnesses.
DAV applauds the intent of H.R. 5641, the ``Heroes at Home
Act,'' which would allow VA to contract with certified medical
foster homes and pay for care of veterans already eligible for
VA paid nursing home care.
DAV is pleased with VA's innovation by offering medical
foster homes as part of its long-term care program. Notably
patient participation while voluntary into this program reports
and yields exceedingly high veteran satisfaction.
Under this program, the cost to VA is less than $60 a day.
Understandably, VA perceives this program as a cost-effective
alternative to nursing home placement and it is gaining
popularity in the VA based on its expansion of this program.
However, because this program operates under VA's community
residential care authority, veterans in medical foster home
programs have to pay for their care from about $50 to as much
as $130 a day even veterans who are otherwise entitled to
nursing home care fully paid for by VA whether it is under the
law or by VA's policy.
As part of The Independent Budget, DAV is greatly concerned
that veterans living in medical foster homes are required to
use personal funds as payment. These would include VA
disability compensation. In addition, veterans who do not have
the resources to pay a medical foster home caregiver may not
avail themselves of such a critical benefit.
DAV urges the Subcommittee to favorably consider this bill
and that it be moved expeditiously.
H.R. 6123 would sharpen rehabilitative requirements within
the VA to ensure that veterans with TBI under VA care are
afforded the opportunity for maximal rehabilitation, which will
hopefully lead to independence and a higher quality of life.
DAV appreciates the bill's intent to fix an existing gap in
current law affecting the treatment of brain injured veterans.
And this legislation is fully consistent with our National
Resolution and, therefore, endorse this bill and urge enactment
by Congress.
DAV also supports H.R. 6127, which would provide access for
certain veterans to VA health care under the Department's
special treatment authority under Priority Group 6.
Much like my colleague, Mr. Blake, from PVA, we do ask for
the Subcommittee's consideration to afford the same eligibility
of other veterans who were exposed to toxic and environmental
hazards, specifically those veterans who were exposed to open
air burn pits in Iraq and Afghanistan.
You know, tests on these burn pits, Mr. Chairman, in the
war zones have revealed that the fires have released dioxins,
benzene, volatile organic compounds including substances which
cause cancer.
Finally, DAV supports the draft legislation to make
improvements to VA's programs for homeless veterans. As the
Subcommittee is aware, there is a great need for specific
emphasis on the needs of homeless women veterans, women
veterans, and homeless veterans with children. Homeless
veterans suffering from serious mental illness is also a
vulnerable population.
Section 2 would provide comprehensive services to the
vulnerable population of homeless veterans with special needs.
And we note that Section 3 of this bill is identical to Section
3 of H.R. 4810, which the House has unanimously passed in March
of this year.
DAV believes this section would provide organizations
serving homeless veterans the flexibility to look at their
program design to provide the full range of supportive services
in the most economical manner.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions you or other Members of the
Subcommittee may have. Thank you.
[The prepared statement of Mr. Atizado appears on p. 56.]
Mr. Michaud. Thank you very much, Mr. Atizado.
Mr. Ibson.
STATEMENT OF RALPH IBSON
Mr. Ibson. Mr. Chairman, Mr. Brown, thank you for inviting
Wounded Warrior Project to testify this morning.
And let me preface my remarks by explaining that Wounded
Warrior Project's public policy is informed fully by our daily
contacts and work with wounded warriors and their family
members across the country.
Several of the bills under consideration today address
issues of profound concern to those warriors and their
families. And of those, H.R. 6123, Mr. Walz's bill, is of
exceptional importance and addresses deep concerns that we have
heard from many, many families.
As Mr. Walz indicated, VA facilities have many, many
dedicated, committed rehabilitation staff, yet the services
provided are often limited in duration and in scope.
Just yesterday as part of a several day workshop, an
empowerment summit focused on and serving combat veterans with
PTSD, I had the occasion to speak to a veteran from Maine, a
combat veteran who explained that he also had TBI, and had not
really made much use of his eligibility for VA care. He went to
the Togas VA Medical Center and was advised that they would
provide him therapy for residuals of his TBI, but limited to 12
sessions. And the explanation was, ``we do not provide
maintenance therapy.''
Well, as this gentleman pointed out to me and as research
clearly indicates, there is profound cause for concern with
that approach where gains that have been made, cognitive and
otherwise, can be lost and that veteran's conditions simply
regresses.
For young veterans with severe TBI, and there are many,
many of them, reintegration into their communities and pursuing
goals such as meaningful work and independent living may be as
important as their medical recovery. But many have difficulty
with community integration, and social isolation can be a
persistent issue. Yet, individuals with severe TBI who receive
individualized services to foster independence and social
interaction are able to participate meaningfully in community
settings.
These patients often need more than medical rehab to
achieve maximum independence and they encounter difficulties at
many VA facilities, which either perceive they lack the
authority, or simply are unwilling to provide, nonmedical
supports that are provided in other VA programs. These include
supported employment or life skills coaching.
As Mr. Walz indicated, his bill is a simple one. It would
eliminate and close gaps, eliminate barriers in the system, and
we think lead to enhanced recovery and fuller rehabilitation
for veterans with many levels of TBI. And we strongly support
it.
Let me touch on a few other bills that raise issues for
wounded warriors.
H.R. 5428 would direct VA to disseminate, display, and
educate Department employees on an Injured and Amputee
Veterans' Bill of Rights relating to VA prosthetics and
orthotics.
While there have been substantial improvements in VA
prosthetics care over the years, the bill does address
important concerns that warriors have voiced with us.
We are not confident, however, that enacting this measure
would solve the problems that it highlights. To direct VA to
disseminate the list of so-called rights does not make those
expectations enforceable, nor does the bill require VA to take
actions that would convert those expectations into reality.
Nevertheless we would be pleased to work with the
Subcommittee and Committee to explore ways to bolster the bill.
H.R. 4041 would direct VA to fund training of recovery
coordinators through a school of nursing and medicine. We
concur with earlier expressed views that there is a need to
enlarge the program to make greater numbers of FRCs available,
particularly to warriors who did not get an FRC because the
program was created in 2007. Many of those with severe injuries
predating that date have not had that kind of help and still
need it.
We are not persuaded, though, that VA needs the authority
that H.R. 4041 would establish nor that its methodology is
necessarily an optimal one in terms of avenues for training
future FRCs.
We concur with earlier expressed views that H.R. 6127 is
consistent with earlier legislation that established health
care eligibility related to toxic exposures. But we do question
the incident-specific focus of the bill and believe that there
would be merit in taking a more systematic approach given the
range of toxic exposures that OIF/OEF veterans have
experienced.
And, lastly, we would comment on H.R. 3843 discussed
earlier. We certainly share a concern for ensuring the quality
of care afforded veterans in VA health care facilities. At the
same time, a vibrant medical quality assurance program is an
important element in fostering a culture of quality
improvement.
And while transparency is certainly important in sustaining
confidence in the quality of VA health care, confidentiality
has long been deemed a critical element in ensuring the
integrity of an effective medical quality assurance program.
While we take no position in terms of how best to balance
those competing tensions, transparency against confidentiality
and a strong quality assurance program, this is an area where
we would caution the Committee to proceed in a very carefully
and in a measured way.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Ibson appears on p. 67.]
Mr. Michaud. Thank you very much, Mr. Ibson.
And I want to thank the other three panelists as well for
your testimony on all the bills we have before us today.
Any questions, Mr. Brown?
Mr. Brown of South Carolina. No questions.
Mr. Michaud. Thank you.
As we move forward looking at these bills, later we will
probably submit additional questions in writing to each of you.
So, if you could respond in a timely manner, I would appreciate
it.
If there are no questions, I would like to thank the second
panel.
I would like to now recognize Congresswoman Pingree who has
H.R. 6220. She is my colleague from Maine. I appreciate her
willingness to come today and her advocacy on veterans' issues.
She definitely has been a true advocate for veterans.
I know you have been tied up in the Rules Committee, so I
want to thank you for taking the time to come over to present
testimony to the Subcommittee on H.R. 6220.
STATEMENT OF HON. CHELLIE PINGREE, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF MAINE
Ms. Pingree. Thank you very much, Chairman Michaud.
I apologize for being late this morning, but it is a busy
morning. I guess we are trying to cram everything into as
little time as possible.
And I want to thank you on your great work on behalf of
veterans in the State of Maine. It is a pleasure to serve as
your junior member in the State of Maine.
Chairman Michaud and Ranking Member Brown, thank you for
having me here today. I am happy to be here in front of the
Veterans' Affairs Subcommittee on Health to talk about the bill
I recently introduced, the ``Inform All Veterans Act,'' H.R.
6220.
This bill will ensure that veterans are given complete
information about service-connected benefits at all VA medical
centers. All too often a veteran will visit a VA medical
center, ask how to file a claim for service-connection, and are
either not given correct information on how to pursue their
claim or, worse, they leave the medical center thinking their
claim is underway when it is not.
This is a symptom of the Veterans Health Administration,
Veterans Benefits Administration not communicating well with
each other, operating effectively, or operating in silos.
Interagency communication is a necessity, especially when we
are talking about basic earned services.
Under this bill, the VHA would be required to ask during
the check-in process if a veteran would like information about
the disability claims process. If the answer is yes, then
straightforward, easy to understand literature is shared, which
will outline how to contact VBA to start the disability claims
process.
I believe Congress has a responsibility to take care of our
veterans and I know you all do as well. We cannot do that if we
do not inform them about health care and compensation their
service has earned them.
This common-sense approach will help veterans avoid the
bureaucratic red tape that often prohibits many veterans from
even filing a claim.
Again, thank you, Chairman Michaud and Ranking Member
Brown, for allowing me to be here today and for all both of you
do on behalf of our Nation's veterans. I am happy to answer any
questions that you have about this bill.
[The prepared statement of Congresswoman Pingree appears on
p. 71.]
Mr. Michaud. Thank you very much, Ms. Pingree, for bringing
forth the legislation.
Mr. Brown, do you have any questions?
Mr. Brown of South Carolina. I appreciate very much you
coming. Certainly it has been a pleasure to serve with your
Ranking Member from the great State of Maine.
Ms. Pingree. I will bring that news back home. Thank you
very much.
Mr. Michaud. Thank you very much.
I know Mr. Filner is on his way, but why don't we go with
panel three who is Dr. Bob Jesse, from VHA. He is accompanied
by Walter Hall, who is the Assistant General Counsel.
STATEMENT OF ROBERT L. JESSE, M.D., PH.D., PRINCIPAL DEPUTY
UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY WALTER A.
HALL, ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL,
U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Jesse. Well, good morning, Mr. Chairman and Members of
the Subcommittee. Thank you for inviting me here today to
present the Administration's views on several bills that would
affect the VA's programs of benefits and services.
Joining me today is Mr. Walter Hall, the Assistant General
Counsel.
Before I begin my remarks, I would like to thank Ranking
Member Brown for his service on the Committee and in Congress
as he retires at the end of this term. America's veterans and
VA have benefitted from your efforts. Thank you.
Turning to the legislation under consideration, VA agrees
with the intent of many of the items on today's docket and
looks forward to working together to understand how we can best
support and improve care for veterans.
First, H.R. 3843, the ``Transparency for America's Heroes
Act,'' would dramatically limit the scope of confidentiality of
VA benefits in assessing the quality of its programs. While VA
strongly supports transparency in its programs and has done
more to enable veterans to make informed decisions with regard
to patient care than almost any other health care system in the
country, we do oppose this legislation.
Confidentiality of records that contain discussion of
quality of health care, even if they do not identify an
individual, is instrumental to ensuring that employees are
willing to be forthcoming about quality issues that arise at
their facilities.
Current law protects a limited category of records,
specifically quality assurance records. In order to qualify for
these protections, these records must meet the criteria
outlined in VA's implementing regulations.
VA welcomes the opportunity to meet with the Committee to
discuss current protections in the law as well as additional
approaches to increasing the transparency in VA's quality
assurance programs.
Similarly, VA agrees with the intent of H.R. 5428, the
Injured and Amputee Veterans' Bill of Rights, and we recognize
the unique needs of injured and amputee veterans. We understand
that injured and amputee veterans have clinical needs that are
distinct from those of other patients, but we cannot support
rights that would limit VA's ability to monitor and control
quality of care and provider performance.
What we cannot provide to our own clinics in prosthetics
and orthotic services, we readily purchase through contractual
arrangements with more than 600 vendors and providers who are
approved by the Department.
VA also supports the intent of H.R. 5516, the ``Access to
Appropriate Immunizations for Veterans Act of 2010,'' and H.R.
5996, which would support the prevention, diagnosis, treatment,
and management of chronic obstructive pulmonary disease.
VA is already doing a great deal on each of these areas to
address the goals of this legislation. For example, our medical
benefits package offers veterans immunizations against
infectious diseases. And VA has long maintained smoking
cessation is a major focus for health promotion and disease
prevention.
The delivery of preventive care, which includes
vaccinations and tobacco intervention has been well established
in VA's performance measurement system for over 10 years.
VA strongly supports a draft bill under consideration that
reflects the Secretary's proposed legislation and we deeply
appreciate the Committee's consideration of these initiatives.
This bill will improve VA's ability to serve veterans and
strengthen VA's recruitment and retention efforts in several
important ways.
We deeply value the contributions of our employees and
enjoy a collaborative and positive working relationship with
the unions across the country. We hold retention of employees
as a critically important goal and encourage the management
teams of VA facilities to offer professional development
opportunities and to encourage personal growth.
However, VA does not support H.R. 5543, a bill affecting
collective bargaining regarding compensation other than rates
of basic pay. VA has testified previously about other proposals
that were very similar and VA believes that this bill suffers
in the same ways as the earlier measures did.
H.R. 5543 would subject many discretionary aspects of the
title 38 compensation to collective bargaining. H.R. 5543 would
result in unprecedented changes that would be disruptive to the
VA health care system. It would permit unions to bargain over,
grieve, and arbitrate a subject--employee compensation--that is
generally exempted from collective bargaining.
This bill would allow independent, third-party arbitrators
and other non-VA, nonclinical, labor third parties who lack
clinical training and expertise to make compensation
determinations.
Over the past year, VA has worked closely with all of our
union partners to address concerns they have raised regarding
the subjects that are excluded from collective bargaining by
law.
All these union leaders recently met with Secretary
Shinseki to discuss recommendations of a joint union/VA work
group. The Secretary has accepted several of the work group's
recommendations and will make a final decision on all of them
shortly.
We would be glad to brief the Committee on our continuing
efforts in this area.
Mr. Chairman, this concludes my prepared statement. I would
be pleased to answer any questions.
[The prepared statement of Dr. Jesse appears on p. 71.]
Mr. Michaud. Thank you very much, Doctor.
In reference to H.R. 3843, in light of the recent safety
lapse in certain medical centers involving dirty reusable
medical equipment, I do not know why the VA would oppose this
legislation.
What steps has the VA taken to bring transparency to
patient safety?
Dr. Jesse. Well, I think the transparency comes at the end
of a process in many respects so that when issues like the
Reusable Medical Equipment issues arise, it does take some
amount of time to work through the process of understanding
what happened and who is responsible. And we have several
mechanisms with which we can do that.
Initially you can use the quality assurance protections to
go and do interviews, but, in fact, what we have done in almost
all these cases is to use administrative investigation boards,
which actually are public. This Committee gets copies of their
reports.
Mr. Michaud. When you look at quality assurance, it is my
understanding that the OIG has cited VA several times for not
complying with their recommendations.
I guess my only concern is, what is it going to take to get
VA to do what it should be doing?
Dr. Jesse. My understanding of this is that every OIG
recommendation be closed out at some point. So they cannot be
ignored or, you know, just be swept aside.
And so there actually is a process for us to go through and
to acknowledge each of the recommendations and come to an
agreement with the OIG that, in fact, we have met what they
requested.
I will admit that sometimes that process is a lot longer
than both the OIG or VA would like, but often the issues are
very complex.
Mr. Michaud. Yes. I have seen the OIG reports. In some
cases, after 10 years, VA has still not acted on these
recommendations.
I guess the concern that I have is, veterans lives are at
stake, so when is management going to wake up and deal with
these serious problems? I am just concerned about VA not moving
forward to address some of these serious concerns.
Dr. Jesse. Yes sir, and as are we. And we actually have, I
think, new processes at least at the administrative level to
ensure that we are tracking and from our perspective, we have
been ensuring that at facility levels, Veterans Integrated
Service Network levels, attention is being paid to these
issues.
Sometimes it requires national solutions including, for
instance, implementation of IT fixes that will take
considerably more time. In the interim, we can often put in
stop-gap measures that do not fully meet what the OIG's
require, but at least we are moving in the correct direction.
Mr. Michaud. On the collective bargaining issue, I have
heard stories of VA nurses who have no recourse if they are
denied overtime pay, which negatively affects retention.
Does VA have administrative solutions to help address these
problems? If not through the bill that is before us, are there
other solutions, and how quickly would these solutions be
available?
Dr. Jesse. I will defer to Mr. Hall for that one.
Mr. Hall. Yes, sir. As Dr. Jesse said in his testimony, the
Secretary recently met with all the union leaders to discuss
the results, the outcomes of a work group that has been
together for the last 9 months looking at all the section 7422
issues and coming up with recommendations as to how best
address their concerns with the way section 7422 has been
interpreted by the Department and to develop methods to make
the outcomes more coherent, more understandable to them, and
more reasonable as far as how they are interpreted to provide
them some mechanism or some recourse when situations, which are
not bargainable present issues, for example, the pay issues
that technically cannot be addressed under the law for good
reasons in certain situations, but they have overlap into
situations where it does not seem to make much sense.
We are going to continue to work with them and develop
mechanisms and procedures and policies and provide training to
both management and the unions on how those mechanisms will
apply. And that is ongoing. It is going on now.
Mr. Michaud. Mr. Brown.
Mr. Brown of South Carolina. Thank you very much. I
appreciate both of you coming today and I thank you for helping
take care of all of our veterans coming back from these and
previous wars.
In previous testimony, we heard that you have somewhere
around 300,000 employees and you treat over six million
veterans a year. It is a massive undertaking.
But we certainly do not want to make light of any issues
that might come up in our Districts. We recognize that there is
a massive task and a lot of effort going forward to serve our
veterans. We recognize that you have an intense commitment to
veterans just like we do and we are grateful for that.
My question is about immunization. I know that that is a
big thing trying to get people to be vaccinated. The flu shots
might be available at this time.
How do you actually go about trying to reach your base
population?
Dr. Jesse. Well, for influenza immunization, whether it is
the seasonal or H1N1, this is an event that has to occur
annually. The vaccines change, although, in fact, I think H1N1
will be incorporated into the seasonal vaccine this year, which
is different than say Pneumovax which only has to be done
essentially once.
Mr. Brown of South Carolina. Or tetanus or some other.
Dr. Jesse. Tetanus is every 10 years. So we will start with
the annuals. When those vaccines become available, first of
all, that is a very strict performance measure. We look at the
rates of immunization with expectations that everyone including
the staff are immunized. And facilities have taken many
different approaches to this. In the end, it is not the
approach but the outcome that is the most important.
But just for example, to make it easy, rather than having
to have a clinic appointment to get your vaccine, they will
often just set up vaccination clinics in the main lobby. So
where I am from, even the staff, would just walk down the lobby
and go in and get my vaccine.
So we do that in a very concentrated period to try and get
as many veterans as possible, but every patient presenting for
clinic will be checked on whether they had the vaccine or not.
And the nurses are then essentially empowered to give the
vaccine without requiring a physician.
My personal anecdote to this is in one of my clinics a year
or so ago, all four of the patients, the first four patients I
had seen had been instructed by the nurse to ask me if I had
gotten my vaccine because they were looking out for me. So it
is----
Mr. Brown of South Carolina. Let me interrupt you if I
might. I know that in the general population, the drugstores
advertise, ``come here and get your vaccination.'' If you are a
Medicare patient, all you need to do is sign some kind of
document.
Do we have any kind of a contract arrangement with these
folks so it would make it a little easier for the veterans? I
represent the Charleston area. We do have some clinics out in
the north Charleston region, but the main hospital is downtown.
And somebody, say, living in St. Stephen, or some rural parts
of Berkeley County, the commute certainly might be a couple
hours of time.
Do you have working arrangements with any of the local
providers?
Dr. Jesse. We have arrangements through our broad outreach
networks, but obviously you cannot do a flu vaccine through
telehealth. So that is one area where we actually have to have
personal contact.
I am not aware that we do, but I will certainly take that
back as a notion and see if we can move that forward. I do not
know if there is any legal reason we can or cannot do it, but
certainly we want to get them all vaccinated. And understanding
there is a relatively narrow window of time when we have to get
the seasonal flu shot in, it would make sense.
Mr. Brown of South Carolina. I think the general population
has become very concerned about getting the flu. I think there
is a lot of national media that draws them to receive that
vaccination.
I was just thinking that we could make it a little bit more
convenient for them to be able to get it. I think that would be
so important. I appreciate your interest on that.
Thank you.
[The VA subsequently provided the following information:]
Question 1: Does VA currently have any arrangements with private
health care providers or retailers to provide influenza vaccinations to
its enrollees?
Response: No. All vaccinations are administered by VA staff or
through arrangements with VA affiliates. Veterans Health Administration
(VHA) facilities offer seasonal influenza vaccine to all enrolled
Veterans who meet criteria for vaccination at no cost. Veterans may
choose to receive their flu vaccine through retail establishments or
through other places within their communities at their own or third
party payers' expense. Local Public Health Departments often have flu
vaccination programs that offer vaccine to anyone in the community
including Veterans and their families, sometimes at no cost or on
sliding scales.
Question 2: Furthermore, does VA have the authority to enter
into such arrangements?
Response: Yes, VA is able to contract for these services under
existing Federal Acquisition Regulations.
Enrolled Veterans who require these services as part of a
continuation of care, will be eligible for payment for these services,
if VA facilities are unavailable, or geographically inaccessible under
the Fee authorities. This requires a pre-authorization from VA. We do
not have the authority to authorize services provided without pre-
authorization.
There is also no authority to pay for these services where VA
facilities are available or when Veterans are not actively receiving
health care services from VA. These limitations may impact the number
of Veterans who could be covered either under the Fee authorities or
via a contract.
Although VA does have the authority to preauthorize this service
for eligible Veterans on a Fee basis, the procedural requirements prior
to receiving such preauthorization are likely to deter most Veterans
from utilizing such non-VA medical care. In addition, many Veterans
would be required to receive the service at a VA facility due to the
geographic inaccessibility criteria and the fact that Veterans
receiving care from VA can readily be immunized during their regular
visits to VA. If VA were to pursue such a strategy, a national contract
is the most appropriate vehicle for providing these services.
The challenge facing VHA (as well as in the private sector) is
the resistance among some individuals to recognize the benefit of
receiving flu vaccine. Reasons for not receiving flu vaccine include
fear of needles, concerns that the vaccine isn't safe, or that the
vaccine will actually make the recipient sick with flu, and some simply
don't want foreign drugs in their bodies.
We continue to educate the VA community about the safety and
effectiveness of influenza vaccine. Availability of influenza vaccine
is not anticipated to be an issue during the 2010-11 flu season. For
the upcoming flu season, VA has ordered a total of 3.3 million doses of
flu vaccine compared to 2.6 million doses ordered for the 2009-2010 flu
season.
In summary, public health experts recognize influenza
vaccination as a powerful tool to prevent the spread of influenza.
Currently flu vaccine is available through all VA medical facilities at
no cost to eligible Veterans and staff. VA believes that our community
approach to influenza vaccination ultimately has a positive impact on
the health of our Veteran population, VA staff, and others within our
facilities.
Question 3: Would such arrangements be feasible?
Response: It may be feasible to award a national contract for
this purpose but it would not be cost-effective, nor is there evidence
of a need for this service. VA vaccinates large numbers of Veterans
through its medical centers and Community Based Outpatient Clinics
(CBOCs) and Veterans also have access to low cost or no cost vaccine
through their local health departments. VA procures its vaccines at
extremely competitive prices and offers them to Veterans at all VA
Medical Centers and CBOCs; therefore accessibility is not an issue. The
current VA cost for each dose of influenza vaccine is $9.48 when
administered by VA personnel. Current costs in community pharmacies
average $30 per vaccination. If VA used a reimbursement model, it would
cost an additional $7 to process a patient's claim, for a cost
differential of $27.52 per patient, If 25 percent of VA's patients used
this service, it would cost an additional $77 million dollars per year.
New Federal recommendations from the Centers for Disease Control
and Prevention's (CDC) Advisory Committee on Immunization Practices
(ACIP) are that all eligible persons age 6 months and older should
receive seasonal influenza vaccination (CDC MMWR, August 6, 2010 (59)).
To reduce the threat of influenza-related illnesses and deaths within
the U.S. and individual communities, VHA continues to have an
aggressive campaign to promote influenza vaccination. Of Veterans
enrolled in VA, flu vaccination rates for those Veterans aged 50 or
older have continually been higher than the national average. During
the 2008/2009 influenza season, VHA vaccinated 69 percent of those age
50 to 64 compared to the national rate of 40 percent. For those 65 and
older, the VHA vaccination rate was 83 percent compared to the national
rate of 66 percent. That same year, VHA vaccinated 64 percent of health
care workers. (VHA Office of Quality and Performance; Occupational
Health, Safety and Prevention Strategic Health Care Group; and CDC MMWR
August 6, 2010 (59); RR8, page 30).
In 2009 VHA's Public Health Strategic Health Care Group (PHSHG)
conducted national Veteran patient focus groups on influenza. From
these focus groups, Veterans indicated a robust awareness of influenza
vaccination campaigns and accessibility to flu vaccine. This awareness
can be linked to facilities' implementation of best practices for flu
vaccination and strong public health messaging to target Veteran
populations. VHA has made flu vaccination convenient to Veterans by
providing flexible hours for flu vaccination clinics, ``drive-thru''
flu vaccination programs and walk-in vaccine clinics not requiring an
appointment.
Mr. Michaud. Well, once again, I would like to thank you,
Dr. Jesse and Mr. Hall, for coming today. And there probably
will be more questions submitted for the record as we move
forward with the bills that were included today. And I want to
thank you for your testimony.
And, likewise, I would like to thank the two previous
panels as well.
If there are no other questions, I would adjourn the
hearing. Thank you all for coming. I appreciate it.
Dr. Jesse. Thank you, Mr. Chairman.
[Whereupon, at 11:05 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
I would like to thank everyone for coming today.
Today's legislative hearing is an opportunity for Members of
Congress, veterans, the VA and other interested parties to provide
their views on and discuss introduced legislation within the
Subcommittee's jurisdiction in a clear and orderly process. This is an
important part of the legislative process that will encourage frank
discussions and new ideas.
We have twelve bills before us today which address a number of
important issues for our veterans and provide the staff of the
Department of Veterans Affairs with the necessary tools to provide the
best care for our veterans. First, we have a bill that would bring more
transparency to the VA's medical quality assurance program, through
which the Department aims to provide a systematic review of their
health care activities. Specifically, VA would be required to make
medical quality assurance records available to the public so that
veterans and the general public will have access to important
information about the care that is provided at VA health care
facilities. Next, we have legislation providing for a bill of rights
for our injured and amputee veterans given the large numbers of our
servicemembers who are returning home with injuries to or loss of their
limbs. We also have several bills that would improve the health care
that our veterans receive such as a pilot program for chronic
obstructive pulmonary disease; provision of immunizations to address
vaccine-preventable diseases; adult medical foster homes for veterans;
improved TBI care; help for homeless veterans with special needs; and
the extension of health care eligibility for veterans who served in the
Qarmat Ali region of Iraq. Finally, we have bills before us today that
would help the staff of the Department of Veterans Affairs provide
better care for our veterans. This includes a bill to better train
Federal Recovery Coordinators; a bill to train VA health care
facilities staff to provide important information about VBA benefits;
and a bill to authorize collective bargaining over certain compensation
related labor-management disputes.
I look forward to hearing the views of our witnesses on the bills
before us today.
Prepared Statement of Hon. Henry E. Brown, Jr., Ranking Republican
Member, Subcommittee on Health
Thank you, Mr. Chairman, and good morning.
We have a number of important veterans' bills before us today and I
look forward to hearing from several of my colleagues, our friends from
various veterans' service organizations, and representatives from the
Department of Veterans Affairs (VA) to address their potential merits
and/or unintended consequences.
Our Ranking Member, Steve Buyer, is the sponsor of two of the bills
on the agenda--H.R. 5641, the Heroes at Home Act and H.R. 6127, the
Extension of Health Care Eligibility for Veterans who Served at Qarmat
(Car-mot) Ali Act. Unfortunately, Steve is unable to be here this
morning and I ask unanimous consent that his statement be included in
the record.
In his absence, I would like to take a few minutes to explain these
important legislative initiatives.
H.R. 5641, the Heroes at Home Act, would increase the long-term
care options for veterans by allowing VA to enter into a contract with
a certified adult foster home to pay for the long-term care of veterans
already eligible for VA-paid nursing home care.
Medical foster homes are non-institutional settings that provide a
personalized approach to long-term care. Veterans who choose medical
foster home care reside in the home of their chosen foster home
caregiver who in turn provides that veteran with around-the-clock care
and company.
Each prospective caregiver is required to pass a VA screening,
Federal background check, and home inspection and must agree to undergo
annual caregiver training and regular announced and unannounced home
visits by VA's adult foster home coordinators and professionals from
VA's Home Care Team. In addition, each veteran must agree to enroll in
VA's Home Health Services to provide added support.
As the need for long-term care grows, it will become increasingly
important to provide our honored veterans with options that allow them
to make the care choice that best fits their needs. VA has been
assisting veterans in obtaining medical foster home care since 2002 and
many of the veterans who benefitted from this unique service have
service-connected disability ratings that entitle them to VA-paid long-
term care.
H.R. 5641 would authorize VA to contract with medical foster homes
to cover the costs of care for those veterans already eligible for VA
provided nursing home care.
H.R. 6127, the Extension of Health Care Eligibility for Veterans
who Served at Qarmat Ali Act, is legislation that is particularly dear
to the veterans in my home State. It would extend the VA health care
enrollment period by 5 years for veterans who served at Qarmat (Car-
mot) Ali, Iraq and were notified of possible exposure to a toxic
chemical known as sodium dichromate.
Not long after the conflict in Iraq began, Army National Guard
units from South Carolina--my home State--as well as units from
Indiana, Oregon, West Virginia, and individual augmentees from 17 other
States across the Nation were called to serve at the Qarmat (Car-mot)
Ali water treatment facility.
Unfortunately, these veterans recently received notification by VA
that during their service they may have been exposed to a toxic
chemical which could result in a number of serious respiratory issues,
skin lesions, burns, and other ear, nose, throat, and skin disorders.
While these veterans were eligible to enroll in VA health care for
5 years after separation from service, those who reentered civilian
life following their 2003 deployment would have been required to enroll
by 2008--a full 2 years before initial notification of the potential
exposure and subsequent health risk.
It is essential that these veterans have immediate access to VA's
high quality health care system in order to receive preventative care
and services to improve health outcomes and quality of life.
Further, my good friend and colleague from Florida, Mr. Stearns,
also has two bills before us today concerning important preventative
care methods to improve the health and well-being of American veterans.
I thank him for his leadership on this Subcommittee and anticipate
hearing his comments and further discussion of these initiatives.
I want to thank my many colleagues who have sponsored the bills on
our agenda this morning and all of the witnesses who have taken the
time to participate today. I yield back the balance of my time.
Prepared Statement of Hon. Joe Sestak, a Representative
in Congress from the State of Pennsylvania
Chairman Michaud, Ranking Member Brown, and distinguished Members
of the Subcommittee, to begin, I would like to acknowledge the very
hard work of this Committee and our colleagues of both parties in the
110th and 111th Congresses who have provided the Department of Veterans
Affairs unprecedented ways and means to care for our Veterans and their
families. Though the VA had been severely underfunded for too long,
congressional efforts since 2007 now afford our Veterans of three
generations access to the best care ever afforded those who go into
harm's way on our behalf.
However, with those additional resources the VA has the
responsibility to Congress, the American public, and most especially
our Veterans to see that it operates to the highest possible standards
of care. In support of that goal it is an honor to appear before you
today to discuss my bill, H.R. 3843, the Transparency for America's
Heroes Act. This legislation directs the Secretary of Veterans Affairs
to make available on the Department of Veterans Affairs (VA) Web site
redacted records and documents--but not personal identifying
information--created by the VA as part of a medical quality-assurance
program. It would also require the Secretary to ensure that any such
records created during the 2-year period before the enactment of this
Act are also made available in the same manner.
I authored this bill because I have grown increasingly troubled by
reports that give rise to concern of a lingering lack of consistent
care and accountability within the VA. I must be very clear that I have
the highest regard for the thousands of dedicated professionals of the
VA--many of whom have spent their entire careers in service to our
Veterans. However, for the past 24 months there have been too many
revelations of substandard care for Veterans. Congress and the American
public have been belatedly informed of prostate cancer victims who
received insufficient treatment, the possible exposure of more than
1,800 Veterans to serious diseases, including Hepatitis and HIV, while
undergoing routine dental procedures, deficiencies in thoracic care and
last September we learned--only after a Freedom of Information Act
request was filed--that some elderly Veterans were being subjected to
substandard, potentially neglectful care in the Philadelphia Community
Living Center at the Philadelphia VA Medical Center.
The nursing home, according to the Long Term Care Institute's
report, ``failed to provide a sanitary and safe environment for their
residents . . . (and) there was a significant failure to promote and
protect their residents' rights to autonomy and to be treated with
respect and dignity.'' Some of the examples cited shock the conscience.
For example, one patient with an open foot wound was left unattended
for so long that maggots were found falling out of the wound.
Additionally, the floor was found to be covered with dried blood and
feeding tubes. Another diabetic patient complained of chronic failure
on the staff's part to administer his insulin shots on schedule.
After hearing these reports, it came to my attention that there
were two other recent inspections, one by the Inspector General of the
VA and one by the Joint Commission on Accreditation of Health Care
Organizations, both of which concluded that the facility met quality
standards based on the metrics used. However, it took this separate,
external investigation by the Long Term Care Institute--using a
different set of inspection criteria--to identify the serious problems
at the facility under its old leadership.
What concerns me is the two VA-conducted reviews failed to discover
these deficiencies, and that a Freedom of Information Act (FOIA)
request was required to bring this latest revelation of poor care to
light. In fact, the report should not have even been released after the
FOIA petition was filed under current law because the third-party
inspection was conducted under the VA's quality-assurance authority. In
this case, the report was inadvertently leaked by a VA official who did
not follow the normal protocol. This leads me to believe that there may
be numerous other cases of deficient care which will never see the
light of day because the inspections in question, like the one
conducted by the Long Term Care Institute, were conducted under the VA
quality-assurance authority.
Under current law, records and documents created by the VA as part
of a designated quality-assurance program are confidential and
privileged, and as a result cannot be disclosed to any person or entity
except when specifically authorized by statute. The stated rationale
for this practice is, according to the VA, to ``create a proactive
culture of quality improvement allowing for early identification and
resolution of quality issues.'' The VA also states that ``elimination
of protected document status for quality management activity documents
would possibly have a chilling effect on the level of objectivity
reflected within these improvement activities.''
As a former Admiral who led men and women into battle, I disagree
with this assessment. I am convinced there is a need for a cultural and
procedural sea-change in the way the VA medical system operates--and
that the best way to ensure quality care in the VA is through stringent
oversight. This entails vigilance on the part of both Congress and the
general public. If there are any other instances of inadequate VA care,
they should be revealed immediately along with confirmation that
appropriate corrective actions have been taken. My bill would
accomplish this, without releasing sensitive information which could be
used to identify patients and health care professionals.
If we fail to ensure this kind of accountability, the goals of the
current administration and the hard work of the 110th and 111th
Congress, to finally provide our Veterans the care and resources they
have been denied for so long, will be compromised.
At issue is the very credibility of one of our Nation's most
important and visible health care providers and that of our government
itself. I am reminded of the long-term consequences of government's
failure for over two decades--both in the Executive Branch and
Congress--to treat Veterans and their families in a responsible and
accountable way. As our troops continue to return from Iraq and
Afghanistan, we can, and must, do better.
Thank you, Mr. Chairman.
Prepared Statement of Hon. Timothy J. Walz, a Representative
in Congress from the State of Minnesota
Chairman Michaud, Ranking Member Brown, thank you for holding this
legislative hearing.
I'm here today to talk about H.R. 6123, the Veterans' Traumatic
Brain Injury Rehabilitative Services Improvements Act.
In short, this bi-partisan bill does two things:
First, it would clarify that VA rehab services are not
limited to those provided by a health professional but would cover
other VA services or supports that contribute to maximizing
independence and quality of life.
Second, it would clarify that current provisions for TBI
care are to be read more broadly, not simply to improve lost
functioning but to prevent losing the gains that have been achieved.
Because of ambiguities in current law, TBI treatment at the VA
narrowly focuses TBI care on physical restoration only.
When a veteran suffering from TBI comes to the VA for treatment,
they need to be presented with a comprehensive approach to
rehabilitation that will allow them to recover function, achieve
independence and fully integrate back into their communities.
This bill ensures we provide comprehensive care instead of just
physical rehabilitation, which is what is presently available to our
injured veterans, without creating any new programs within the VA. It
simply uses the programs that are already present at the VA to build a
more complete rehab program.
Our wounded warriors deserve the best care and support we can give
them, and this bill ensures that the VA uses all the tools at its
disposal to care for those heroes that have ``borne the battle.''
That's why this bill has the full support of the Wounded Warrior
Project, the Disabled American Veterans, Blinded Veterans Association,
and the Enlisted Association of the National Guard of the United
States.
I'd like to take this opportunity to thank Ralph Ibson and
Christine Hill of the Wounded Warrior Project for their work on this
bill. Without their dedication and the dedication of countless
veterans' advocates around the country, we wouldn't be where we are
today.
I'd also like to thank Representatives Bilirakis, Miller, and
Pascrell for your support and leadership on this issue.
Thank you again, and I yield the remainder of my time.
Prepared Statement of Hon. John Barrow, a Representative
in Congress from the State of Georgia
Thank you for the chance to testify before you today.
The most consistent and frustrating feedback I get from the people
I represent is from veterans having problems with the VA. I suspect
that it's the same for you in your districts. The initial disability
determination takes too long. Communication with the VA can be weak.
Once they're in, the system can be hard to navigate. Facilities can be
remote.
While I can see how major programs in the VA need a major overhaul,
I realize that's not likely to happen any time soon. For better or
worse, the system works well enough for enough folks that the demand
for a major overhaul will be a long time coming. But I don't think any
of us really believes that the current system works as well as it could
or should.
The problem with today's VA is its complexity. The medical needs of
returning veterans are more complex than they've ever been. And we've
designed very intricate treatments and benefits and services to meet
those needs. Unfortunately, it's become so complex that you need
specialized training to wade through the bureaucracy of it all. My
purpose in coming here today is to introduce you to a bill I've
introduced which will give veterans the tools to navigate the maze.
We all agree that every wounded warrior should have an
individualized plan for recovery, coordinated by a professional, who is
trained to successfully navigate the VA system of services and
benefits.
The Dole/Shalala Commission calls these professionals Federal
Recovery Coordinators, and made them a major component of their
comprehensive recommendations to improve the VA.
A Federal Recovery Coordinator Program has been authorized by
Congress since 2008, but today there are only 20 Federal Recovery
Coordinators spread across the entire country, coordinating the care of
only around 500 wounded veterans. My bill will increase the number of
Federal Recovery Coordinators, formalize their training, and establish
guidelines and best practices for successful care coordination.
As envisioned and designed by the Dole/Shalala Commission, a
Federal Recovery Coordinator would be a nurse or social worker with
master's degree, who has excellent communication, leadership, and
resource navigation skills. Today's wounded warrior might have a unique
combination of traumatic physical injury, PTSD, substance abuse, or
marital problems, trouble finding a job, or trouble reintegrating back
into the community. A Recovery Coordinator acts as an ``air traffic
controller'' to guide veterans to the proper treatment and benefit
options.
I've submitted for the record personal testimonies from a few
returnees I represent, whose Federal Recovery Coordinators have been a
godsend. I commend them to you.
Despite its obvious benefits and successes, the program is in its
infancy and needs some help in order to be all that it can be. My bill
will help in these specific ways:
First and foremost, the bill authorizes formal training for 45 new
FRCS in the next 3 years. It's obvious that we have too many veterans
who desperately need these services, but we don't have nearly enough
coordinators to meet the demand.
Second, my bill authorizes the development of specialized case
management software to complement the work of trained care
coordinators.
Third, my bill authorizes the development of uniform best practices
for recovery coordination. The coordinators out there today are blazing
valuable new trails, but they work out of sight of each other. We need
to develop and promote what works best, so that all of our wounded
warriors will have the best chance of getting what they need.
Our goal here has to be helping the veterans who need it, and to do
it as fast and effectively as we possibly can. I've seen the Federal
Recovery Coordinator Program in action, and I'm convinced that this
really is the best way forward. I appreciate the opportunity to testify
before you, I appreciate the Committee's willingness to take a deeper
look at this legislation, and I'll be happy to answer any questions.
__________
ADDITIONAL MATERIALS
September 27, 2010
Dear Members of the Committee:
My husband is SGT (ret.) Darryl Wallace, an OEF veteran who was
wounded June 9th, 2007 when an IED went off under the seat of his
Humvee. He lost both legs in the explosion, and was sent to Walter Reed
Army Medical Center, and eventually to the Active Duty Rehab Unit at
the Charlie Norwood VA Medical Center in Augusta, Georgia.
I am writing to you to let you know the most helpful thing to us in
my husband's recovery has been the Federal Recovery Coordinator we have
been assigned, Ms. Erin Jolly. She helps when the VA doesn't want to
help or they are giving you the runaround. We can call our FRC and Erin
can get stuff done.
For example, when Darryl was overdosing all the time and he was
being put on the psych ward, he just needed help. Our FRC was able to
get in touch with a treatment center, get all the information together,
and Erin was the one who got everyone in the whole process to get it
done so Darryl could go into treatment. He is doing very well now
because of it.
If I ever have any questions about anything, I call our FRC and she
can tell me the information or can find out if she doesn't know.
FRCs do not give you the runaround.
Once, my husband's VA physician told us she couldn't see him for a
week, and our FRC got him in to see the doctor the same day. If it
wouldn't have been for our FRC a lot of stuff would have been
overlooked: pain management, his well being, and his welfare.
Every wounded warrior needs a Federal Recovery Coordinator because
if they don't like what a doctor or case worker is doing, the FRC will
get it done. It's a big bureaucracy, a lot of stuff gets swept under
the rug, and not dealt with, but the FRC makes sure it all gets
handled.
Our FRC prioritizes what we need, and gets us where we need to go,
when we need to go. I have never had a problem that the FRC has not
been able to solve. She answers calls after hours and when we need her.
When I need her, she's there for me and my husband. She works from home
on her laptop to help us.
I love my FRC and I've told them that when they've called to do
surveys.
Every soldier that comes back needs one. Doctors are excellent but
FRCs play a big part in the recovery too--had it not been for our FRC a
lot of stuff would not have been dealt with.
Tiffany Wallace
Harlem, GA
__________
September 25, 2010
Dear Congressman Barrow:
I believe that the Federal Recovery Coordinator program is a great
program, especially for veterans like myself that do not know how to
navigate through the VA system that well.
I had received inaccurate information about and was not told about
VA services I was entitled to. For instance, I was told I could not get
a benefit while I was an inpatient in the PTSD program at the VA until
after I completed the program. However, my Federal Recovery Coordinator
told me that I could receive benefits while attending the program. This
information was very helpful to me because I was able to get the help
that I needed without worrying about how my family was going to
maintain while I received treatment for PTSD.
My Federal Recovery Coordinator also helped me complete paperwork
to start my benefits. The Federal Recovery Coordinator also keeps me
informed on any updates in VA benefits and services the VA has to
offer. I greatly appreciate all the help of my Federal Recovery
Coordinator has provided me with, without her I would have been lost.
Karl Mitchell
OIF Veteran
Purple Heart recipient
Prepared Statement of Hon. Cliff Stearns, a Representative
in Congress from the State of Florida
Thank you Chairman Michaud and Ranking Member Brown.
I have two bills before the Committee today. H.R. 5516--Access to
Appropriate Immunizations for Veterans and H.R. 5996--a bill to help
veterans with chronic obstructive pulmonary disease (COPD).
H.R. 5996 is a bipartisan bill that I'm proud to have introduced as
the co-founder of the COPD caucus. COPD is the 4th leading cause of
death in the U.S., and is predicated to be the 3rd leading cause of
death by 2020, beating both diabetes and stroke. 126,000 Americans die
each year from this disease--that's about 1 death every 4 minutes.
My bill would increase the VA's ability to diagnose, treat and
manage COPD. COPD is a chronic condition that does not have a cure.
Early detection and treatment is important to slow or arrest the
progression of the disease. It is estimated that more than 12 million
people are diagnosed with COPD and yet this number is believed to be
too small as COPD is often under-diagnosed. The Centers for Disease
Control and Prevention (CDC) estimates that over 24 million Americans
have symptoms of COPD.
Despite all this, there is a lack of COPD awareness by patients and
doctors.
Because this is a progressive disease, early detection is
important.
Because there is no cure, early treatment is vital.
Because the COPD rate is three times higher in the veteran
population than the civilian population, how can the VA not be
providing this type of specialized care? COPD is the fourth most common
diagnosis amongst hospitalized veterans aged 65-74.
H.R. 5996 would have the VA develop treatment protocols and related
tools for the diagnosis, treatment and management of chronic
obstructive pulmonary disease. It would also have the VA establish a
pilot smoking cessation program targeted towards individuals who have
COPD. While there are many ways that someone can develop COPD, the most
common is from smoking. However, it should also be noted that COPD has
underlying genetic risk factors and healthy non-smokers can develop
COPD.
I think it's important to note that this is not giving VA any new
authority. VA already has the authority to do what I'm asking for, but
for whatever reason, they have not aggressively moved to develop these
treatment protocols for the 4th leading cause of death in the United
States. My bill would have the VA begin to develop these treatments for
our veterans.
H.R. 5996 has the support of the U.S. COPD Coalition, the COPD
Foundation, the American Thoracic Society, the American Association for
Respiratory Care, the Alpha-1 Foundation and the Alpha-1 Association.
I'd like to submit their letters of support for the record.
My other bill is the Access to Appropriate Immunizations for
Veterans, H.R. 5516. The VA already has the authority to provide
vaccines to veterans to immunize them against preventable diseases.
However, the VA has only established performance measures for two
vaccines. For these two vaccines against the flu and pneumonia, the
vaccination rate increased from about 27 percent to almost 80 percent
and hospitalization rates dropped in half.
My bill would extend all the Centers for Disease Control &
Prevention's recommended vaccines to the performance measures. It is
important to note that vaccines are not just for children. In fact,
just last week the NY Times ran an article on how important it is for
adults to receive vaccines and booster shots.
I'd like to read a part of this article:
``Adult immunizations are not just an important way to prevent
the spread of disease. Immunizations are also a phenomenally cost-
effective way to preserve health.
`` `When you compare the cost of getting sick with these
diseases to the cost of a vaccine, it's a modest investment,' said Dr.
Robert H. Hopkins, a professor of internal medicine and pediatrics at
the University of Arkansas for Medical Sciences.''
According to the CDC, each year approximately 70,000 adult
Americans die from vaccine-preventable diseases. Influenza alone is
responsible for over one million ambulatory care visits . . . 200,000
hospitalizations . . . and 30,000 deaths. Only 7 percent of Americans
over the age of 60 have received the vaccine to protect them from
shingles, a painful nerve infection. Just 11 percent of young women
have received the vaccine against HPV that cause 70 percent of all
cervical cancers.
Many of our veterans who are in the ``high-risk'' category of
contracting vaccine-preventable diseases--include those with HIV,
Hepatitis C and substance abuse disorder--are enrolled in the VA health
care system and could benefit from receiving vaccinations.
I want the VA to provide superior quality health care to our
veterans. Adding vaccination to the performance measure is a simple
common-sense idea that will increase the level of care available and
save money by stopping preventable diseases. The bill would also
require the VA to report back to Congress on their progress of
supporting vaccinations within the veteran population.
And I'd like to enter this NY Times article into the record and the
CDC's recommended vaccination schedule for adults.
__________
Alpha-1 Association
Miami, FL.
September 28, 2010
The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515
Dear Representative Stearns,
On behalf of the Alpha-1 Association's Board of Directors, I wish
to express our heartfelt appreciation for your leadership in Chronic
Obstructive Pulmonary Disease (COPD) in the veterans' community and to
express our support for the passage of H.R. 5996.
The Alpha-1 Association is a patient-focused and patient-driven
organization dedicated to identifying individuals affected by Alpha-1
and improving the quality of their lives through support, education,
advocacy and to encourage participation in research. As a 501(c) (3)
not-for-profit membership organization, the Association has been
providing services to Alphas and their families since 1991.
This bill affects our patient community. According to the National
Heart, Lung & Blood Institute, 3 percent of the 12 million people that
have been diagnosed with COPD in the United States have Alpha-1.
Alpha-1 is a genetic condition that may result in serious, chronic
lung and/or liver disease at various ages in life (children and
adults). It is often misdiagnosed as asthma or smoking-related Chronic
Obstructive Pulmonary Disease (COPD).
Individuals with Alpha-1 may develop emphysema even if they have
never smoked. Despite treatments, including protein replacement, adults
may require a lung transplant due to severe emphysema.
As the foremost provider of health care services to over 8 million
veterans, the Department of Veterans Affairs has a unique opportunity
to become a leader in the fight against Alpha-1 (Genetic COPD). H.R.
5996 will allow the VA to take a comprehensive approach in reducing the
burden of Alpha-1 through innovative prevention, education and
treatment strategies. It will also provide for the critically needed
research into best practices that will help to simultaneously reduce
costs and improve quality of life.
Our Association and the COPD community care deeply about the need
to address COPD in America's veteran population. The VA system has been
a leader in health systems research and H.R. 5996 will build on a
record of using innovative methods to improve the health of the
veterans it serves. We encourage your colleagues to join you in support
of H.R. 5996. Congress' actions will mark a great step towards
addressing the burden that COPD places on veterans, their families and
the health care delivery system.
We are happy to support your efforts in any way that will aid you
in obtaining passage of H.R. 5996.
Sincerely,
Marlene Erven
Executive Director
__________
American Association for Respiratory Care
Irving, TX.
August 15, 2010
The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515
Dear Representative Stearns:
The American Association for Respiratory Care (AARC) a 50,000
member professional association for respiratory therapists endorses and
fully supports H.R. 5996. This legislation will direct the Secretary of
Veterans Affairs to improve the prevention, diagnosis, and treatment of
veterans with chronic obstructive pulmonary disease (COPD).
Respiratory therapists provide clinical care and services to
pulmonary patients across the continuum of care ranging from the
hospital settings, to rehabilitation centers, to skilled nursing
facilities, to home care and in physician offices.
Among the important provisions of H.R. 5996 is a special emphasis
on assisting our Nation's veterans with smoking cessation efforts--a
leading contributor to COPD. Respiratory therapists are on the front
lines as health care professionals who assist the public with smoking
prevention and cessation efforts.
There are over 1,700 respiratory therapists currently employed in
the Veterans health care system. With the enactment of H.R. 5996, there
will be a cadre of respiratory therapists already in place to help
implement the directives mandated by this important legislation.
Thank you again for your foresight and commitment to our Nation's
veterans and their health care.
Sincerely,
Tim Myers, BS, RRT-NPS
President
__________
American Lung Association
Washington, DC.
October 4, 2010
The Honorable Cliff Stearns
U.S. House of Representatives
Washington, DC 20515
Dear Representative Stearns:
The American Lung Association is pleased to support H.R. 5596,
legislation to improve the prevention, diagnosis, and treatment of
veterans with chronic obstructive pulmonary disease (COPD). Chronic
obstructive pulmonary disease takes a tremendous human and financial
toll on the Department of Veterans Affairs. An estimated 8 percent of
veterans in the Department of Veterans Affairs (VA) health care system
have been diagnosed with COPD. COPD ranks as the fourth most common
reason for hospitalization in the VA patient population. It is the
fourth most common cause of death in the United States, and it is
projected to become the third leading cause of mortality by 2020.
H.R. 5996 will require the development of treatment protocols and
related tools for the prevention, diagnosis, treatment, and management
of chronic obstructive pulmonary disease. The legislation also will
bolster biomedical and prosthetic research programs regarding this
disease. These steps are urgently needed to help improve patient
outcomes.
Between 80 and 90 percent of all COPD cases are caused by smoking.
The best way to prevent COPD and many diseases the VA health care
system manages is to quit smoking or not to smoke in the first place.
H.R. 5996 will help address this by directing the VA, in conjunction
with Centers for Disease Control and Prevention, to develop improved
techniques and best practices for assisting veterans with chronic
obstructive pulmonary disease in successfully quitting smoking.
According to the 2008 Study of Veteran Enrollees' Health and
Reliance Upon VA, over 70 percent of VA enrollees report that they have
smoked at one time in their lives. Currently 19.7 percent smoke. This
is down from 22.2 percent in 2005 and 21.5 percent in 2007 and shows
some important momentum in the right direction. Among the 70 percent of
the VA population who has ever smoked, over twenty 5 percent (25.5) say
they've recently quit smoking, again, a step in the right direction.
Sadly, the VA will continue to battle this problem for some time to
come. The current smoking rate for active duty military is 30.4
percent, with smoking rates highest among personnel ages 18 to 25--
especially among soldiers and Marines. The Department of Veterans
Affairs estimates that more than 50 percent of all active duty
personnel stationed in Iraq smoke.
H.R. 5596 is an important step to address COPD and the toll of
tobacco on our Nation's veterans. We look forward to working with you
to pass this lifesaving legislation.
Sincerely,
Charles D. Connor
President and Chief Executive Officer
cc: The Honorable John Lewis&
__________
COPD Foundation
Washington, DC.
August 10, 2010
The Honorable Cliff Stearns
2370 Rayburn House Office Building
Washington, DC 20515
Dear Representative Stearns,
On behalf of the COPD Foundation's Board of Directors, I wish to
express our heartfelt appreciation for your leadership in Chronic
Obstructive Pulmonary Disease (COPD) in the veterans' community and to
express our support for the passage of H.R. 5996.
The COPD Foundation is the national not-for-profit organization
solely dedicated to representing individuals with COPD in the United
States. As you know, COPD, or Chronic Obstructive Pulmonary Disease, is
an umbrella term used to describe progressive lung diseases,
encompassing emphysema, chronic bronchitis, refractory asthma, and
severe bronchiectasis.
The NIH estimates that 12 million adults have COPD and another 12
million are undiagnosed or developing COPD. COPD is currently the
fourth leading cause of death in the U.S. and it is estimated to become
the third leading cause of death by 2020. The impacts on the economy
are severe, with national costs projected to be $49.9 billion in 2010,
in part due to COPD's status as the second leading cause of disability.
As the foremost provider of health care services to over 8 million
veterans, the Department of Veterans Affairs has a unique opportunity
to become a leader in the fight against COPD. H.R. 5996 will allow the
VA to take a comprehensive approach to reducing the burden of COPD
through innovative prevention, education and treatment strategies. It
also provides for critically needed research into best practices that
will help to simultaneously reduce costs and improve quality of life.
Our organization and the COPD community care deeply about the need
to address COPD in America's veteran population. A 2003 study revealed
that COPD was the fourth most common diagnosis amongst hospitalized
veterans and a strong predictor for patient readmission following a
hospital stay. The VA system has been a leader in health systems
research and H.R. 5996 will build on a record of using innovative
methods to improve the health of the veterans it serves. We encourage
your colleagues to join you in support of H.R. 5996. Congress' actions
will mark a great step towards addressing the burden that COPD places
on veterans, their families and the health care delivery system.
We were excited to learn that the House Committee on Veterans'
Affairs will hold a hearing on September 29, 2010 that will include a
discussion of H.R. 5996. If there is an opportunity to provide a
witness at this hearing we would be pleased to identify a patient,
physician or researcher who could lend substance to the discussion of
COPD in the Veterans' population. We are happy to support your efforts
in any way that will aid you in obtaining passage of H.R. 5996.
Sincerely,
John W. Walsh
President
__________
EFFORTS
Kansas City, MO.
October 1, 2010
Dear Representative Stearns,
On behalf of EFFORTS, www.emphysema.net, an online COPD, support,
advocacy organization we wish to thank you for your leadership with
regard to COPD and our Veterans and to offer our full support for the
passage of H.R. 5996.
Currently, COPD ranks as the fourth leading cause of death in the
U.S. behind heart disease, cancer, and cardiovascular disease, and it
is the only major disease that continues to show increased mortality
rates each year. In contrast, seven of the other ten leading causes of
death actually showed decreases in mortality.
In Healthy People 2010, a publication of The Centers for Disease
Control (CDC) and the National Institutes of Health (NIH), one central
recommendation was that developing better methods for early detection
of COPD is of utmost importance. It is often stated that COPD is
diagnosed after age 65. However, in a recent survey of 338 members of
our EFFORTS organization, we found that the age of diagnosis averaged
47 years for females and 56 years for males. It was also noted that
many were experiencing symptoms of their disease long before they were
actually diagnosed. Unfortunately, it is not at all uncommon for
someone to have lost 50 percent or more of his/her lung function before
they are diagnosed.
COPD is an enormous economic burden to society. It strikes during
the height of the productive years, significantly interferes with the
ability to earn a living, forces many to go on Medicare disability or
take early retirement at an early age, and often disrupts the lives of
the individual and family for many years before death occurs. According
to data from the NHLBI, the direct costs of health care services and
indirect costs related to loss of productivity for COPD were $26
billion in 1998 and $30.4 billion in 2000. Medical expenses for COPD
patients are extremely high because of frequent visits to the emergency
room, extended hospital stays, and expensive medications. In 1997,
there were an estimated 13.4 million physician office visits and more
than 600,000 hospitalizations for COPD (NHLBI, 2001). Data from the
Centers for Disease Control indicate that diseases of the respiratory
system rank #3 in the number of emergency room visits. It is expected
that all of the costs associated with COPD will continue to spiral
upward because the prevalence of COPD is continuing to rise each year.
There are only a few treatment options available to the millions of
patients who suffer from this killer disease. None provides a cure and
only treat the symptoms. Physicians can experiment with medications
developed for asthma, consider surgery, prescribe oxygen, and/or refer
the patient for pulmonary rehabilitation. Unfortunately, Lung Volume
Reduction Surgery (LVRS), a procedure shown to be helpful to some but
not all patients, is not covered by Medicare and many insurance
companies because it is considered to be an experimental procedure.
Lung transplantation is a viable option, but the strict medical
requirements and critical shortage of organ donors make it available to
a relatively small number of patients. Pulmonary rehabilitation,
universally recognized as extremely important for optimizing patients'
overall physical conditioning, is not universally available to everyone
in need because it is not covered by Medicare in most States.
One medicine was developed specifically for COPD a few years ago.
Another ``blockbuster'' drug with great promise has been tested and
approved in several countries outside the U.S., but has not yet been
approved by the FDA. At a recent hearing at the FDA (9/02), it was
determined that although this important drug was safe and shown to
bring significant improvement in measures of lung function, the FDA
still wanted additional testing. This ruling will cause a significant
delay in the availability of this important drug to people with COPD.
We believe that the continuing rise in death and disability due to
COPD in this country is distinct public health emergency. Millions of
children under the age of 18 begin smoking every day. Approximately 15
percent to 20 percent of those who smoke will eventually develop
severely disabling COPD, and there are growing concerns about the
harmful effects of our environment on lung function.
Many patients with COPD are totally reliant on the Veterans
Administration for their medical care. As an organization, EFFORTS is
excited to learn that the House Committee on Veterans Affairs will be
holding a hearing that will include a discussion of COPD and will
support your efforts in any way that will aid the passage of H.R. 5996.
Sincerely,
EFFORTS Executive Board
Joan Esposito V.P. N.J.
Ann Lornie V.P. UK
Maggie Borger IL
Edna Fiore CO.
Jean Rommes IA.
Michael MacDonald MA. &
Linda Watson N.Y.
President
__________
NTM Info and Research, Inc.
Coral Gables, FL.
October 1, 2010
The Honorable Cliff Stearns
2370 House Office Building
Washington, DC 20515
Dear Representative Stearns,
On behalf of NTM Info & Research (NTMir), I wish to express our
appreciation for your leadership in Chronic Obstructive Pulmonary
Disease (COPD) in the veterans' community and to express our support
for the passage of H.R. 5996.
NTMir is the national not-for-profit organization dedicated to
pulmonary nontuberculous mycobacterial (NTM) disease. COPD, or Chronic
Obstructive Pulmonary Disease, is an umbrella term used to describe
progressive lung diseases, encompassing emphysema, chronic bronchitis,
refractory asthma, severe bronchiectasis, and NTM lung disease.
The NIH estimates that 12 million adults have COPD and another 12
million are undiagnosed or developing COPD. COPD is currently the
fourth leading cause of death in the U.S. and is estimated to become
the third leading cause of death by 2020. The impacts on the economy
are severe, with national costs projected to be $49.9 billion in 2010,
in part due to COPD's status as the second leading cause of disability.
As the foremost provider of health care services to over 8 million
veterans, the Department of Veterans Affairs has a unique opportunity
to become a leader in the fight against COPD. H.R. 5996 will allow the
VA to take a comprehensive approach to reducing the burden of COPD
through innovative prevention, education and treatment strategies. It
also provides for critically needed research into best practices that
will help to simultaneously reduce costs and improve quality of life.
NTMir and the COPD community care deeply about the need to address
COPD in America's veteran population. A 2003 study revealed that COPD
was the fourth most common diagnosis among hospitalized veterans and a
strong predictor for patient readmission following a hospital stay. The
VA system has been a leader in health systems research and H.R. 5996
will build on a record of using innovative methods to improve the
health of the veterans it serves. We encourage your colleagues to join
you in support of H.R. 5996. Congress' actions will mark a great step
toward addressing the burden that COPD places on veterans, their
families and the health care delivery system.
Sincerely,
Philip Leitman
President
__________
Respiratory Health Association of Metropolitan Chicago
Chicago, IL.
October 4, 2010
Honorable Cliff Stearns
U.S. Representative
2370 Rayburn House Office Bldg.
Washington, DC 20515
Dear Congressman Stearns,
Respiratory Health Association of Metropolitan Chicago (RHAMC)
urges support of H.R. 5996 which seeks to improve the prevention,
diagnosis, and treatment of veterans with COPD. The legislation directs
the Veterans Administration Secretary to focus attention and resources
toward addressing COPD within the population they serve.
RHAMC has been dedicated to community lung health since 1906. Our
mission is to promote healthy lungs and fight lung disease through
research, advocacy and education. RHAMC launched the COPD Initiative in
response to the growing impact of COPD upon our communities. The goals
are to increase COPD awareness, educate the public and health care
community, advance COPD policies, advocate for people living with COPD.
There is a growing, active and engaged COPD patient community that
is advocating for improved programming and coverage addressing COPD.
The patients and caregivers in our communities seek more resources
dedicated to addressing COPD.
COPD is the fourth leading cause of death in Illinois. An estimated
500,000 adults in Illinois alone suffer from COPD. Smoking is the
primary cause, but exposure to lung irritants like vapors and dusts in
occupational settings as well as secondhand smoke contribute to COPD.
In the past 5 years, more women died of COPD than men in the United
States. In Illinois, more women than men are hospitalized every year
for COPD.
Veterans Administration needs to take a comprehensive approach to
reducing the burden of COPD through innovative prevention, education
and treatment strategies. This legislation also provides for critically
needed research into best practices that will help to simultaneously
reduce costs and improve quality of life.
We applaud the House Committee on Veterans' Affairs for addressing
this issue and we support passage of H.R. 5996.
Sincerely,
Joel J. Africk
President and Chief Executive Officer
__________
New York Times
September 24, 2010
Cost and Lack of Awareness Hamper Adult Vaccination Efforts
By Lesley Alderman
VACCINES are not just for children.
About 11,500 cases of whooping cough, or pertussis, have been
reported nationwide so far this year. In California, where the
infections are nearing a record high, nine infants have died.
It is likely that some of those children had not received all their
shots, experts say. But some of those deaths might have been prevented
if more adults, too, had been immunized.
Though public health authorities have long recommended that adults
get a pertussis booster shot, just half have done so. Without it, they
risk passing this illness to vulnerable children.
``Almost everyone understands how important it is for children to
be immunized,'' said Dr. Melinda Wharton, deputy director of the
National Center for Immunization and Respiratory Diseases at the
Centers for Disease Control and Prevention, ``but adults need vaccines
too.''
Far too few get them. The C.D.C. recommends that people 19 and
older receive immunizations against as many as 14 infectious diseases.
(Not all adults require every vaccine.) Yet most adults rarely think
about getting the shots--until they step on a rusty nail or begin
planning travel to a developing country.
Only 7 percent of Americans over age 60, for instance, have
received the herpes zoster vaccine, which prevents shingles, a painful
nerve infection. Just 11 percent of young women have received the
vaccine against the two types of human papilloma virus that cause 70
percent of all cervical cancers.
Why are adults so behind on vaccinations? For one thing, the shots
can be expensive (from $20 to $200 a dose for some, and some require
three doses). But a bigger part of the problem is a lack of awareness.
Doctors often fail to remind patients that they require booster shots,
and consumers are not well informed about the need.
In a 2007 survey by the National Foundation for Infectious
Diseases, 40 percent of respondents incorrectly stated that, if they
had received vaccines as a child, they did not need them again; 18
percent said vaccines were not necessary for adults.
The new health care law should help get more adults to roll up
their sleeves. Under the law, group and individual health plans, as
well as Medicare, must provide preventive health services, including
immunizations recommended by the C.D.C., free of charge. That means no
co-payments, co-insurance or deductibles.
The hope is that since vaccines will be free, more doctors will
suggest them and more patients will ask for them, said Jeffrey Levi,
executive director of Trust for America's Health, a nonprofit group
that works to prevent epidemics.
Here's the catch. If you are in a group or individual health plan,
your plan must be new, or it must have undergone substantial changes,
in order for the new requirements to apply. In addition, certain recent
vaccine recommendations will not be covered right away. If you are
uncertain, call your insurer.
Adult immunizations are not just an important way to prevent the
spread of disease. Immunizations are also a phenomenally cost-effective
way to preserve health.
``When you compare the cost of getting sick with these diseases to
the cost of a vaccine, it's a modest investment,'' said Dr. Robert H.
Hopkins, a professor of internal medicine and pediatrics at the
University of Arkansas for Medical Sciences.
If you end up in the emergency room with a bad case of the flu or
pneumonia, your bill could be thousands of dollars. A flu shot is just
$20, or often free; the pneumonia vaccine is about $77.
Here is how to get up-to-date on your shots--whether you have a new
insurance plan, an old plan or no plan at all.
THE VACCINES YOU NEED Tear out the immunization chart accompanying
this article or print it out online. Note the vaccines you should be
getting, based on your age and health status.
This year, for the first time, the C.D.C. recommends that everyone,
regardless of age or health, get an influenza shot. Most people need
only one. This year the flu shot provides protection against the H1N1
virus and two seasonal viruses.
Most other vaccines are intended for specific age groups or for
those with particular risk factors. The zoster vaccine, for example,
has been tested only in older people. There is little evidence that it
could benefit younger people, whose immune systems are still strong.
Next, figure out which vaccines you have already received. Your
doctor should be able to help. But if you have switched physicians a
number of times, you may have to reconstruct your history on your own.
``When in doubt, get vaccinated,'' said Dr. Hopkins. ``There's very
little risk with getting a second dose of a vaccine.''
IF YOU HAVE INSURANCE Call your primary care physician and explain
that you would like to get your vaccinations updated.
Some offices do not stock vaccines, so it is wise to tell the staff
in advance what you will need. You may find that certain vaccines are
not available right away; your doctor can tell you where to find them,
or how long the wait will be.
Next, call your insurer and ask if they will cover vaccines free of
charge. If not, ask how much they charge. If the fees are high, see
below for alternate options.
IF YOU LACK COVERAGE You can still pay out-of-pocket for
immunizations at the doctor's office, of course. But the shots may be
less expensive at other places.
YOUR HEALTH DEPARTMENT If money is tight, find out if your State or
community health department provides vaccinations for adults.
Unfortunately, there is no Federally funded program for adult
immunizations, only for children.
The C.D.C. Web site provides an interactive map to help locate the
health department or immunization clinic in your area.
YOUR LOCAL PHARMACY Many retail clinics administer vaccines,
including CVS MinuteClinics and Walgreens Take Care Clinics.
MinuteClinics offer 10 vaccines for adults, including shots for
hepatitis A ($117) and B ($102), meningitis ($147), pneumococcal
disease ($77) and DTaP, which protects you from diphtheria, tetanus and
pertussis ($82).
There are 500 CVS clinics across the country, and all are open
seven days a week. No appointments or prescriptions are necessary.
Walgreens clinics offer travel vaccines, like the one for typhoid
fever, as well.
Even if your local pharmacy does not have a clinic, you may be able
to get some of the shots you need there. In all States, pharmacists are
licensed to give flu shots; in some States, they can administer other
vaccines as well, like the one to protect against pneumonia.
Check with a local pharmacy and find out what shots they are
licensed to provide and at what cost.
YOUR EMPLOYER Inquire at your company's human resources or wellness
office. Some companies provide free flu shots for employees, as well as
their families. Few companies provide other vaccines, but it can't hurt
to ask.
Remember that when you get immunized, you are not only ensuring
your own good health but the health of those around you.
Footnotes
Recommended Adult Immunization Schedule--UNITED STATES 2010
For complete statements by the Advisory Committee on Immunization
Practices (ACIP), visit www.cdc.gov/vaccines/pubs/ACIP-list.htm.
1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap)
vaccination
Tdap should replace a single dose of Td for adults aged 19 through
64 years who have not received a dose of Tdap previously.
Adults with uncertain or incomplete history of primary vaccination
series with tetanus and diphtheria toxoid-containing vaccines should
begin or complete a primary vaccination series. A primary series for
adults is 3 doses of tetanus and diphtheria toxoid-containing vaccines;
administer the first 2 doses at least 4 weeks apart and the third dose
6-12 months after the second; Tdap can substitute for any one of the
doses of Td in the 3-dose primary series. The booster dose of tetanus
and diphtheria toxoid-containing vaccine should be administered to
adults who have completed a primary series and if the last vaccination
was received ;10 years previously. Tdap or Td vaccine may be used, as
indicated.
If a woman is pregnant and received the last Td vaccination ;10
years previously, administer Td during the second or third trimester.
If the woman received the last Td vaccination <10 years previously,
administer Tdap during the immediate postpartum period. A dose of Tdap
is recommended for postpartum women, close contacts of infants aged <12
months, and all health-care personnel with direct patient contact if
they have not previously received Tdap. An interval as short as 2 years
from the last Td is suggested; shorter intervals can be used. Td may be
deferred during pregnancy and Tdap substituted in the immediate
postpartum period, or Tdap can be administered instead of Td to a
pregnant woman.
Consult the ACIP statement for recommendations for giving Td as
prophylaxis in wound management.
2. Human papillomavirus (HPV) vaccination
HPV vaccination is recommended at age 11 or 12 years with catch-up
vaccination at ages 13 through 26 years.
Ideally, vaccine should be administered before potential exposure
to HPV through sexual activity; however, females who are sexually
active should still be vaccinated consistent with age-based
recommendations. Sexually active females who have not been infected
with any of the four HPV vaccine types (types 6, 11, 16, 18, all of
which HPV4 prevents) or any of the two HPV vaccine types (types 16 and
18, both of which HPV2 prevents) receive the full benefit of the
vaccination. Vaccination is less beneficial for females who have
already been infected with one or more of the HPV vaccine types. HPV4
or HPV2 can be administered to persons with a history of genital warts,
abnormal Papanicolaou test, or positive HPV DNA test, because these
conditions are not evidence of prior infection with all vaccine HPV
types.
HPV4 may be administered to males aged 9 through 26 years to reduce
their likelihood of acquiring genital warts. HPV4 would be most
effective when administered before exposure to HPV through sexual
contact.
A complete series for either HPV4 or HPV2 consists of 3 doses. The
second dose should be administered 1-2 months after the first dose; the
third dose should be administered 6 months after the first dose.
Although HPV vaccination is not specifically recommended for
persons with the medical indications described in Figure 2, ``Vaccines
that might be indicated for adults based on medical and other
indications,'' it may be administered to these persons because the HPV
vaccine is not a live-virus vaccine. However, the immune response and
vaccine efficacy might be less for persons with the medical indications
described in Figure 2 than in persons who do not have the medical
indications described or who are immunocompetent. Health-care personnel
are not at increased risk because of occupational exposure, and should
be vaccinated consistent with age-based recommendations.
3. Varicella vaccination
All adults without evidence of immunity to varicella should receive
2 doses of single-antigen varicella vaccine if not previously
vaccinated or the second dose if they have received only 1 dose, unless
they have a medical contraindication. Special consideration should be
given to those who (1) have close contact with persons at high risk for
severe disease (e.g., health-care personnel and family contacts of
persons with immunocompromising conditions) or (2) are at high risk for
exposure or transmission (e.g., teachers; child-care employees;
residents and staff members of institutional settings, including
correctional institutions; college students; military personnel;
adolescents and adults living in households with children; nonpregnant
women of childbearing age; and international travelers).
Evidence of immunity to varicella in adults includes any of the
following: (1) documentation of 2 doses of varicella vaccine at least 4
weeks apart; (2) U.S.-born before 1980 (although for health-care
personnel and pregnant women, birth before 1980 should not be
considered evidence of immunity); (3) history of varicella based on
diagnosis or verification of varicella by a health-care provider (for a
patient reporting a history of or presenting with an atypical case, a
mild case, or both, health-care providers should seek either an
epidemiologic link with a typical varicella case or to a laboratory-
confirmed case or evidence of laboratory confirmation, if it was
performed at the time of acute disease); (4) history of herpes zoster
based on diagnosis or verification of herpes zoster by a health-care
provider; or (5) laboratory evidence of immunity or laboratory
confirmation of disease.
Pregnant women should be assessed for evidence of varicella
immunity. Women who do not have evidence of immunity should receive the
first dose of varicella vaccine upon completion or termination of
pregnancy and before discharge from the health-care facility. The
second dose should be administered 4-8 weeks after the first dose.
4. Herpes zoster vaccination
A single dose of zoster vaccine is recommended for adults aged ;60
years regardless of whether they report a prior episode of herpes
zoster. Persons with chronic medical conditions may be vaccinated
unless their condition constitutes a contraindication.
5. Measles, mumps, rubella (MMR) vaccination
Adults born before 1957 generally are considered immune to measles
and mumps.
Measles component: Adults born during or after 1957 should receive
1 or more doses of MMR vaccine unless they have (1) a medical
contraindication; (2) documentation of vaccination with 1 or more doses
of MMR vaccine; (3) laboratory evidence of immunity; or (4)
documentation of physician-diagnosed measles.
A second dose of MMR vaccine, administered 4 weeks after the first
dose, is recommended for adults who (1) have been recently exposed to
measles or are in an outbreak setting; (2) have been vaccinated
previously with killed measles vaccine; (3) have been vaccinated with
an unknown type of measles vaccine during 1963-1967; (4) are students
in postsecondary educational institutions; (5) work in a health-care
facility; or (6) plan to travel internationally.
Mumps component: Adults born during or after 1957 should receive 1
dose of MMR vaccine unless they have (1) a medical contraindication;
(2) documentation of vaccination with 1 or more doses of MMR vaccine;
(3) laboratory evidence of immunity; or (4) documentation of physician-
diagnosed mumps.
A second dose of MMR vaccine, administered 4 weeks after the first
dose, is recommended for adults who (1) live in a community
experiencing a mumps outbreak and are in an affected age group; (2) are
students in postsecondary educational institutions; (3) work in a
health-care facility; or (4) plan to travel internationally.
Rubella component: 1 dose of MMR vaccine is recommended for women
who do not have documentation of rubella vaccination, or who lack
laboratory evidence of immunity. For women of childbearing age,
regardless of birth year, rubella immunity should be determined and
women should be counseled regarding congenital rubella syndrome. Women
who do not have evidence of immunity should receive MMR vaccine upon
completion or termination of pregnancy and before discharge from the
health-care facility.
Health-care personnel born before 1957: For unvaccinated health-
care personnel born before 1957 who lack laboratory evidence of
measles, mumps, and/or rubella immunity or laboratory confirmation of
disease, health-care facilities should consider vaccinating personnel
with 2 doses of MMR vaccine at the appropriate interval (for measles
and mumps) and 1 dose of MMR vaccine (for rubella), respectively.
During outbreaks, health-care facilities should recommend that
unvaccinated health-care personnel born before 1957, who lack
laboratory evidence of measles, mumps, and/or rubella immunity or
laboratory confirmation of disease, receive 2 doses of MMR vaccine
during an outbreak of measles or mumps, and 1 dose during an outbreak
of rubella.
Complete information about evidence of immunity is available at
www.cdc.gov/vaccines/recs/provisional/default.htm.
6. Seasonal Influenza vaccination
Vaccinate all persons aged ;50 years and any younger persons who
would like to decrease their risk of getting influenza. Vaccinate
persons aged 19 through 49 years with any of the following indications.
Medical: Chronic disorders of the cardiovascular or pulmonary
systems, including asthma; chronic metabolic diseases, including
diabetes mellitus; renal or hepatic dysfunction, hemoglobinopathies, or
immunocompromising conditions (including immunocompromising conditions
caused by medications or HIV); cognitive, neurologic or neuromuscular
disorders; and pregnancy during the influenza season. No data exist on
the risk for severe or complicated influenza disease among persons with
asplenia; however, influenza is a risk factor for secondary bacterial
infections that can cause severe disease among persons with asplenia.
Occupational: All health-care personnel, including those employed
by long-term care and assisted-living facilities, and caregivers of
children aged <5 years.
Other: Residents of nursing homes and other long-term care and
assisted-living facilities; persons likely to transmit influenza to
persons at high risk (e.g., in-home household contacts and caregivers
of children aged <5 years, persons aged ;50 years, and persons of all
ages with high-risk conditions).
Healthy, nonpregnant adults aged <50 years without high-risk
medical conditions who are not contacts of severely immunocompromised
persons in special-care units may receive either intranasally
administered live, attenuated influenza vaccine (FluMist) or
inactivated vaccine. Other persons should receive the inactivated
vaccine.
7. Pneumococcal polysaccharide (PPSV) vaccination
Vaccinate all persons with the following indications.
Medical: Chronic lung disease (including asthma); chronic
cardiovascular diseases; diabetes mellitus; chronic liver diseases,
cirrhosis; chronic alcoholism; functional or anatomic asplenia (e.g.,
sickle cell disease or splenectomy [if elective splenectomy is planned,
vaccinate at least 2 weeks before surgery]); immunocompromising
conditions including chronic renal failure or nephrotic syndrome; and
cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to
HIV diagnosis as possible.
Other: Residents of nursing homes or long-term care facilities and
persons who smoke cigarettes. Routine use of PPSV is not recommended
for American Indians/Alaska Natives or persons aged <65 years unless
they have underlying medical conditions that are PPSV indications.
However, public health authorities may consider recommending PPSV for
American Indians/Alaska Natives and persons aged 50 through 64 years
who are living in areas where the risk for invasive pneumococcal
disease is increased.
8. Revaccination with PPSV
One-time revaccination after 5 years is recommended for persons
with chronic renal failure or nephrotic syndrome; functional or
anatomic asplenia (e.g., sickle cell disease or splenectomy); and for
persons with immunocompromising conditions. For persons aged ;65 years,
one-time revaccination is recommended if they were vaccinated ;5 years
previously and were younger than aged <65 years at the time of primary
vaccination.
9. Hepatitis A vaccination
Vaccinate persons with any of the following indications and any
person seeking protection from hepatitis A virus (HAV) infection.
Behavioral: Men who have sex with men and persons who use injection
drugs.
Occupational: Persons working with HAV-infected primates or with
HAV in a research laboratory setting.
Medical: Persons with chronic liver disease and persons who receive
clotting factor concentrates.
Other: Persons traveling to or working in countries that have high
or intermediate endemicity of hepatitis A (a list of countries is
available at wwwn.cdc.gov/travel/contentdiseases.aspx).
Unvaccinated persons who anticipate close personal contact (e.g.,
household contact or regular babysitting) with an international adoptee
from a country of high or intermediate endemicity during the first 60
days after arrival of the adoptee in the United States should consider
vaccination. The first dose of the 2-dose hepatitis A vaccine series
should be administered as soon as adoption is planned, ideally ;2 weeks
before the arrival of the adoptee.
Single-antigen vaccine formulations should be administered in a 2-
dose schedule at either 0 and 6-12 months (Havrix), or 0 and 6-18
months (Vaqta). If the combined hepatitis A and hepatitis B vaccine
(Twinrix) is used, administer 3 doses at 0, 1, and 6 months;
alternatively, a 4-dose schedule, administered on days 0, 7, and 21-30
followed by a booster dose at month 12 may be used.
10. Hepatitis B vaccination
Vaccinate persons with any of the following indications and any
person seeking protection from hepatitis B virus (HBV) infection.
Behavioral: Sexually active persons who are not in a long-term,
mutually monogamous relationship (e.g., persons with more than one sex
partner during the previous 6 months); persons seeking evaluation or
treatment for a sexually transmitted disease (STD); current or recent
injection-drug users; and men who have sex with men.
Occupational: Health-care personnel and public-safety workers who
are exposed to blood or other potentially infectious body fluids.
Medical: Persons with end-stage renal disease, including patients
receiving hemodialysis; persons with HIV infection; and persons with
chronic liver disease.
Other: Household contacts and sex partners of persons with chronic
HBV infection; clients and staff members of institutions for persons
with developmental disabilities; and international travelers to
countries with high or intermediate prevalence of chronic HBV infection
(a list of countries is available at www.cdc.gov/travel/
contentdiseases.aspx).
Hepatitis B vaccination is recommended for all adults in the
following settings: STD treatment facilities; HIV testing and treatment
facilities; facilities providing drug-abuse treatment and prevention
services; health-care settings targeting services to injection-drug
users or men who have sex with men; correctional facilities; end-stage
renal disease programs and facilities for chronic hemodialysis
patients; and institutions and nonresidential daycare facilities for
persons with developmental disabilities.
Administer or complete a 3-dose series of HepB to those persons not
previously vaccinated. The second dose should be administered 1 month
after the first dose; the third dose should be administered at least 2
months after the second dose (and at least 4 months after the first
dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is
used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose
schedule, administered on days 0, 7, and 21-30 followed by a booster
dose at month 12 may be used.
Adult patients receiving hemodialysis or with other
immunocompromising conditions should receive 1 dose of 40 g/mL
(Recombivax HB) administered on a 3-dose schedule or 2 doses of 20 g/
mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0,
1, 2 and 6 months.
11. Meningococcal vaccination
Meningococcal vaccine should be administered to persons with the
following indications.
Medical: Adults with anatomic or functional asplenia, or persistent
complement component deficiencies.
Other: First-year college students living in dormitories;
microbiologists routinely exposed to isolates of Neisseria
meningitidis; military recruits; and persons who travel to or live in
countries in which meningococcal disease is hyperendemic or epidemic
(e.g., the ``meningitis belt'' of sub-Saharan Africa during the dry
season [December through June]), particularly if their contact with
local populations will be prolonged. Vaccination is required by the
government of Saudi Arabia for all travelers to Mecca during the annual
Hajj.
Meningococcal conjugate vaccine (MCV4) is preferred for adults with
any of the preceding indications who are aged :55 years; meningococcal
polysaccharide vaccine (MPSV4) is preferred for adults aged ;56 years.
Revaccination with MCV4 after 5 years is recommended for adults
previously vaccinated with MCV4 or MPSV4 who remain at increased risk
for infection (e.g., adults with anatomic or functional asplenia).
Persons whose only risk factor is living in on-campus housing are not
recommended to receive an additional dose.
12. Selected conditions for which Haemophilus influenzae type b
(Hib) vaccine may be used
Hib vaccine generally is not recommended for persons aged ;5 years.
No efficacy data are available on which to base a recommendation
concerning use of Hib vaccine for older children and adults. However,
studies suggest good immunogenicity in patients who have sickle cell
disease, leukemia, or HIV infection or who have had a splenectomy.
Administering 1 dose of Hib vaccine to these high-risk persons who have
not previously received Hib vaccine is not contraindicated.
13. Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal,
meningococcal, influenza [inactivated influenza vaccine]) and live
vaccines generally are avoided in persons with immune deficiencies or
immunocompromising conditions. Information on specific conditions is
available at www.cdc.gov/vaccines/pubs/acip-list.htm.
Prepared Statement of Jacob B. Gadd, Deputy Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Committee:
Thank you for this opportunity for The American Legion to present
our views on today's pending legislation.
H.R. 3843_``Transparency for America's Heroes Act''
This bill would direct the Secretary of Veterans Affairs to place
medical quality-assurance records on the Department of Veterans Affairs
(VA) Web site.
The American Legion has no position on this legislation.
H.R. 4041_To Authorize Certain Improvements in the Federal Recovery
Coordinator Program
The purpose of this bill is to improve upon the Federal Recovery
Coordinator (FRC) program by having VA establish recovery coordinator
training at a qualified nursing or medical school selected by the
Secretary of VA. The qualified nursing or medical school will lead a
literature review and development of evidence-based guidelines for
recovery coordination, development of training modules for care
coordination and software that is compatible with VA systems for
recovery coordination. It will also lead a consensus conference on
evidence-based care coordination. Additionally, this bill authorizes
the qualified nursing or medical school to train 45 recovery
coordinators over the course of 3 years.
In 2007, The American Legion approved Resolution 29, Improvements
to Implement a Seamless Transition, which fully supported legislation
to designate a single Recovery Coordinator to ensure an efficient
rehabilitation and transition from military to civilian life and
eliminate delays and gaps in treatment and services. By the provisions
of the National Defense Authorization Act, Public Law 110-181, the FRC
program began in 2008. The program was designed to create
individualized care coordination plans for severely injured
servicemembers in order to ensure a warm handoff for severely wounded
servicemembers transitioning between DoD and VA as well as coordinate
state and local resources. With close to two million servicemembers
having deployed in Operations Iraqi Freedom (OIF), Enduring Freedom
(OEF) and New Dawn, VA only reported to date that less than 1,000
servicemembers have been assisted. The American Legion recommends 1)
expanding the program areas of the FRC program to include program
eligibility, 2) increasing FRC staff to one individual coordinator per
state and 3) improved communication at the national, state and local
levels.
The American Legion believes that coordination of care, especially
for those who are severely wounded, is essential to ensure they receive
the education and benefits they need and deserve. However, The American
Legion believes efforts to improve care coordination must be directed
at not only the severely wounded but any veteran transitioning to
ensure they do not fall through the cracks. Currently, only those
servicemembers diagnosed with Traumatic Brain Injury (TBI), Post
Traumatic Stress (PTS), visual impairment, amputation, burns or spinal
cord injury are eligible for assistance through the program. The
American Legion supports expansion of FRC program eligibility for any
veteran transitioning from active duty, guard or reserve for any
illness or injury.
VA reported in 2010 that five new FRCs are in the process of being
hired, which will bring the total number of full-time FRC staff to 25
across the country. These FRCs are stationed at: Walter Reed Army
Medical Center; National Naval Medical Center; Brooke Army Medical
Center; Balboa Naval Medical Center; San Diego Naval Medical Center;
Camp Pendleton, CA; Eisenhower Army Medical Center, GA; Michael E.
DeBakey VA Medical Center, TX; Richmond VA Medical Center; and, Palo
Alto VA Medical Center. The American Legion recommends having a FRC
within each state to ensure all active duty, reserve and guard units
receive the same education, outreach and benefits assistance.
The American Legion's flagship transition program, Heroes to
Hometowns, seeks to coordinate national, State and local resources
similar to the FRC program. The Heroes to Hometowns program assists
veterans with filing VA claims or benefits, applying for Temporary
Financial Assistance (TFA) as well as coordinating education or
employment opportunities before the servicemember returns to his or her
community. Even though FRC helped in the creation of the National
Community Resource Directory, The American Legion recommends enhanced
communication between national, state and local levels to ensure
maximum awareness of benefits available. Many times, The American
Legion has had difficulty contacting the FRCs through phone, email or
mailing address. In addition, the program should increase its outreach
through use of a dedicated Web page to update current contact
information.
In regards to the development of a computerized tracking program,
The American Legion applauds the new application created by VA in 2009,
the Care Management and Tracking and Reporting Application (CMTRA).
This tracking tool allows VA to coordinate care amongst a wide variety
of providers such as the OEF/OIF care management team and specialty
care providers to establish an individualized care plan for each
veteran. The American Legion recommends consolidation and expansion of
a single tracking tool between DoD, VA and the private sector to
prevent redundancy or any veterans that may fall through the cracks.
H.R. 5428_To Direct the Secretary of Veterans Affairs to Educate
Certain Staff of the Department of Veterans Affairs and to
Inform Veterans about the Injured and Amputee Veterans Bill of
Rights
This bill seeks to ensure print materials are created about the
Injured and Amputee Veterans Bill of Rights and posted in VA
prosthetics and orthotics clinics so that veterans are aware of their
rights. In addition, staff of these clinics would be required to
receive training on these patient rights and the Secretary would be
responsible for providing outreach through Web sites or veteran service
organizations.
Many veterans of Iraq and Afghanistan have been subjected to
Improvised Explosive Devices (IEDs) which have resulted in a
significant increase in the number of amputations from previous
conflicts. DoD reported in 2010 that there have been a total of 1,552
servicemembers that suffered amputations. Promoting information about
veterans' rights in the clinics as well as increases through targeted
outreach will help VA improve their business processes and encourage
veterans to receive their treatment at VA.
The American Legion continues to advocate for advancement in VA's
outreach practices and stands ready to assist VA in promoting benefits
and services.
The American Legion fully supports this legislation.
H.R. 5516_``Access to Appropriate Immunizations for Veterans Act of
2010''
The purpose of this bill is to ensure quality and timely scheduling
of patient immunizations by VA. Specifically, this bill will ``create
quality measures and statistical metrics as well as an annual report to
ensure VA is meeting its obligations in providing immunizations.''
One of the provisions of this bill requires VA to keep metrics and
measures in place to track influenza and pneumococcal vaccinations. The
Veterans Health Administration (VHA) issued a VHA Directive on November
12, 2009 that stated, ``Influenza vaccination rates of veteran patients
are monitored in the VHA performance measurement system, under the
`seasonal outpatient influenza measure.' '' The directive also mandates
vaccination and documentation of the influenza immunization by all
patients, staff and volunteers within VA Medical Centers. However, an
overall performance measure for all immunizations provided by the
Department of Veterans Affairs is not monitored by VA Central Office.
In VA's FY 2009 Performance and Accountability Report, two evaluation
metrics-Clinical Practice Guidelines (CPGI) and Prevention Index (PI)
are utilized to track VA's progress for this initiative. The results
from Strategic Goal Three, ``Prevention Index IV'' reported an 89
percent goal attained by VA in ``promoting healthy lifestyle changes
with early identification of disease, immunizations and prevention
screenings.''
While The American Legion does not have a specific resolution
supporting patient immunizations quality and scheduling, The American
Legion supports quality and performance measures designed to enhance
veterans' safety and quality of care.
H.R. 5543_To Repeal the Prohibition on Collective Bargaining with
Respect to Matters and Questions Regarding Compensation of
Employees of the Department of Veterans Affairs other than
Rates of Basic Pay
This bill seeks to revoke the collective bargaining rules on open
disclosure of compensation of VA employees, with the exception of
employee's basic pay fee structure. It is the policy of The American
Legion not to be involved with VA's management and employee relations.
The American Legion does not have a specific position on this piece
of legislation.
H.R. 5641_To Authorize the Secretary of Veterans Affairs to Enter Into
Contracts for the Transfer of Veterans to Non-Department Adult
Foster Homes for Veterans Who Are Unable to Live Independently
VA is authorized under Title 38, Code of Federal Regulations (CFR)
Section 17.38 (a)(1)(ix)) to provide a comprehensive array of medically
necessary in-home services to enrolled veterans. This bill seeks to add
a provision in title 38, United States Code (U.S.C.), Section 1720 that
VA would be authorized to transfer veterans needing long-term care
services to ``Foster Homes,'' upon the request of the veteran or
Secretary of Veterans Affairs.
VA issued VHA Handbook 1141.02, Medical Foster Home Procedures, in
November 2009, which outlined the Department's policy on definition,
responsibilities, selection, training, quality monitoring and financial
arrangements for this program.
VA defines a Medical Foster Home (MFH) in VHA Handbook 1141.02 as:
(1) MFH is an adult foster home combined with a VA interdisciplinary
home care team, such as VA Home Based Primary Care (HBPC) or Spinal
Cord Injury--Home Care (SCI-HC), to provide non-institutional long-term
care for veterans who are unable to live independently and prefer a
family setting. (2) MFH is a form of Community Residential Care (CRC)
for the more medically complex and disabled veterans, and is generally
distinguished from other CRC homes by the following: (a) the home is
owned or rented by the MFH caregiver; (b) the MFH caregiver lives in
the MFH and provides personal care and supervision, (c) There are not
more than three residents receiving care in the MFH, including both
veterans and non-veterans, (d) veteran MFH residents are enrolled in a
VA HBPC or SCI-HC Program. Each VA Medical Center facility appoints a
MFH Coordinator which oversees the recruitment of staff, new
applications for MFH in the community, training, quality assurance and
inspections, and maintaining files of patients and MFH caregivers.
While this program has been highlighted and encouraged because of
the additional cost savings and access to care options for the veteran
and VA, The American Legion seeks additional feedback from users of
this MFH program about the level of patient safety and feedback on
their quality of care that would be provided in a non-traditional care
setting.
The American Legion does not have an official position at this
time.
H.R. 5996_To Direct the Secretary of Veterans Affairs to Improve the
Prevention, Diagnosis, and Treatment of Veterans with Chronic
Obstructive Pulmonary Disease
The purpose of this bill is to improve patient care and treatment
for Chronic Obstructive Pulmonary Disease (COPD) by: ``(1) developing
treatment protocols and tools for the prevention, diagnosis, treatment
and management, (2) improving biomedical and prosthetic research, (3)
entering into a pilot program with VA, Centers for Disease Control and
Prevention (CDC), Indian Health Service, Health Resources and Services
Agency to develop best practices in treatment of COPD and (4) VA and
CDC research unique needs and develop smoking cessation tools and
techniques.''
The American Legion concurs with this piece of legislation to
improve upon current knowledge, research and treatment of COPD.
H.R. 6123_To Amend Title 38, United States Code, to Improve the
Provision of Rehabilitative Services for Veterans with
Traumatic Brain Injury, and for other purposes
The purpose of this bill is to improve rehabilitation services for
veterans suffering from traumatic brain injury (TBI). Because of
ambiguities in current law, TBI treatment at VA narrowly focuses TBI
care on physical restoration. This legislation would clarify the
definition of rehabilitation so veterans will receive care that
adequately addresses their physical and mental health needs, as well as
quality of life and prospects for long-term recovery and success.
The American Legion supports this bill as it seeks to provide
comprehensive care instead of just physical rehabilitation for veterans
suffering from TBI. The American Legion is very supportive of ensuring
that the quality of life of our wounded servicemembers is addressed
with as much fervor as the simple, physical aftereffects.
H.R. 6127_To Amend Title 38, United States Code, to Provide for the
Continued Provision of Health Care Services to Certain Veterans
Who Were Exposed to Sodium Dichromate While Serving as a Member
of the Armed Forces At or Near the Water Injection Plant at
Qarmat Ali, Iraq, During Operation Iraqi Freedom
During the spring and summer of 2003, about 800 servicemembers
guarded a water injection facility in the Basrah oil fields at Qarmat
Ali, Iraq. Servicemembers included National Guard, Reserve, and Active
Duty Soldiers. This facility was contaminated with sodium dichromate
dust, which is a source of hexavalent chromium, a chemical that is
known to cause cancer. Health problems associated with such exposure
include respiratory issues, skin lesions, burns, increased rates of
lung cancer, and other ear, nose, throat, and skin disorders.
Some of the Qarmat Ali veterans who separated from service
following their deployment in 2003 may no longer be eligible to enroll
in VA health care under the 5-year open enrollment period Congress
established for non-service connected veterans. As a result, they must
first file a claim and seek a service-connected disability rating
before enrolling in the VA health care system and gaining access to the
comprehensive medical care VA provides.
H.R. 6127 would correct this unintended gap in services by
extending the enrollment eligibility period for Qarmat Ali veterans by
5 years from the date of notification. This would allow them to
immediately begin receiving services at VA medical facilities for any
and all of their health care needs.
In 2010, the American Legion approved Resolution 12: The American
Legion Policy on Hazardous Environmental Exposures. The resolution
supports legislative and administrative actions by Congress and VA to
properly study the long-term effects of all environmental exposures and
ensure that veterans are properly cared for and compensated for
diseases and other disabilities scientifically associated with a
particular exposure. Included within the scope of this resolution are
environmental exposures such as Agent Orange, Gulf-War related hazards,
ionizing radiation, Project Shipboard Hazard and Defense (SHAD), ground
water contamination at Camp Lejuene, multiple contaminants at Fort
Drum, NY, Fort Dugway, UT and Fort McClellan, AL and overseas concerns
related to sodium dichromate, toxic exposures at the Naval Air Facility
in Atsugi, Japan and burn pits in Balad, Iraq and other locations which
have all caused a variety of health problems.
While the American Legion supports H.R. 6127 as far as it goes, we
would additionally recommend a comprehensive environmental exposures
bill that would provide for the conduct of full studies to determine
the health consequences of exposure to suspected environmental hazards
so that veterans can receive the proper care and compensation due them
as a result of their service to our Nation.
Draft Legislation to Amend Title 38, USC, to Make Certain Improvements
in Programs for Homeless Veterans Administered by the Secretary
of Veterans Affairs, and for Other Purposes
This bill seeks to expand the VA grant program for homeless
veterans with special needs, which includes those seriously mentally
ill, frail and elderly, terminally ill and homeless women veterans.
This bill would also change reimbursement policy from a per diem rate
to annual cost of furnishing services. This emphasis on these special
subgroups and the reimbursement change would provide needed attention
and resources that will enable Homeless Service Care Providers to
assist these homeless veterans with needed care and services. For
example, the number of homeless woman veterans has doubled in the past
decade, up from 3 percent to 5 percent according to VA. This increase
of women veterans is due to their exposure to combat related
situations.
With the continuance of the wars in Iraq and Afghanistan, it is
widely known that psychological stress, such as post-traumatic stress,
TBI and other mental illnesses play a significant role in pushing a
certain population of veterans into homelessness. Funding, along with
grants that go to homeless veterans programs and organizations that
assist this vulnerable demographic, are desperately needed. The
American Legion understands that homeless veterans need a sustained
coordinated effort that provides secure housing and nutritious meals;
essential physical health care, substance abuse aftercare and mental
health counseling; as well as personal development and empowerment. If
enacted, this grant program will provide necessary medical and
rehabilitative services to homeless veterans with special needs that
will allow them to readjust and live a better quality of life.
The American Legion supports improvements to VA's homeless programs
but encourages Congress and VA to address the growing concern with
homeless women veterans, especially those with children.
Draft Legislation to Amend Title 38, United States Code, to Ensure That
the Secretary of Veterans Affairs Provides Veterans With
Information Concerning Service-Connected Disabilities at Health
Care Facilities
The purpose of this draft legislation is to ensure that the VA's
Veterans Health Administration (VHA) provides veterans accessing their
health care benefits with information or assistance in obtaining their
claims and ratings benefits from the Veteran Benefit Administration
(VBA). To accomplish this objective, this draft legislation suggests
listing VBA claims information and benefits in various locations in VA
Medical Centers, that VHA staff in the hospital discuss VBA benefits
with each of their enrolled patients and provide contact information to
help the veteran initiate their VBA claims and benefits.
Several American Legion Department (State) Service Officers have
identified that VHA providers are not assisting veterans with questions
the provider interprets as ``claims-related.'' Additionally, there is a
lack of awareness on the part of VHA providers that Veteran Service
Organizations (VSO) are available for referral to assist veterans with
the VA claims process. In a specific case, there was a lack of required
training on veteran-specific health issues and potential benefits
claims with Cold Injury Residuals, Agent Orange and other presumptive
conditions. Also, Vietnam veterans diagnosed and treated for prostate
cancer by a VA urologist were not advised to file a claim and missed an
opportunity for 100 percent service connection as a result.
The American Legion is working with VA Central Office to understand
the reasons for this disconnect between VHA and VBA and we intend to
recommend a Fast Letter or new VHA directive be sent to the field to
clarify VA's policy on treating physicians providing the necessary
medical evidence on the veteran's behalf as the VA provider can act as
an advocate in the claims process.
The American Legion supports this draft legislation and recommends
each VA Medical Center Facility have a VHA/VBA training liaison
position to facilitate biannual training and updates on VBA regulations
for VHA providers so that these providers will inform veterans of their
earned benefits and rights to file a claim for VBA compensation and
pension.
Draft Legislation to Amend Title 38, United States Code, to Make
Certain Improvements in Laws Relating to Health Care for
Veterans, and for Other Purposes
This draft legislation seeks to make improvements to several health
care matters. First, the legislation would allow VA's Under Secretary
for Health to provide assistance in organizing and hosting the
Association of Military Surgeons in the United States annual meeting.
The American Legion does not have an official position or affiliation
with this group but generally supports advances and benchmarking
between DoD, VA and other Federal agencies in terms of research,
provider training and education.
Secondly, the draft legislation recommends clarification to VA's
regulations on contracting with Non-Department Facilities and that the
Secretary of Veterans Affairs ``provide individual authorization or act
in such other manner as the Secretary determines appropriate.'' The
American Legion has two positions on this section. First, The American
Legion's Resolution 172: GI Bill of Health, adopted at the 2010
Convention states that veterans be authorized to utilize any
appropriate government health care facility in order to reduce travel
time, travel expense and undue stress on the veteran and/or their
caregiver. Secondly, VA is authorized to contract or fee-base care into
the community. The American Legion's System Worth Saving Task Force
noted that in each of the 32 VA Medical Facilities visited this year,
the facility Purchased Care budget continues to increase. In the last 4
years, VA's Purchased Care costs have doubled. The American Legion
attributes this increase to the lack of specialty providers and access
to care in rural communities. The American Legion believes that any
veteran should be able to receive quality care close to their home but
that VA must hire the needed specialty providers and increase access to
prevent the rising costs of Purchased Care in the community.
Thirdly, the draft legislation would extend the life of the VA
Advisory Committee on Homeless Veterans beyond its present termination
date of December 30, 2011 to December 30, 2014. The American Legion
supports this extension.
Fourth, this legislation seeks to amend the participating provider
agreement to improve on collection of third-party reimbursements. Under
the terms of the 1997 Balanced Budget Act, VHA was given the authority
to bill, collect, and retain third-party reimbursements for outpatient
medications, nursing home and hospital care. The American Legion
supports improvements in VA's ability to recover third-party
reimbursements for treatment of non-service medication conditions and
supports the intent of this section.
Fifth, the draft legislation addresses a VA employment requirement
for participants in the health professionals' educational assistance
program. The American Legion does not have a resolution or comments on
this provision of the legislation.
Six, the legislation recommended ``on-call'' pay for VHA employees
in IT fields. In addition, the seventh recommendation from the draft
legislation proposes that VA not be authorized to pay for more than
1,000 physicians and dentists employees within IT fields. The
legislation stipulates that providers must have qualifying board
certification and training and that their pay be tied to VA's pay
schedules. It is the policy of The American Legion not to be involved
with VA's management and employee relations and therefore does not have
a position on these provisions.
The eighth section of the draft legislative seeks to extend VA's
Joint Incentives Program from September 30, 2015 to September 30, 2020.
The joint incentives program was designed to allow both DoD and VA
Executive Committees to maintain a joint account to promote
coordination, sharing and funding of programs between both agencies.
The American Legion does not have a specific resolution but supports
the general intent of this program and its extension.
The last provision of this draft legislation recommends creation of
Franchise Fund to refund veterans whose third-party insurances were
billed incorrectly. While there may be a delay in VA recouping third-
party insurance payments, this Franchise Fund would allow VA to
promptly fund the veterans' third party account until the veterans'
third-party insurance company fixes the mistake. The American Legion
supports this provision.
As always, the American Legion thanks this Committee for the
opportunity to testify and represent the positions of the over 2.4
million veteran members of this organization.
Prepared Statement of Carl Blake, National Legislative Director,
Paralyzed Veterans of America
Chairman Michaud and Members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA), I would like to thank you for the
opportunity to present PVA's views on legislation pending before the
Subcommittee. PVA appreciates the efforts of the Subcommittee to
support the Department of Veterans Affairs (VA) and the care of our
Nation's veterans. With the inevitable future budget challenges to
come, PVA looks forward to your support to protect those who have done
so much to protect us all, America's veterans. In particular, we hope
for your continued support of those requiring specialized health care,
a vital service that is often unmatched in the civilian health care
sector.
H.R. 3843, the ``Transparency for America's Heroes Act''
PVA cautiously supports H.R. 3843, the ``Transparency for America's
Heroes Act.'' Transparency is critical for the public to be able to see
and understand what its government is doing. In the case of VA quality-
assurance records, it only makes sense that this transparency is
critical to veterans, and those who serve veterans such as Veterans
Service Organizations (VSO), and their understanding of how well VA is
doing its job. Requiring VA to publish redacted medical quality-
assurance records on the VA's Web site will provide users of the VA a
better understanding of the successes or failures of the VA in the
quality of care they provide our veterans. This may encourage greater
efforts on the part of VA employees, staff and leaders to ensure the
best care is provided to veterans while ensuring openness. PVA's
concern stems from the need for privacy in health care records. It is
important that sufficient safeguards be put in place to prevent the
unintended release of personal health information that may be
detrimental to a VA patient.
H.R. 4041, to authorize improvements in the Federal Recovery
Coordinator Program
PVA fully supports H.R. 4041 that will implement the Federal
Recovery Coordinator Program. PVA agrees with the recommendation of the
Dole-Shalala Commission that a nationwide Federal Recovery Coordinator
Program will expand partnerships and collaborations to benefit veterans
of Operation Iraqi Freedom and Operation Enduring Freedom. As specified
in the legislation, there are a large number of services available to
transitioning veterans, but no good mechanism for coordinating medical
care for wounded warriors. There are so many programs that veterans can
have a difficult time navigating through this sea of help. While this
coordinator program may not solve all the challenges of coordinating
care, it will go a long way to providing for knowledgeable health care
professionals that can help wounded warriors navigate the often
confusing maze of services.
In addition, provisions of the legislation that will establish a
qualified nursing or medical school lead to review and develop
evidence-based guidelines for recovery coordination should ensure that
the program meets the needs of those being trained and the veterans
that are served. While initially only 45 coordinators are authorized to
be trained, PVA would recommend an expansion of the program dependent
on its demonstrated success.
H.R. 5428, to direct the Secretary of VA to educate VA staff
PVA supports H.R. 5428 to better educate injured and amputee
veterans on their rights and the requirement that VA staff who work at
prosthetics and orthotics clinics or who work as patient advocates for
veterans understand these rights as well. This bill would ensure that
VA prosthetics clinics around the country prominently display the
``Injured and Amputee Veterans Bill of Rights'' and that VA employees
understand it. This reaffirms the idea that a veteran in need of an
assistive device or prosthetic gets the highest quality item available
and in a timely manner. As expressed in previous testimony on this
topic, PVA is concerned that this legislation's language seems to
ignore veterans who may be in need of special equipment who suffer from
a specific disease and not a physical injury.
H.R. 5516, the ``Access to Appropriate Immunizations for Veterans Act
of 2010''
PVA strongly supports H.R. 5516, the ``Access to Appropriate
Immunizations for Veterans Act of 2010.'' It is accepted fact that
proper and timely administration of immunizations can prevent the onset
of more significant medical issues. By requiring the Secretary to
ensure these immunizations are administered in compliance with the
recommended adult immunization schedule, and requiring quality measures
to ensure this is done, it can be expected that veterans using the VA
will be healthier and less likely to suffer potential medical ailments.
The Department of Defense (DoD) follows these procedures to ensure a
more ready military force. It only makes medical and economic sense
that the health gains achieved by the DoD program for individuals prior
to leaving service should be continued to maintain and benefit the
health of veterans. Proper and timely immunizations are a guarantee of
better medical health in the VA patient population.
H.R. 5543, to repeal the prohibition on collective bargaining
PVA supports H.R. 5543 to repeal the prohibition on collective
bargaining with respect to compensation for VA employees which may
improve the collective bargaining rights and procedures for certain
health care professionals in the VA. As PVA testified in March of this
year, these changes may be a positive step in addressing the
recruitment and retention challenges the VA faces to hire key health
care professionals, particularly registered nurses (RN), physicians,
physician assistants, and other selected specialists. While PVA
supports the repeal, this support is contingent on determinations that
such repeal will in no way affect the care provided to veterans. This
is the single purpose of the VA and its employees and must always
remain so.
H.R. 5641, the ``Heroes at Home Act''
PVA generally supports H.R. 5641, the ``Heroes at Home Act.''
However, it is essential that proper protections are put in place to
ensure that it is the desire of the veteran to be transferred to a non-
VA nursing home and only in the case that the foster home meets VA
standards at the time of transfer. It is critical that to support this
program, VA verifies that the home is in compliance with VA standards
before a veteran is transferred. Too often a facility may have been in
compliance in the past and the same certification is used to judge the
current status of the facility. This must not be allowed to occur in
the case of these vulnerable veterans.
H.R. 5996, to direct the Secretary to improve the treatment of veterans
with pulmonary disease
PVA supports H.R. 5996 to direct the Secretary to improve the
treatment of veterans with chronic obstructive pulmonary disease
(COPD), develop a pilot program to demonstrate best practices for
diagnosis and management of COPD, and develop improved techniques and
best practices for smoking cessation. However, PVA is concerned with
language in Section 1(a) that it is ``Subject to the availability of
appropriations provided for such purpose . . . '' This legislation
essentially establishes an unfunded mandate that Congress is telling
the Secretary he can ignore. While this may be a result of the current
tight budget environment, if this legislation is needed to provide for
our Nation's veterans, the Secretary should be instructed to implement
the programs and they should be appropriately funded by Congress. This
legislation outlines excellent programs to improve the health of
veterans. Without stronger requirements directing the Secretary to
implement these programs, they may not be implemented by VA due to its
other competing requirements.
H.R. 6123, ``Veterans' Traumatic Brain Injury Rehabilitative Services'
Improvement Act of 2010''
PVA supports H.R. 6123, the ``Veterans' Traumatic Brain Injury
Rehabilitative Services' Improvement Act of 2010.'' Together with
Improvised Explosive Devices (IED), Traumatic Brain Injury (TBI) has
become a signature wound of the current wars in Afghanistan and Iraq.
Today, we still do not fully understand the impact or gravity of TBI.
In April 2008, the RAND Corporation Center for Military Health Policy
Research completed a comprehensive study titled Invisible Wounds of
War: Psychological and Cognitive Injuries, Their Consequences, and
Services to Assist Recovery. RAND found that the effects of TBI were
poorly understood, leaving a gap in knowledge related to how extensive
the problem is or how to handle it. RAND found 57 percent of those
reporting a probable TBI had not been evaluated by a physician for
brain injury. Military service personnel who sustain catastrophic
physical injuries and suffer severe TBI are easily recognized, and the
treatment regimen is well established. In recent testimony, PVA has
raised continuing concerns about servicemembers who do not have the
immediate outward signs of TBI getting appropriate care. The military
has implemented procedures to temporarily withdraw individuals from
combat operations following IED attacks for an assessment of possible
TBI, creating a significant military impact, but believing it necessary
for soldier health even if it reduced combat forces.
On July 12, 2006, the VA Office of the Inspector General (OIG)
issued Health Status of and Services for Operation Enduring Freedom/
Operation Iraqi Freedom Veterans after Traumatic Brain Injury
Rehabilitation. The report found that better coordination of care
between DoD and VA health-care services was needed to enable veterans
to make a smooth transition. While VA and DoD have done extensive
improvements of coordination since that report, the OIG Office of
Health Care Inspections conducted follow-on interviews to determine
changes since the initial interviews conducted in 2006. The OIG
concluded that 3 years after completion of initial inpatient
rehabilitation, many veterans with TBI continue to have significant
disabilities and, although case management has improved, it is not
uniformly provided to these patients.
Because all the impacts of TBI are still unknown, this legislation
to expand services and care, providing for quality of life and not just
independence, and emphasizing rehabilitative services, is important to
the ongoing care of TBI patients. It is imperative that a continuum of
care for the long term be provided to veterans suffering from TBI. PVA
believes this legislation is a step toward ensuring that care.
H.R. 6127
PVA generally supports this legislation; however, we do have some
concerns with the issues surrounding this bill. While we see no real
argument with granting these men and women who experienced the
exposures outlined by this bill access to the VA health care system, we
question why this is the only group singled out for enrollment. Given
the longstanding discussions about Operation Iraqi Freedom veterans
being exposed to burns pits or servicemembers exposed to hazardous
materials in any number of settings, we believe proper consideration
needs to be given to a broader spectrum of veterans and servicemembers.
H.R. 6188, the ``Veterans Homelessness Prevention and Early Warning
Act''
PVA also supports the draft legislation that outlines the VA's
notice and response requirements for defaults in loan payments
guaranteed by the VA. The recent collapse of the housing market coupled
with the struggles that many veterans face in the employment market
have created a situation where many veterans and their families are
defaulting on home loans and often losing their homes. This legislation
will ensure that veterans who are placed in this situation are quickly
identified so that they may be provided needed assistance by the VA.
Draft Legislation on Ensuring VA Provides Veterans with Information
Concerning Service-Connected Disabilities
PVA supports the draft legislation to ensure health care
professionals of VA provide veterans with information concerning
service-connected disabilities and information on submitting claims,
establishing service connection for a disability and contact
information of appropriate VA offices. The claims process can be
cumbersome and daunting and information to ease this process will be
helpful for the veterans. PVA would also hope that as part of this
process, VA would inform veterans of the availability of help from
congressionally chartered Veterans Service Organizations (VSO) that can
provide free help to veterans in understanding their rights and
pursuing any appropriate claims for service-connected injuries.
Draft Legislation on Improvements to VA Homeless Programs
PVA generally supports the provisions of the discussion draft on
improvements to VA homeless programs. Too many veterans continue to
live on the streets due to drug, mental health, financial and
employment challenges. The expansion of grant programs for improvements
to facilities and increased outreach to more homeless veterans may help
them receive services and rehabilitation and achieve the Secretary's
goal to end veterans' homelessness. In addition, the improvement of
payments for providing services to homeless veterans may increase the
number of veterans who can be served by homeless veteran providers. But
as PVA testified last October, we do have some concerns about the long-
term effects of the legislation.
PVA has always supported the idea of comprehensive care for
homeless veterans. Seldom is there one issue that leads veterans to
become homeless. Comprehensive care can be expensive. Additionally,
often homeless veterans reside in urban areas where the cost of living
is very high and there are limited opportunities for help. Section 3 of
the discussion draft allows the Secretary to increase the rates of
payment to reflect anticipated changes in the cost of services and
takes into account the cost of providing these services in particular
geographic areas.
While we welcome this consideration, PVA is concerned about the
long-term effects on VA homeless program funding. By adjusting the
payments for geographic areas, which we believe is aimed at providing
greater funding to high cost localities, this may actually reduce the
total number of homeless veterans that can be served if future
increases in overall program funding are insufficient. While the
argument could be made that ``reductions'' in funding for low cost
areas may offset increases to high cost areas, the funding levels
provided for homeless programs are seldom sufficient to provide for all
the veterans who may need to take advantage of these critical services.
PVA would recommend a very cautious approach on this legislation to
ensure the most vulnerable veterans are not inadvertently hurt in
efforts to provide greater funds for some of them.
Draft Health Care Legislation
PVA supports the draft legislation that would address a number of
items in the VA health care system. We are particularly pleased to see
that the Subcommittee is considering the extension of the Advisory
Committee on Homeless Veterans, particularly in light of the focus that
the Administration has placed on eliminating homelessness among
veterans.
We do have a question about Section 4 of the legislation. We are
unclear about the additional authority beyond simple contracting for
services in non-Department facilities outlined in Section 4 of the
bill. Specifically, we would like to know what purpose this expansion
of authorizing language serves and how it will serve to benefit the
VA's processes?
PVA would like to thank the Subcommittee once again for allowing us
to provide testimony on these important health care issues facing our
veterans. We certainly appreciate the continued attention this
Subcommittee has placed on these issues. I would be happy to answer any
questions that you might have. Thank you.
Prepared Statement of Adrian M. Atizado, Assistant National
Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to
testify at this important hearing of the Subcommittee on Health. DAV is
an organization of 1.2 million service-disabled veterans, and we devote
our energies to rebuilding the lives of disabled veterans and their
families.
Mr. Chairman, the DAV appreciates your leadership in enhancing
Department of Veterans Affairs (VA) health care programs on which many
service-connected disabled veterans must rely. At the Subcommittee's
request, the DAV is pleased to present our views on eleven (11) bills
before the Subcommittee today.
H.R. 3843--Transparency for America's Heroes Act
This measure would amend title 38, United States Code, Sec. 5705 to
make available on VA's Web site certain redacted records, documents, or
parts of documents that are associated with the Department's medical
quality-assurance program. It would also require such records or
documents created during the 2-year period before the bill's enactment
to be similarly made available. Current law specifies that such records
``are confidential and privileged and may not be disclosed to any
person or entity.'' 38 U.S.C. Sec. 5705(a).
The existing restrictions protect the integrity of the VA's medical
quality assurance program, carried out by or for VA for the purpose of
improving the quality of medical care or improving the utilization of
health care resources in VA medical facilities. These review activities
may involve continuous or periodic data collection and may relate to
the structure, process, or outcome of health care provided in the VA.
38 CFR Sec. 17.500.
The Need for Confidentiality
H.R. 3843 would amend title 38, United States Code, Sec. 5705
affecting disclosure of records and documents resulting from medical
quality assurance activities and designated across a number of foci.\1\
These records and documents are a crucial part of VA's health care
quality and safety activities.
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\1\ Department of Veterans Affairs, VHA Directive 2008-077: Quality
Management (QM) and Patient Safety Activities That Can Generate
Confidential Documents, November 7, 2008.
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The VA has implemented nationwide internal and external reporting
systems for organizational learning and improvement that supplement the
existing accountability systems. These systems are designed around
confidentiality to encourage maximal reporting of potential and
actually occurring problems by non-punitive methods that would then be
converted into corrective actions. Authoritative sources,2,3
surveys, and focus groups of both VA and external health care workers
found that health care providers' view of punitive actions extended
beyond typical administrative punishment to include factors such as
embarrassment, shame, and negative impact on professional reputation.
Protection from these factors means emphasizing prevention--not
punishment, and is essential for VA to continue receiving candid
reports on adverse events and/or close calls from which it could then
learn and undertake improvement and prevention efforts. Assuring non-
punitive, confidential, and voluntary programs is necessary for the
Department to receive reports to subsequently implement corrective
actions.
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\2\ Institute of Medicine, ``To Err is Human: Building a Safer
Health System'', November 1999.
\3\ The Joint Commission, ``2008 Comprehensive Accreditation Manual
for Hospitals: The Official Handbook,'' PI-1.
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Conversely, the Institute for Healthcare Improvement (IHI) has
found that all employee reporting programs (voluntary and mandatory)
result in substantial underreporting.\4\ Several studies have shown
that computer monitoring strategies have identified many times more
potential adverse events than were reported through employee reporting
mechanisms.5,6,7 The IHI's ``Trigger Tools'' are also used
to identify adverse events and detect safety
problems.8,9,10,11 Moreover, not having specific facility
and patient information has caused frustration when VA Central Office
and oversight bodies have requested Veterans Health Administration
(VHA) data regarding adverse events. Facility patient safety managers
have also had to create secondary, duplicative systems in order to
capture the patient information needed for effective reviews and
reports.
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\4\ Institute for Healthcare Improvement, ``Introduction to Trigger
Tools for Identifying
Adverse Events,'' Available at: http://www.ihi.org/IHI/Topics/
PatientSafety/SafetyGeneral/Tools/
IntrotoTriggerToolsforIdentifyingAEs.htm, Accessed: August 25, 2010.
\5\ David W. Bates, MD, MSc, et al., ``Detecting Adverse Events
Using Information Technology,'' J Am Med Inform Assoc, Vol. 10, No. 2,
March-April 2003, pp. 115-128.
\6\ M. K. Szekendi, et al., ``Active surveillance using electronic
triggers to detect adverse events in hospitalized patients,'' Qual Saf
Health Care, Vol. 15, June 2006, pp. 184-190.
\7\ C. W. Johnson, ``How will we get the data and what will we do
with it then? Issues in the reporting of adverse health care events,''
Qual Saf Health Care, Vol. 12, December 2003, p. ii64.
\8\ Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger
tool: A practical methodology for measuring medication related harm.
Quality and Safety in Health Care. 2003 Jun;12(3):194-200.
\9\ Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the
neonatal intensive care unit: Development, testing, and findings of an
NICU-focused trigger tool to identify harm in North American NICUs.
Pediatrics. 2006 Oct;118(4):1332-1340.
\10\ Griffin FA, Classen DC. Detection of adverse events in
surgical patients using the Trigger Tool approach. Quality and Safety
in Health Care. 2008 Aug;17(4):253-258.
\11\ Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R.
Development and evaluation of the Institute for Healthcare Improvement
Global Trigger Tool. Journal of Patient Safety. 2008 Sep;4(3):169-177.
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In this instance, consideration of H.R. 3843 requires a balance
between confidentiality and transparency to maintain VA employees'
perception that VA's quality and safety activities would not become
punitive in nature, while continuing to allow for candid reporting.
The Need for Transparency: Health Care
Under Executive Order 13410, ``[h]ealth care programs administered
or sponsored by the Federal Government promote quality and efficient
delivery of health care through the use of health information
technology, [and] transparency regarding health care quality.'' Its
purpose also includes making relevant information available to program
beneficiaries, enrollees, and providers in a readily useable manner and
in collaboration with similar initiatives in the private sector and
non-Federal public sector. In addition, VA has been actively seeking
ways for veteran patients and their families to take a more active role
in their health care, and to help manage their health care rather than
being advised what to do through a provider-centered
system.12,13
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\12\ Department of Veterans Affairs. ``Patient Centered Medical
Home Model Concept Paper,'' March 15, 2010. Available at: http://
www1.va.gov/PrimaryCare/docs/pcmh_ConceptPaper.doc; Accessed: August
26, 2010.
\13\ http://www.patientsafety.gov/patients.html#intro; Accessed:
August 26, 2010.
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There is a clear recognition that veterans and their families need
accurate information about the quality of care in VA-owned or
contracted facilities in order to make informed choices. These choices
depend, in part, on the most complete, timely information available.
In the 111th Congress, VA testified on a succeeding bill, S. 1427,
``Department of Veterans Affairs Hospital Quality Report Card Act of
2009.'' VA indicated that health care transparency is one of its major
Strategic Transformation Initiatives this fiscal year and is working
with the Centers for Medicare and Medicaid Services (CMS) to post VA
comparable data on the CMS ``Hospital Compare'' Web site (http://
www.hospitalcompare.hhs.gov). The Department reported it was similarly
exploring other public reporting programs.\14\
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\14\ Cross, Gerald M, Acting Under Secretary for Health, Department
of Veterans Affairs. Statement to the Senate, Committee on Veterans
Affairs. ``Hearing on Pending Legislation,'' Hearing, October 21, 2009.
Available at: http://www.veterans.senate.gov/
hearings.cfm?action=release .display&release_id=faa07041-78f1-45c7-
93f1-fff7b5a6f978; Accessed: August 26, 2010.
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In the 110th Congress, DAV testified before this Subcommittee on a
similar bill, H.R. 1448, ``The VA Hospital Quality Report Card Act of
2007.'' This bill sought to establish a ``hospital report card''
covering a variety of activities of inpatient hospital care occurring
in the medical centers of the Department to provide increased
disclosure and accountability in the VA system. The DAV supported this
bill, because it was consistent with trends occurring in private sector
health care enabling patients to review the quality and safety of their
care.
Notably, VA at that time opposed the bill as written as too
prescriptive in its requirements, and stated that much of the
information required by H.R. 1448 is available through other avenues,
such as The Joint Commission's (previously known as the Joint
Commission on Accreditation for Healthcare Organizations) Web site that
provides standardized comparative data in a form that has been tested
for consumer understandability and usefulness.
S. 1427 (111th) and H.R. 1448 (110th), both sought to provide
easily accessible reports published in acceptable lay terms on the
quality of VA's medical centers that include quality-measures data that
allow for an assessment of health care effectiveness, safety,
timeliness, efficiency, patient-centeredness, and equity. In contrast,
the bill now before the Subcommittee would simply make publicly
available redacted versions of VA's medical quality-assurance records.
It is uncertain whether making such documents available on VA's Web
site would meet the needs of veterans and their families to make
informed decisions.
Other key issues related to transparency must also be addressed in
addition to availability of information via the Internet. Any such
reports should be readable, understandable, and meaningful. Also,
accommodation should be provided so individuals may gain access by
telephone or mail requests, and during personal onsite visits. Finally,
and equally important, VA should encourage wide public awareness of the
availability of such information, how and where to access it, and
appropriate limitations on its use. We ask the Subcommittee staff to
address these shortcomings in the bill.
The Need for Transparency: Disability Compensation
Title 38, United States Code, Sec. 5705 is also the basis for
needed transparency in our organization's work representing service-
connected disabled veterans' claim for disabilities suffered as the
result of VA medical treatment governed by title 38, United States
Code, Sec. 1151.
According to VHA Handbook 1050.01, VHA National Patient Safety
Improvement Handbook (May 23, 2008), VHA facility staff have an
obligation to inform--or disclose to--patients any adverse events
consequent to their care. Routine disclosure of adverse events to
patients has been VHA's national policy since 1995. However, a 2008
report by VA's Office of Inspector General (VAOIG) shows that only 21
(54 percent) of 39 audited facilities had provided full disclosure.\15\
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\15\ Department of Veterans Affairs, Office of Inspector General,
Evaluation of Quality Management in Veterans Health Administration
Facilities Fiscal Year 2007, May 2008.
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Without such disclosure, many claims based on Sec. 1151 have been
denied because of confidentiality protections afforded to quality
assurance records under title 38, United States Code, Sec. 5705 and
title 38, Code of Federal Regulations, Sec. Sec. 17.500-17.511.
Analysis of such records could demonstrate proximate causes of injury
by carelessness, negligence, lack of proper skill, error in judgment,
equipment failure, or similar instance of fault on the part of the
Department's employees in furnishing the hospital care or medical
services involved that caused the injuries.
According to title 38, United States Code, Sec. 5705(b) and subject
to protections in title 5, United States Code, 552a (the Privacy Act),
title 38, United States Code, Sec. 5701 (veterans' names and
addresses), and title 38, United States Code, Sec. 7332 (drug and
alcohol abuse, sickle cell anemia, HIV infection), the Secretary must,
upon request, disclose quality assurance documents to several branches
of government, organizations, and persons. Moreover, the statute does
not prohibit the release of medical quality assurance records within
VA. See Sec. 5705(b)(5) (``Nothing in this section shall be construed
as limiting the use of [medical quality assurance records] within the
Department.''). DAV believes this authority includes VA employees such
as regional office (RO) adjudicators and rating boards, physicians who
conduct VA examinations, and Members of the Board of Veterans Appeals
(Board) since these VA employees are clearly ``within VA.'' However, we
commonly find claims based on title 38, United States Code, Sec. 1151
not fully developed because those claims do not contain quality
assurance records to validate the injuries claimed.
In 2000, Congress passed the ``duty to assist'' legislation that
requires the Department to assist a veteran in gathering all records
relevant to a claim. 38 U.S.C. Sec. 5103A(c)(2). In not exercising the
authority provided under title 38, United States Code Sec. 5705(b)(5),
the RO or the Board as part of their duty to assist the claimant
violates the statutory mandate to gather all relevant medical records
set forth in title 38, United States Code, Sec. 5103A(c)(2).
Furthermore, DAV believes the VA adjudication manual instructions for
medical quality-assurance records conflict with the statutory
requirements of title 38, United States Code, Sec. Sec. 5103a and 5705
and violates the duty to assist provisions in the development of a
claim made pursuant to a law administered by the Secretary.
A note contained in the VA Adjudication Manual \16\ that discusses
quality-assurance records states:
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\16\ VA Adjudication Manual 21-1, Part IV, Chapter 22, Subchapter
1, Sec. 22.03.
Do not request quality assurance investigative reports. These
reports are confidential under 38 U.S.C. Sec. 5705 and cannot be used
as evidence in adjudication of claims under 38 U.S.C. Sec. 1151. If
quality assurance investigative reports are received from a VA medical
facility, return the reports immediately. Do not file copies of these
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reports in the veteran's folder.
At best, the Department's instructions are an erroneous
interpretation of VA's statutory obligations, conflict with his duties
and responsibilities set forth in title 38, United States Code,
Sec. Sec. 5103A and 5705, and are not entitled to any ``Chevron''
deference. See Chevron U.S.A. Inc. v. Natural Resources Defense
Council, 467 U.S. 837 (1984); see also Timex V.I., Inc. v. United
States, 157 F.3d 879 (Fed. Cir. 1998) at 881-882.
In these instances, our organization must argue for a determination
as to whether medical quality-assurance records relevant to a veteran's
claim exist, then collect the records if they do exist, and consider
the veteran's claim in light of such records. We believe it should be
held that this VA Adjudication Manual provision violates the duty to
assist provisions in the development of a claim made pursuant to a law
administered by the Secretary. In this light, and with our stated
caveat relating to access to this information by means other than the
Internet, we support the purposes of this bill and urge the
Subcommittee to advance this legislation in an amended form. Also, we
ask the Subcommittee to work with your colleagues on the Disability
Assistance and Memorial Affairs Subcommittee to address our concerns
with respect to the non-availability of quality assurance records to
assist disabled veterans with their claims under Sec. 1151 of title 38,
United States Code.
H.R. 4041--To authorize certain improvements in the Federal Recovery
Coordinator Program, and for other purposes.
This measure would require VA to identify a qualified nursing or
medical school to develop a literature review and evidence-based
guidelines for recovery coordination, establish a consensus conference,
and develop training modules for care coordination. The bill would
authorize $1.2 million for that effort. Also, the bill would authorize
$500,000 for training 45 recovery coordinators by the designated
nursing or medical school, and would authorize $1.2 million for the
development, validation and piloting of technology tools and software
that is compatible with VA and Department of Defense (DoD) systems for
recovery coordination.
DAV remains concerned about the gaps that exist in the Federal
Recovery Coordination Program (FRCP) and social work case management.
These gaps were highlighted by disabled veterans and their families in
hearings held by the House Veterans' Affairs Subcommittee on Oversight
and Investigation in 2009 and 2010 and warrant continued oversight and
evaluation by this Subcommittee.
Issues discussed during those hearings include a multilayer
bureaucracy of clinical case managers at VA, DoD and private
facilities, Wounded Transition Unit (WTU) Liaisons, DoD Military
Liaisons, VA Clinical Rehabilitation Nurses, Transition Patient
Advocates, Veterans Benefits Administration (VBA) Counselors,
transition support coaches, multiple health care providers, and Federal
Recovery Coordinators (FRCs) to make and facilitate key referrals and
consultations to manage the patient's needs toward achieving Federal
Individualized Recovery Plan (FIRP) goals. Another is the integration
of Information Technology (IT) access within VA and the Military
Training Facility (MTF)--although DoD and VA state that these
challenges will be overcome with the implementation of more IT
integration between VA and DoD through such initiatives as the single
common personal identifier, which is a significant step toward making
the complex Virtual Lifetime Electronic Record (VLER).
The capacity for individual attention paid by FRCs to each client
in their caseload to meet individual needs and achieve FIRP goals is a
primary concern for DAV. We believe caseload standards should be based
on the scope of professional responsibilities, the volume of clients to
be served, the amount of time the FRC needs to spend with clients, the
breadth and complexity of client problems or services, and the length
and duration of case mix in determining case manager-client
involvement. The number of cases an FRC can realistically handle is
limited to the degree to which caseloads consist of acute, high-risk,
multi-need clients--that is, the degree of acuity of the medical
condition and complexity of non-medical needs of their clients.
Further, as part of The Independent Budget, the DAV recommends DoD
and VA must outline the requirements for assigning new or additional
FRCs caring for severely injured servicemembers in concert with
tracking workload, geographic distribution, and the complexity and
acuity of injured servicemembers' medical conditions.
A September 16, 2008, report to Congress on the development of a
comprehensive policy for DoD and VA on the care, management, and
transition of recovering servicemembers addresses the maximum number of
recovering servicemembers whose cases may be assigned to a recovery
care coordinator as required by the Wounded Warrior Act. It states that
the appropriate workload or case ratio for FRCs is not known. These are
new positions for which there are no comparable data or ratios.
Currently, all FRCs are tracking time utilization. New cases are
distributed based on existing caseloads. In the near future, the FRCP
will implement acuity based measures to more precisely balance
caseloads.\17\
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\17\ Report to Congress on the Comprehensive Policy Improvements to
the Care, Management and Transition of Recovering Servicemembers (NDAA
Section 1611 and 1615), September 16, 2008. Available at: http://
prhome.defense.gov/WWCTP/docs/09-16-08_1900_Final_Report_to
_Congress_-_1611_and_1615.pdf; Accessed: September 2, 2010.
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According to VA testimony in April 2009 about the FRCP, predicting
the total number of FRCs required for the program at any point in time
depends on the number of eligible servicemembers and veterans enrolling
and workload criteria based on intensity of needs. The program
supervisor located in VA's Central Office in Washington, D.C. monitors
time utilization statistics and the program has developed a hiring plan
based on estimates of eligible populations and a variety of estimated
workloads. If referral and enrollment rates are higher or lower than
projected, the number of new FRCs hired can be adjusted
accordingly.\18\
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\18\ Guice, Karen, Executive Director of the Federal Recovery
Coordination Program, Department of Veterans Affairs. Statement to the
Subcommittee on Oversight and Investigations, House Committee on
Veterans Affairs. ``Leaving No One Behind: Is the Federal Recovery
Coordination Program Working?'' Hearing, April 28, 2009. Available at:
http://www4.va.gov/OCA/testimony/hvac/soi/090428KG.asp; Accessed:
September 2, 2010.
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DAV believes FRC caseload size must realistically allow for
meaningful opportunities for face-to-face client contact. As caseload
size increases, the FRC has a declining capacity to perform ongoing
comprehensive coordination of care and support activities such as
follow-up, monitoring, and reassessment. However, flexibility of
caseload should exist but only for a limited time frame as is provided
in the Wounded Warrior Act. Overburdened FRCs do not serve the program
mission, the veteran, servicemembers, or their families. It is the
joint responsibility of VA, DoD, and the FRCP to address and remedy
caseload issues and concerns. To this end, we encourage the
Subcommittee to work with both VA and DoD to determine whether
additional FRCs are needed and if so, what the appropriate number would
be.
FRCP Education, Training, and Technology Tools
The Wounded Warrior Act requires a comprehensive policy on
improvements to care, management, and transition of recovering
servicemembers that includes standard training requirements and
curricula for recovery care coordinators under the program. The
requirement for successful completion of the training program before a
person may assume the coordinator duties.
We understand there are efforts underway to explore whether the
Medical College of Georgia (MCG) School of Nursing Clinical Nurse
Leader curriculum could be adapted for the needed national training
program for FRCs. The MSC School of Nursing has proposed a 6-month,
post-Master's certificate program using their clinical nurse leader
program to help train and certify VA and DoD's recovery coordinators.
Notably, the Charlie Norwood VA Medical Center, the Eisenhower Army
Medical Center at Fort Gordon, and the MCG School of Nursing, are
currently collaborating in the treatment of severely injured
servicemembers. The Charlie Norwood VA hosts an active duty
rehabilitation facility for military personnel.
Although the FRCP is operated as a joint DoD and VA program, VA is
responsible for the administrative duties, and program personnel are
employees of the agency. VA support includes technical and information
technology support, human resources management, and programmatic
support from both VBA and VHA. DoD provides assistance to the program
through the Line of Action Co-Lead and the Strategic Oversight
Committee and staff. This support includes assistance with development
of appropriate tools, and coordination of activities. FRCs are also
supported by their host facilities as determined by a Memorandum of
Agreement with each facility. These are in addition to the financial
requirements for both DoD and as noted in the Memorandum of
Understanding of October 30, 2007.
DAV urges the Subcommittee to work with both VA and DoD to
determine whether the provisions of H.R. 4041 to require a literature
review, evidence-based guidelines for recovery coordination, consensus
conference, and training modules for care coordination would enhance
the FRCP.
Also, the bill seems ambiguous in both the purpose and intended
uses of the care coordination software and the language in Section
2(c)(1)(A), which would require the VA to enter into relationship with
a subcontractor. Further, we urge the Subcommittee to include a public
reporting requirement summarizing the results of the software pilot
program. Finally, we recommend technical changes to the language, since
the program to which it refers is the Federal Recovery Coordination,
not Coordinator, Program.
H.R. 5428--To direct the Secretary of Veterans Affairs to educate
certain staff of the Department of Veterans Affairs and to inform
veterans
about the Injured and Amputee Veterans Bill of Rights,
and for other purposes.
This bill would ensure that an ``Injured and Amputee Veterans Bill
of Rights'' is printed on signage and displayed prominently in every VA
prosthetics and orthotics clinic, while requiring VA employees at the
clinics and patient advocates serving veterans receiving care there to
receive training on such Bill of Rights.
The bill would require the Secretary of Veterans Affairs to conduct
outreach to inform veterans of such Bill of Rights, and would direct VA
to monitor and resolve related complaints from veterans. VA would be
required to collect information relating to alleged mistreatment of
injured and amputee veterans at each VA medical center and to submit
such information quarterly to the VA's Chief Consultant in Prosthetics
and Sensory Aids for the purposes of investigation and resolution of
such complaints.
Although DAV has no specific resolution calling for an Injured and
Amputee Bill of Rights, DAV fully supports VA's Amputee System of care.
DAV, as part of The Independent Budget, strongly supports full
implementation of the VA amputation system of care program and
encourages Congress to provide adequate resources for the staffing and
training of this important program. The Independent Budget recommends
that VA expeditiously implement the proposed system providing proper
staffing levels and training to ensure VA provides superior health
services for aging and newly injured veterans who need these unique
services. Also, the VISN prosthetics representatives should maintain
and disseminate objectives, policies, guidelines, and regulations on
all issues of interpretation of prosthetics policies, including
administration and oversight of VHA's Prosthetics and Orthotics
Laboratories. The overall goals of this bill appear to be in line with
these stated recommendations and objectives; therefore, we have no
objection of the passage of this measure.
H.R. 5516--Access to Appropriate Immunizations for Veterans Act of 2010
This measure would require the Secretary of Veterans Affairs to
make available periodic immunizations against certain infectious
diseases as adjudged necessary by the Secretary of Health and Human
Services through the recommended adult immunization schedule
established by the Advisory Committee on Immunization Practices. The
bill would include such immunizations within the authorized
preventative health services available for VA-enrolled veterans. The
bill would establish publicly reported performance and quality measures
consistent with the required program of immunizations authorized by the
bill. The bill would require annual reports to Congress by the
Secretary confirming the existence, compliance and performance of the
immunization program authorized by the bill.
Although DAV has no adopted resolution from our membership dealing
specifically with this matter of immunizations for infectious diseases,
the delegates to our most recent National Convention in Atlanta,
Georgia, July 31-August 3, 2010, adopted Resolution No. 036, calling on
VA to maintain a comprehensive, high quality, and fully funded health
care system for the Nation's sick and disabled veterans, specifically
including preventative health services. Preventative health services
are an important component of the maintenance of general health,
especially in elderly and disabled populations with compromised immune
systems. If carried out sufficiently, the intent of this bill could
also contribute to significant cost avoidance in health care by
reducing the spread of infectious diseases and obviating the need for
health interventions in acute illnesses of those without such
immunizations. Therefore, DAV is pleased to support this bill and urges
its enactment.
H.R. 5543--To amend title 38, United States Code, to repeal the
prohibition
on collective bargaining with respect to matters and questions
regarding
compensation of employees of the Department of Veterans Affairs other
than rates of basic pay, and for other purposes.
Mr. Chairman, this bill would restore some bargaining rights for
clinical care employees of the VHA that were eroded by the former
Administration. The bill would amend subsections (b) and (d) of section
7422 of title 38, United States Code, by striking ``compensation'' both
places it appears and inserting ``basic rates of pay'' in its place.
The intent of the bill would be to authorize employee representatives
of recognized bargaining units to bargain with VHA management over
matters of employee compensation other than rates of basic pay.
DAV does not have an approved resolution from our membership on the
specific issues addressed by this bill. However, we believe labor
organizations that represent employees in recognized bargaining units
within the VA health care system have an innate right to information
and reasonable participation that result in making the VA health care
system a workplace of choice, and in particular, to fully represent VA
employees on issues impacting their working conditions.
Congress passed section 7422, title 38, United States Code, in
1991, in order to grant specific bargaining rights to labor in VA
professional units, and to promote effective interactions and
negotiation between VA management and its labor force representatives
concerned about the status and working conditions of VA physicians,
nurses and other direct caregivers appointed under title 38, United
States Code. In providing this authority, Congress granted to VA
employees and their recognized representatives a right that already
existed for all other Federal employees appointed under title 5, United
States Code. Nevertheless, Federal labor organizations have reported
that VA severely restricted the recognized Federal bargaining unit
representatives from participating in, or even being informed about, a
number of human resources decisions and policies that directly impact
conditions of employment of the VA professional staffs within these
bargaining units. We are advised by labor organizations that when
management actions are challenged, VA officials (many at the local
level) have used subsections (b), (c) and (d) of section 7422 as a
statutory shield to obstruct any labor involvement to correct or
ameliorate the negative impact of VA's management decisions on
employees, even when management is allegedly not complying with clear
statutory mandates (e.g., locality pay surveys and alternative work
schedules for registered nurses, physician market pay compensation
panels, etc.).
We believe this bill, which would rescind VA's ability to bargain
on matters of compensation other than rates of basic pay, is an
appropriate remedy to address part of the bargaining problem in the VA
professional ranks. We understand recently VA has given Federal labor
organizations some indication of additional flexibility in negotiating
labor-management issues such as some features of compensation, and we
are hopeful that this change signals a new trend in these key
relationships that directly affect sick and disabled veterans. We
endorse the intent of this bill and urge its enactment, while
continuing to hope that VA and Federal labor organizations can find a
sustained basis for compromise.
H.R. 5641--Heroes at Home Act
Since 1951, the VA's Community Residential Care (CRC) Program has
provided health care and sheltered supervision to eligible veterans not
in need of acute hospital care, but who, because of medical and/or
psychosocial health conditions, are not able to live independently and
have no suitable family or significant others to aid them.
The CRC Program is an important component in VA's continuum of
long-term care services operating under the authority of title 38,
United States Code, Section 1730. Any veteran who lives in an approved
CRC residence in the community is under the oversight of the CRC
Program. This program has evolved through the years to encompass
Medical Foster Home (MFH), Assisted Living, Personal Care Home, Family
Care Home, and Psychiatric CRC Home.
New partnerships between Home Based Primary Care (HBPC) and the
MFHs and CRCs have allowed veterans to live independently in the
community, as a preferred means to receive family-style living with
room, board, and personal care. Under the MFH Program, the
administrative costs for VHA are less than $10 per day, and the cost of
Home Based Primary Care, medications and supplies averages less than
$50 per day. Understandably, VA perceives this program as a cost-
effective alternative to nursing home placement, and it is gaining
popularity as evidenced by the program's expansion.
DAV is pleased with VA's innovation by offering the MFH program as
part of its long-term care program. Notably, patient participation in
this program, while voluntary, yields very high satisfaction ratings
from veterans. But because MHF operates under the CRC authority,
participating veterans must pay the MFH caregiver approximately $1,500
to $4,000 per month for room and board, 24-hour supervision, assistance
with medications, and whatever personal care may be needed.\19\ Even
veterans who are otherwise entitled to nursing home care fully paid for
by VA under the Veterans Millennium Health Care and Benefits Act
(Millennium Act) \20\ or under VA's policy on nursing home
eligibility\21\, must pay to live independently in a CRC or MFH.
According to VA, MFH is appropriate for certain veterans whose
conditions warrant a nursing home level of care but who prefer a non-
institutional setting. In other words, were it not for MFH, veterans
who meet the nursing home level of care standards would qualify for VA
paid care to receive it. In addition, veterans who do not have the
resources to pay the MFH caregiver are not able to avail themselves of
this benefit.
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\19\ 38 U.S.C. Sec. 1730(a)(3).
\20\ P.L. 106-117, 113 Stat. 1545 (1999) required that through
December 31, 2003, VA provide nursing home care to those veterans with
a service-connected disability rated at 70 percent or greater, those
requiring nursing home care because of a condition related to their
military service who do not have a service-connected disability rating
of 70 percent or greater, and those who were admitted to VA nursing
homes on or before the effective date of the act. Subsequent law
extended these provisions.
\21\ VA's policy on nursing home eligibility required that VISNs
provide nursing home care to veterans with 60 percent service-connected
disability ratings who are also classified as unemployable or Permanent
and Total Disabled.
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We applaud the intent of H.R. 5641, a bill that would allow VA to
contract with a certified MFH and pay for care of veterans already
eligible for VA paid nursing home care. As part of The Independent
Budget, DAV is greatly concerned that veterans living in the MFH
environment are required to pay for their stays using personal funds,
including their VA disability compensation.
Given the purposes of this bill and its probable cost, we are
concerned VA will not enter into such contracts. In VA's Geriatrics and
Extended Care (GEC) Strategic Plan,\22\, VA acknowledges the
eligibility mismatch between inpatient and non-institutional long-term
care and possible adverse impact on VA's extended care program.
Similarly, DAV recognizes VA long-term care services, especially
alternative, non-bed, community and home-based programs, are not
uniformly available in all VA health care facilities. Accordingly, the
delegates to our most recent National Convention assembled in Atlanta,
Georgia, July 31-August 3, 2010, passed National Resolution No. 209,
calling for legislation to expand the comprehensive program of long-
term care services for service-connected disabled veterans regardless
of their disability ratings.
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\22\ U.S. Department of Veterans Affairs. Patient Care Services.
Geriatrics and Extended Care Strategic Plan. Washington DC, December
24, 2008.
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In a special article written for the State of the Art Planning
Committee by Kenneth Shay, DDS, MS, Director of VA Geriatric Programs,
and James F. Burris, MD, Chief Consultant for VA Geriatrics and
Extended Care, they note there are three fundamental building blocks of
long-term care for chronically ill elders. They are personal care,
housing, and chronic disease care. Meaningful goals for long-term care
relate to maintaining and improving function and quality of life while
maximizing safety and autonomy. Because these goals are not always
compatible, there need to be tradeoffs and ranked priorities. In
addition, they cite the most-rapid growth in non-VA extended care
options has been in ``assisted living,'' a loosely defined and
minimally regulated set of residential and care services that VA does
not have statutory authority to provide or pay for. Yet suitably
supportive housing is a key component of non-institutional long-term
care, so VA has sought to implement alternative, creative solutions to
facilitate disabled veterans' access to supportive living options
without the agency actually paying the costs of room and board.\23\
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\23\ Shay K, Burris JF. Setting the stage for a new strategic plan
for geriatrics and extended care in the Veterans Health Administration:
summary of the 2008 VA State of the Art Conference, ``The changing
faces of geriatrics and extended care: meeting the needs of veterans in
the next decade''. J Am Geriatr Soc. 2008 Dec;56(12):2330-9.
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Assisted living bridges the gap between home care and nursing
homes. Assisted living is a general term that refers to a wide variety
of residential settings that provide 24-hour room and board and
supportive services to residents requiring minimal need for assistance
to those who require some ongoing assistance with personal care and
activities of daily living. VA's MFH program is commonly known as adult
foster care homes in the private sector and some residences that are
licensed as adult foster care homes may call themselves ``assisted
living.'' An adult foster care is a residential setting that provides
24-hour room and board, personal care, protection and supervision for
adults, including the elderly who require supervision on an ongoing
basis but do not require continuous nursing care.
Clearly, VA's MFH program should be realigned under a more
appropriate statutory authority. Public Law 106-117 authorized an
Assisted Living Pilot Program (ALPP) carried out in VA's VISN 20.
Conducted from January 29, 2003, through June 23, 2004, and involving
634 veterans who were placed in assisted living facilities, the pilot
project yielded an overall assessment report submitted to Congress
stating, ``the ALPP could fill an important niche in the continuum of
long-term-care services at a time when VA is facing a steep increase in
the number of chronically ill elderly who will need increasing amounts
of long-term care.'' \24\ Unfortunately, VA's transmittal letter that
conveyed the ALPP report to Congress stated that VA was not seeking
authority at that time to provide assisted living services, because VA
considered assisted living to be primarily a housing function.
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\24\ Susan H, Marylou G, et al., Evaluation of Assisted Living
Pilot Program. Report to Congress. Washington, DC, Office of Geriatrics
and Extended Care, VHA, July 2004.
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Despite VA's reticence, the 2004 ALPP report seemed most favorable,
and assisted living appears to be an unqualified success. In fact,
Title XVII, Section 1705, of the National Defense Authorization Act for
Fiscal Year 2008, Public Law 110-181, authorizes VA to provide assisted
living services.
Current estimates show more than 900,000 Americans live in
approximately 39,500 assisted living residences in the United
States.\25\ The 2009 MetLife survey put the average cost of assisted
living providing 10 or more services at $41,628 annually in 2009, but
found that private room nursing home rates average $79,935 per year,
and semi-private room rates average $72,270 per year.\26\ In fiscal
year (FY) 2009, VA spent over $5.2 billion--about 12 percent of its
total health care spending--to provide for veterans' long-term care
needs. Nearly 82 percent ($4.2 billion) of VA's total long-term care
spending in FY 2009 was for nursing home care. For FY 2011, VA expects
to spend over $6.8 billion--over 13 percent of its total health care
budget--to provide for veterans' long-term care needs. Over 78 percent
($5.4 billion) of VA's total long-term care spending in FY 2011 will be
for nursing home care.
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\25\ American Association of Homes and Services for the Aging.
Aging Services: The Facts. Available at: www.aahsa.org. Accessed on:
\26\ MetLife Mature Market Institute. The 2009 MetLife Market
Survey of Nursing Home,
Assisted Living, Adult Day Services, and Home Care Costs. New York, NY
2009. Available
at: http: // www.metlife.com / assets / cao / mmi / publications /
studies / mmi-market-survey-nursing-home-assisted-living.pdf. Accessed
on: September 8, 2010.
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While DAV would not oppose favorable consideration of this measure,
we ask this Subcommittee to address our concerns and the glaring hole
in VA's long-term care program considering the Department's stated long
term care mission is to ``continue to focus its long-term care
treatment in the least restrictive and most clinically appropriate
setting by providing more non-institutional care than ever before and
providing Veterans with care closer to where they live.'' \27\ This is
not the case today.
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\27\ Department of Veterans Affairs. FY 2011 Budget Submission:
Medical Programs and Information Technology Programs. Vol. 2:1A-8.
Washington, DC. February 2010.
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H.R. 5996--To direct the Secretary of Veterans Affairs to improve the
prevention, diagnosis, and treatment of veterans with chronic
obstructive
pulmonary disease.
This bill would require VA to develop treatment protocols and
related tools for the prevention, diagnosis, treatment, and management
of chronic obstructive pulmonary disease (COPD), and improve biomedical
and prosthetic research programs regarding COPD.
The bill would require VA to develop pilot programs to demonstrate
best practices for the diagnosis and management of COPD, in
coordination with the Director of the Centers for Disease Control and
Prevention (CDC), the Director of the Indian Health Service, and the
Administrator of the Health Resources and Services Administration.
Moreover, the bill would require VA to develop improved techniques and
best practices, in coordination with the Director of the CDC, for
assisting individuals with COPD in smoking cessation.
DAV has no specific resolution adopted by our membership to support
this particular measure; however, we recognize that until 1976,
cigarettes were routinely included free of charge in military field
rations and for decades were sold at deeply discounted prices in
commissaries and exchanges. Except for Navy and Marine bases, tobacco
products are still sold at discounted prices in military exchanges and
commissaries. Military-induced smoking accounts for a significant
percentage of the higher lung cancer rates, perhaps as high as 50
percent to 70 percent of the excess deaths. The percentage of active
duty military who ever smoked was highest during the Korean and Vietnam
Wars (75%). Currently overall 32.2 percent of active duty military
personnel smoke versus 19.8 percent of adults in the civilian
population and 22.2 percent of veterans overall.
In terms of maintaining and improving the general health of
veterans and of our membership, and consistent with VA's health
maintenance mission, DAV would offer no objection to the enactment of
this bill.
H.R. 6123--Veterans' Traumatic Brain Injury Rehabilitative Services'
Improvements Act of 2010
If enacted this bill would sharpen rehabilitative requirements
within the VA to ensure that veterans with traumatic brain injury (TBI)
under VA care are afforded opportunity for maximal rehabilitation,
including in their behavioral and mental health care needs, and to
sustain improvements they have made during the acute rehabilitative
period following injury, and hopefully leading to independence and a
better quality of life. The bill would redefine the term
``rehabilitative services'' as it appears in section 1701(8) of title
38, United States Code, by including elements that address sustenance
of VA efforts to prevent loss of functional gains achieved early in the
rehabilitative process, and to maximize an injured individual's
independence. Finally, the bill would amend section 1710E(a) of title
38, United States Code, to clarify that in the instance of the
Secretary's execution of a cooperative agreement with a public or
private entity with long-term neurobehavioral rehabilitation and
recovery programs, for hospital care or medical services for a brain-
injured veterans, that such cooperative agreements would also include
rehabilitative services for these veterans.
We appreciate the intentions of the sponsors of this bill to fill
an existing gap in current law affecting the treatment of brain injured
veterans. Our members adopted DAV National Resolution No. 215 at our
most recent convention, held in Atlanta, Georgia July 31-August 3,
2010. That resolution urges Congress and the Department of Veterans
Affairs to establish a comprehensive rehabilitation program, and to
sustain effective programs for veterans with traumatic brain injury.
This legislation is fully consistent with our resolution; therefore, we
endorse the bill and urge Congressional enactment.
H.R. 6127--To amend title 38, United States Code, to provide for
the continued provision of health care services to certain veterans
who were exposed to sodium dichromate while serving as a member of the
Armed Forces at or near the water injection plant at Qarmat Ali,
Iraq, during Operation Iraqi Freedom.
This measure would provide access to VA health care for veterans
who were in and around the water injection facility in the Basrah oil
fields at Qarmat Ali, Iraq, during the spring and summer of 2003. These
veterans would be able to enroll, within a 5 year window of
notification of exposure from the VA, into the VA health care system
under the Department's ``special treatment'' authority of Priority
Group 6 to receive VA health care.
DAV supports this bill in accordance with our Resolution No. 298
calling for congressional oversight and Federal vigilance to provide
for research, health care, and improved surveillance of disabling
conditions resulting from military toxic and environmental hazards
exposures. We also ask for the Subcommittee's consideration to afford
the same eligibility to those veterans who were exposed to toxic
substances as a result of disposing a poisonous mixture of plastics,
metals, paints, solvents, tires, used medical waste and asbestos
insulation in open-air trash burn pits in Iraq and Afghanistan. Tests
on the burn pits in the war zones have shown that the fires released
dioxins, benzene and volatile organic compounds, including substances
known to cause cancer.
Exposure to these toxic substances is not in question since VA is
already gathering data to monitor potential health problems in troops
who say they were made ill by exposure to smoke from open-air burn pits
in Iraq and Afghanistan with the goal of establishing potential
correlations with health problems among affected veterans.
Draft Legislation--To amend title 38, United States Code, to ensure
that
the Secretary of Veterans Affairs provides veterans with information
concerning service-connected disabilities at health care facilities.
DAV supports the intention of this bill in particular ensuring the
availability of information at readily accessible locations. We urge
the Subcommittee to include contact information of congressionally
chartered Veterans Service Organizations (VSO) that can provide free
counseling and assistance to veterans and their dependents in pursuing
claims for compensation of service-connected conditions. We are
concerned however, with the administrative burden on VA employees
orally being required to ask each veteran who visits a VA facility if
the veteran would like to receive information when the total number
outpatient care encounters in FY 2009 was 92,892,834.\28\ While we
support the good intentions of this bill, this notification requirement
may prove impossible to implement.
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\28\ Department of Veterans Affairs, Office of Inspector General,
Health care Inspection Review of Inappropriate Copayment Billing for
Treatment Related to Military Sexual Trauma, February 2008.
---------------------------------------------------------------------------
Draft Legislation--To amend title 38, United States Code, to make
certain
improvements in programs for homeless veterans administered by the
Secretary of Veterans Affairs, and for other purposes.
Veterans are over-represented in the homeless population. According
to the VA, about one-third of the adult homeless population has served
in uniform. Current population estimates suggest that over 130,000
veterans are homeless on any given night and twice as many experience
homelessness at some point during the course of a year. Homelessness is
also a growing problem for our veterans returning from Iraq and
Afghanistan, especially as they face higher rates of unemployment, and
often carry the effects of posttraumatic stress disorder (PTSD) and
traumatic brain injury (TBI) into their post-service years. Statistics
from VA and the National Coalition for Homeless Veterans (NCHV)
indicate two-thirds of homeless veterans do not receive the help they
need to transition from homelessness to become productive citizens.
Section 2 of this draft bill would expand the existing special
needs grant program by including new eligible public or nonprofit
private entities that meet prescribed criteria and requirements as well
as authorize increased appropriations levels for this program. Those
homeless veterans with special needs include women, women with minor
dependents, frail elderly; terminally ill; or chronically mentally ill.
Mr. Chairman, there is a great need for specific emphasis on the
needs of homeless women veterans, homeless veterans with children, and
homeless veterans suffering from serious mental illness. We have
greater numbers of women veterans coming to VA with post-deployment
mental health needs due to combat exposure, which puts them at higher
risk for becoming homeless. Likewise, many homeless veterans with minor
children have been unable to avail themselves of VA's excellent
programs because no support for their children is available in VA
programs. It is clear this measure will provide comprehensive services
to this vulnerable population including homeless veterans who are frail
elderly, terminally ill, or suffering from serious mental illness.
Section 3 of this draft bill would increase the amount authorized
to be appropriated for the Grant and Per Diem (GPD) program for
homeless veterans to reflect anticipated changes in the cost of
furnishing services and to take into account the cost of providing
services in a particular geographic area. It would also make these
payments based on annual costs instead of daily costs. This section is
identical to Section 3 of H.R. 4810, the End Veterans Homelessness Act
of 2010, which was unanimously passed by the House on March 22, 2010.
H.R. 4810 includes provisions addressing VA's concern outlined in
testimony submitted to this Subcommittee on October 1, 2009, by
allowing the Department to make payments to per diem grant recipients
on a quarterly basis, and would create a quarterly reconciliation
process where adjustments are made to increase or decrease payments.
DAV believes Section 3 of the draft bill would provide organizations
serving homeless veterans the flexibility to look at their program
designs to provide the full range of supportive services in the most
economical manner.
The delegates to our most recent National Convention in Atlanta,
Georgia, July 31-August 3, 2010, adopted Resolution No. 223, which
urges Congress to sustain sufficient funding to support the VA's
initiative to eliminate homelessness among veterans in the next 5 years
and strengthen the capacity of the VA Homeless Veterans program.
Furthermore, our resolution urges Congress to continue to authorize
and appropriate funds for competitive grants to community-based and
public organizations including the Department of Housing and Urban
Development to provide health and supportive services to homeless
veterans placed in permanent housing. Accordingly, DAV supports this
measure but urges the Subcommittee to ensure adequate funding levels
are appropriated for VA homeless programs, which historically have been
seldom sufficient to provide for all the veterans who may need to take
advantage of these critical services.
Mr. Chairman, this concludes DAV's testimony on these measures. DAV
appreciates the opportunity to offer our positions on these bills. I
would be pleased to address any questions from you or other Members of
the Subcommittee.
Prepared Statement of Ralph Ibson, Senior Fellow for Policy,
Wounded Warrior Project
Chairman Michaud, Ranking Member Brown and Members of the
Subcommittee:
Thank you for inviting Wounded Warrior Project (WWP) to offer our
views on legislation pending before the Subcommittee.
Wounded Warrior Project was founded on the concept of warriors
helping warriors. From our outstanding service programs to advocacy, we
work to help ensure that this generation of wounded warriors thrives--
physically, psychologically and economically. WWP's policy objectives
are targeted to filling gaps in programs or policies--and eliminating
barriers--that impede warriors from thriving. As such, we bring an
important perspective to this morning's hearing.
Our public policy positions reflect the experiences and concerns of
those wounded warriors and family members we serve on a day to day
basis around the country. Several of the issues that would be addressed
by legislation under consideration today are of great interest to our
constituency, and we look forward to discussing those bills. Several
other bills address concerns that our warriors and families have simply
not encountered, and we will not offer a position on those issues.
One of the bills before you, H.R. 6123, addresses some of the
deepest concerns we have heard from warrior's families, and we are very
pleased to be able to enthusiastically support this important bill.
Traumatic Brain Injury Rehabilitation
Impressive military logistics and advances in military medicine
have saved the lives of OEF/OIF combatants who would likely not have
survived in previous conflicts. As a result, servicemembers are
returning home in unprecedented numbers with severe polytraumatic
injuries. Among the most complex are severe traumatic brain injuries.
Each case of traumatic brain injury is unique. Depending on the injury
site and other factors, individuals may experience a wide range of
problems--from profound neurological and cognitive deficits manifested
in difficulty with speaking, vision, eating, or incontinence to marked
behavioral symptoms. While individuals who have experienced a mild or
moderate TBI may experience symptoms that are only temporary and
eventually dissipate, others may experience symptoms such as headaches
and difficulty concentrating for years to come. Those with severe TBI
may face such profound cognitive and neurological impairment that they
require a lifetime of caretaking. As clinicians themselves recognize,
it is difficult to predict a person's ultimate level of recovery.\1\
But to be effective in helping an individual recover from a brain
injury and return to a life as independent and productive as possible,
rehabilitation must be targeted to the specific needs of the individual
patient. In VA parlance, rehabilitation must be ``veteran-centered.''
---------------------------------------------------------------------------
\1\ Sharon M. Benedict, PhD, ``Polytrauma Rehabilitation Family
Education Manual,'' Department of Veterans Affairs Polytrauma
Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia;
http://saa.dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf
(accessed April 27, 2010).
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While many VA facilities have dedicated rehabilitation-medicine
staff, the scope of services actually provided to veterans with a
severe TBI can be limited, both in duration and in the range of
services VA will provide or authorize. It is all too common for
families--reliant on VA to help a loved one recover after sustaining a
severe traumatic brain injury--to be told that VA can no longer provide
a particular service because the veteran is no longer making
significant progress. Yet ongoing rehabilitation is often needed to
maintain function,\2\ and veterans with traumatic brain injury who are
denied maintenance therapy can easily regress and lose cognitive,
physical and other gains made during earlier rehabilitation.
---------------------------------------------------------------------------
\2\ Ibid.
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Some do make a good recovery after suffering a severe TBI. But many
have considerable difficulty with community integration even after
undergoing rehabilitative care, and may need further services and
supports.\3\ Medical literature has documented the need to use
rehabilitative therapy long after acute care ends to maintain function
and quality of life.4,5,6 While improvement may plateau at a
certain point in the recovery process, it is essential that progress is
maintained through continued therapy and support. The literature is
clear in demonstrating the fluctuation that severe TBI patients may
experience over the course of a lifetime. One study found that even 10
to 20 years after injury individuals were still suffering from feelings
of hostility, depression, anxiety, and further deficiencies in
psychomotor reaction and processing speed.\7\ While some are able to
maintain functional improvements gained during acute rehabilitative
therapy, others continue to experience losses in independence,
employability, and cognitive function with increasing intervals of
time.\8\ Given such variation in individual progress rehabilitation
plans must be dynamic, innovative, and long term--involving patient-
centered planning and provision of a range of individualized
services.\9\
---------------------------------------------------------------------------
\3\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH;
``Systems of Care,'' in Textbook of Traumatic Brain Injury (4th ed.),
American Psychiatric Publishing (2b), 533-568.
\4\ Hoofien D, Gilboa A, Vakils E, et al. ``Traumatic brain injury
(TBI) 10-20 years later: a comprehensive outcome study of psychiatric
symptomatology, cognitive abilities and psychosocial functioning.''
Brain Injury 15.3(2001):189-209.
\5\ Sander A, Roebuck T, Struchen M, et al. ``Long-term maintenance
of gains obtained in postacute rehabilitation by persons with traumatic
brain injury.'' Journal of Head Trauma Rehabilitation 16.4(2001): 356-
373.
\6\ Sloan S, Winkler D, Callaway L. ``Community Integration
Following Severe Traumatic Brain Injury: Outcomes and Best Practice.''
Brain Impairment 5.1(May 2004): 12-29.
\7\ Hoofien, et al. 201
\8\ Sander, et al. 370
\9\ Sloan, et al. 22
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For this generation of young veterans, reintegration into their
communities and pursuing life goals such as meaningful employment,
marriage, and independent living may be as important as their medical
recovery. Yet studies have found that as many as 45 percent of
individuals with a severe traumatic brain injury are poorly
reintegrated into their community, and social isolation is reported as
one of the most persistent issues experienced by such patients.\10\ Yet
research has demonstrated that individuals with severe TBI who have
individualized plans and services to foster independent living skills
and social interaction are able to participate meaningfully in
community settings.\11\ While improving and maintaining physical and
cognitive function is paramount to social functioning, many aspects of
community reintegration cannot be achieved solely through medical
services. Other non-medical models of rehabilitative care--including
life-skills coaching, supported employment, and community-reintegration
therapy--have provided critical support for community integration. But
while such supports can afford TBI patients opportunities for gaining
greater independence and improved quality of life, VA medical
facilities too often deny requests to provide these ``non-medical''
supports for TBI patients. While such services could often be provided
under existing law through other VA programs,\12\ it is troubling that
institutional barriers stand in the way of meeting veterans' needs
under a ``one-VA'' approach. Instead, rigid adherence to a medical
model and foreclosing social supports is, unfortunately, a formula for
denying veterans with severe traumatic brain injury the promise of full
recovery. This barrier must be eliminated.
---------------------------------------------------------------------------
\10\ Sloan, et al. 12
\11\ Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH;
``Systems of Care,'' 533-568.
\12\ See VA's program of independent living services (administered
by the Veterans Benefits Administration) under 38 U.S.C. sec. 3120, and
VA's authority under 38 U.S.C. sec. 1718(d)(2) to furnish supported
employment services as part of the rehabilitative services provided
under the compensated work therapy program (administered by the
Veterans Health Administration).
---------------------------------------------------------------------------
H.R. 6123 would amend current law to clarify the scope of VA's
responsibilities in providing rehabilitative care to veterans with
traumatic brain injury. While current law (codified in sections 1710C
and 1710D of title 38, U.S. Code) directs VA to provide comprehensive
care in accord with individualized rehabilitation plans to veterans
with traumatic brain injury, in some instances warriors with severe
traumatic brain injury are not receiving services they need, and in
other instances, VA has cut off rehabilitative services prematurely.
Ambiguities in current law appear to contribute to such problems.
For example, while the above-cited provisions of law do not define the
term ``rehabilitation,'' the phrase ``rehabilitative services'' is
defined for VA health-care purposes (in section 1701(8)) to mean ``such
professional, counseling, and guidance services and treatment programs
as are necessary to restore, to the maximum extent possible, the
physical, mental, and psychological functioning of an ill or disabled
person.'' That provision could be read to limit services to restoring
function, but not to maintaining gains that had been made. (Yet
limiting TBI rehab care in that manner risks setting back progress that
has been made.) The definition is also limited to services to restore
``physical, mental and psychological functioning.'' In our view,
rehabilitation from a traumatic brain injury should be broader, to
include also cognitive and vocational functioning, and, should not
necessarily be limited to services furnished by health professionals.
In essence, H.R. 6123 would provide that in VA's planning for and
providing care to veterans with traumatic brain injuries--
1. rehabilitative services must be directed not simply to
``improving functioning'' but to sustaining improvement and preventing
loss of functional gains that have been achieved (and, as such,
rehabilitation may be continued indefinitely); and
2. rehabilitative services are not limited to services provided by
health professionals but include any other services or supports that
contribute to maximizing the veteran's independence and quality of
life.
WWP strongly supports this legislation. It would eliminate barriers
too many have experienced. Most importantly, it would offer the promise
of making good on the profound obligation we owe those who struggle
with complex life-changing brain injuries.
Prosthetic and Orthotic Services
Turning to another area of keen importance, H.R. 5428 would
establish new requirements regarding VA provision of prosthetic and
orthotic care. Specifically, it would direct VA to disseminate,
display, and educate department employees on an Injured and Amputee
Veterans Bill of Rights; and establish a process for collecting,
monitoring and resolving complaints. We applaud this bill's focus on
provision of high quality prosthetic and orthotic technology and
service, and concur that the proposed bill of rights aptly captures
many concerns voiced by warriors we serve. But we do not believe that
H.R. 5428 goes far enough to resolve those concerns, and would be
pleased to work with the Subcommittee to explore avenues for bolstering
the bill.
To illustrate the concerns we have encountered, let me share a
perspective from retired Army captain Jonathan Pruden, who in 2003
became one of the first IED casualties of Operation Iraqi Freedom.
After 20 operations at 7 different hospitals that included amputation
of his right leg, he works with hundreds of wounded warriors in
Florida, Georgia, South Carolina and Alabama as one of our Area
Outreach Coordinators. Reflecting his own experience, Captain Pruden
reported that--
``VA had attempted three times to make an orthotic for me, but
I'm still wearing the delaminating pair I received at Walter Reed in
2004. I receive my care from a private prosthetist because I feel that
the VA practitioners I met were not going to be able to provide the
level of expertise, fit, or care I desired.
``For many years now the majority of VA patients have been
middle-aged to elderly. I can't tell you how many times I was asked if
I lost my leg due to diabetes or vascular disease. When I went in to my
local prosthetics clinic and started to ask about a Renegade foot vs. a
flex foot or a Ceterus, I got blank stares and a few `Oh, yea, I've
heard about those. They're pretty cool aren't they?' As of October
about 30 percent of VA prosthetists had no national certifications. The
technology and funding seem to be there but without practitioners who
really care it won't matter.''
He described the experience of having been asked recently by the
head of his local VA prosthetics lab to come in and have a socket made
using a new computer-aided design (CAD) device. ``I was happy to do
it,'' he said, ``and went in for a training session with the company
technician. Unfortunately, the only ones who learned how to use the
device were the chief and me. The other prosthetists were present but
clearly showed no interest in learning how to use the new device. Their
attitude seemed to be, that they had been doing this for a long time
and could do what they needed without all this high-tech gadgetry.''
While there have been substantial improvements in VA prosthetic and
orthotic care over the years, the VA-launched Survey for Prosthetic Use
highlights the need for further changes. It showed, for example, that
overall only 16 percent of Vietnam veteran survey participants and 9
percent of OIF/OEF survey participants received prostheses directly
from VA, while 78 percent of Vietnam participants and 42 percent of
OIF/OEF participants used prostheses from private sources under
contract with VA.\13\ Among its other findings were that participants
experienced lower satisfaction when VA was compared with private and
DoD care except for participants with upper-limb loss for whom
satisfaction with prosthetic providers was similar across all
conflicts. A concern across all survey participants was the dearth of
information on new prosthetic devices. The study's findings on
differences in satisfaction between sources of care suggest a need for
continued provider education and system evaluation.\14\
---------------------------------------------------------------------------
\13\ D.G. Smith and G.E. Reiber, ``VA paradigm shift in care of
veterans with limb loss,'' Journal of Rehabilitation Research and
Development, vol. 47, number 4 (2010).
\14\ G.M. Berke, J. Fergason, J.R. Milani, J. Hattingh, M.
McDowell, V. Nguyen, G.E. Reiber; ``Comparison of satisfaction with
current prosthetic care in veterans and servicemembers from Vietnam and
OIF/OEF conflicts with major traumatic limb loss,'' Journal of
Rehabilitation Research and Development, vol. 47, number 4 (2010) 361-
71.
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H.R. 5428, in listing rights that VA should provide to veterans who
have lost a limb, identifies many important expectations VA should be
meeting, and unfortunately, often is not--ranging from continuity and
comparability of care in the transition from DoD to VA to consistent
services and technology at all VA medical facilities. We share some of
the frustration underlying this legislation, and welcome Chairman
Filner's spotlighting these issues. But we are not confident that
enacting this measure would resolve the problems it highlights.
Directing VA to disseminate and display a list of ``rights'' does not
make those expectations enforceable; nor does it require VA to take the
kind of steps that would convert amputees' expectations into reality.
Accordingly, we recommend that the bill be expanded to direct the
Department to institute the kind of changes needed to realize the
measure's objectives.
The Federal Recovery Coordinator Program
H.R. 4041 would direct VA to fund the training of recovery
coordinators through a school of nursing or medicine. We know from the
experience of severely wounded warriors and their families how
singularly important the Federal Recovery Coordinator (FRC) Program has
been. We have also testified to the need to ``grow'' that program--to
ensure, for example, that those who sustained profound injuries prior
to the creation of the FRC program, and who still need such help be
assigned a qualified FRC. The number of FRC's has not grown
commensurately with the need for such support. So we welcome the vision
inherent in the bill that there is a need for additional trained
recovery coordinators. Given the requirements of these demanding
positions, FRC's must be highly experienced health professionals who
are knowledgeable about the health and benefits systems on which
warriors and their families may depend. As such, FRCs may need
specialized education and training. But it is not clear that VA needs
legislation to mount such training; further we defer to the Director of
the FRC program as to whether the model called for under that bill is
necessarily the optimal way to meet the program's training needs.
Other Legislation
H.R. 5641 would provide specific authority for VA's medical foster-
home program--an initiative under which VA both places veterans who
need long-term daily care in family-like settings under contract
arrangements and provides those veterans with home-health services.
Such arrangements can provide a good option for chronically ill or
severely disabled veterans who cannot live with their own families and
do not want to be institutionalized. While we understand that this
program was designed to help older veterans, it may meet a need on the
part of some number of much younger OEF/OIF veterans as well. We
support this provision.
H.R. 6127 would provide VA health care eligibility to veterans who
have received government notification of possible exposure to a
particular carcinogen at or near a specific site in Iraq in 2003 and
have enrolled in the VA health care system within 5 years after such
notification. H.R. 6127 is generally consistent with prior laws, under
which Congress has extended health care eligibility to veterans
presumed to have been exposed to toxic substances (including herbicides
in Vietnam, radiation, and chemical and biological warfare testing). We
have no objection to extending that principle, but question legislating
on an incident by incident basis. Given the potential range of toxic
substances to which veterans might have been exposed in Iraq and
Afghanistan--we recommend that consideration be given to a systematic
approach to addressing toxic exposures that are the subject of VA or
DoD notifications to veterans or servicemembers.
Homeless Veterans' draft bill: The Subcommittee has before it a
draft bill that would make revisions to certain grant programs designed
to assist homeless veterans. Among its provisions, the bill would
clarify that any public or nonprofit private entity with the capacity
to administer a grant is eligible for grant support to assist homeless
``special needs' '' veterans; would establish specific requirements for
such grants; and increase the authorized funding levels for such
grants. It would also revise the framework of the current ``grant and
per diem'' comprehensive service program to eliminate the requirement
that payments to grantees be based on a daily cost of care, and would
provide for annual adjustments in rates of payment. WWP applauds the
goal of eliminating homelessness among veterans, and recognizes the
benefits of VA's partnering with public and nonprofit entities that are
dedicated to helping homeless veterans. We have no objection to fine-
tuning these grant programs, though we have no position on the specific
changes proposed in this measure.
H.R. 3843 would require VA to publish on its Web site an easily
accessible, redacted version of all medical quality-assurance records,
no later than 30 days after the record is created, to include all such
records created during the 2 years prior to the date of enactment. As
we understand it, such records would be redacted to delete the names
and other identifying information of any individual patient or
employee.
This Committee has a long record of concern for ensuring the
quality of the care afforded veterans in the VA health care system--a
concern WWP certainly shares. A vibrant, healthy medical quality-
assurance program is one important element in fostering a culture of
quality-improvement in health-care delivery. Certainly, transparency is
an important element in sustaining confidence in the quality of VA
care. At the same time, confidentiality has long been deemed a critical
element of ensuring the integrity of an effective medical quality-
assurance program. This bill raises questions in that regard. Would
redacted records still contain enough information to lead to
unwarranted identification of patients or clinicians, particularly at
smaller facilities? Would providers, fearful of such disclosures, be
more likely to compromise the quality-assurance process? WWP has no
position on how best to balance the inherent conflict this bill raises
between transparency and ensuring robust systemic health care reviews,
but believes this is an area in which to proceed cautiously.
Thank you for considering our views on these bills. WWP has no
position on the other bills under consideration this morning.
Prepared Statement of Hon. Chellie Pingree, a Representative
in Congress from the State of Maine
Chairman Michaud, Ranking Member Brown, thank you for having me
here today. I am happy to be here in front of the Veterans Affairs
Subcommittee on Health to talk about a bill I recently introduced, the
Inform All Veterans Act, H.R. 6220. This bill will ensure that veterans
are given complete information about service connected benefits at all
VA Medical Centers.
All too often, a veteran will visit a VA Medical Center, ask how to
file a claim for service connection, and are either not given the
correct information on how to pursue their claim, or worse they leave
the Medical Center thinking that their claim is under way when it is
not.
This is a symptom of the Veterans Health Administration and
Veterans Benefits Administration not communicating with each other
effectively and operating as silos. Interagency communication is a
necessity, especially when we are talking about basic, earned services.
Under this bill, the VHA would be required to ask during the check-
in process if a veteran would like information about the disability
claims process. If the answer is yes, then straightforward, easy to
understand literature is shared which will outline how to contact VBA
or a Veterans Service Officer to start the disability claims process.
Congress has a responsibility to take care of our veterans. We
cannot do that if we do not inform them about the health care and
compensation their service has earned. This common sense approach will
help veterans avoid the bureaucratic red tape that prohibits many
veterans from even filing a claim.
Again, thank you Chairman Michaud and Ranking Member Brown for
allowing me to be here today, and for all you have done on behalf of
our Nation's veterans. I am happy to answer any questions the panel has
about this bill.
Prepared Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy
Under Secretary for Health, Veterans Health Administration,
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 several bills that would affect the
Department of Veterans Affairs' programs of benefits and services. With
me today is Walter A. Hall, Assistant General Counsel. Unfortunately,
we do not yet have views and estimates for H.R. 6123, H.R. 6127, or the
draft bills on homeless programs, homeless prevention, and requirements
for providing Veterans with information regarding compensation claims
and service-connected disabilities. We will forward these as soon as
they are available.
H.R. 3843--``Transparency for America's Heroes Act''
Public Law 96-385, enacted on October 7, 1980, established the
confidentiality of medical quality-assurance records now codified at 38
U.S.C. 5705. H.R. 3843 would amend section 5705 to dramatically limit
the scope of this confidentiality. Specifically, the bill would limit
confidentiality to records containing the name or other identifying
information of a patient, employee, or other individual associated with
VA for purposes of a medical-quality assurance program if disclosure
would clearly constitute an invasion of personal privacy. However, this
provision would permit the wholesale release of information if the name
or other identifying information is redacted. Moreover, H.R. 3843 would
require VA to make quality-assurance records available on the
Department's Web site within 30 days of their creation. The bill would
also require VA to make available on the Internet all quality-assurance
records created in the 2-year period preceding enactment of this Act.
VA strongly opposes this legislation. Confidentiality is a
fundamental and critical element of quality-assurance programs. It
improves patient safety outcomes by creating an environment in which
providers may report and examine patient safety events without fear of
recrimination or an increased risk of liability. As with VA, the
Department of Defense, all 50 states and the District of Columbia have
statutory restrictions on disclosure of quality-assurance information.
The public reporting requirements in H.R. 3843 would require a dramatic
departure from this widely held standard and would create an abrupt and
highly disruptive reversal of longstanding and successful VA policy. VA
policy currently provides confidentiality for certain records that
contain discussions of quality of health care, even if they do not
identify an individual. If this information were released, employees
may be less willing to be forthcoming about quality issues that arise
at their facilities. In addition, implementing the legislation would be
both costly and logistically challenging.
While opposed to H.R. 3843, VA is committed to transparency
regarding the quality and safety of the care it provides. Since 2008,
VA has published a Hospital Report Card containing extensive quality
and safety performance data for each of our 153 medical centers. In
addition, select quality data from VA medical centers is posted on the
Centers for Medicare and Medicaid Services' Hospital Compare Web site.
This transparency allows Veterans and other stakeholders to compare the
quality of VA medical centers with other hospitals in their
communities. Due to both logistical and legal reasons, not all VHA
quality data is available on Hospital Compare. VA has created its own
Hospital Compare site to address this gap, although VA's site provides
comparisons among VA medical centers rather than other hospitals in a
Veteran's community. VA also hosts an additional Web site which
publishes industry-standard quality scores developed by The Joint
Commission and the National Committee on Quality Assurance. While
targeting a more technical audience, this site allows readers to
compare VA to other facilities, both locally and nationally. An
enhanced version of this Web site is expected to launch in October
2010.
We understand that some of the interest in transparency is to
promote accountability. VA strongly believes that our employees must be
held to the highest standard when delivering care; however, it is also
imperative that employees know that they can report information fully
and completely so that changes can be made and care can be improved.
The agency is concerned that the release of quality-assurance documents
may create a chilling effect, deterring our employees from providing
accurate information and resulting in poorer quality care. VA welcomes
the opportunity to meet with the Committee to discuss employee
accountability as well as additional approaches to increasing the
transparency in VA's quality-assurance programs.
VA estimates the cost of this provision to be $22 million in FY
2011, $47.9 million over 5 years, and $88.5 million over 10 years.
H.R. 4041--``Improvements in the Federal Recovery Coordinator Program''
H.R. 4041 would require VA to train recovery coordinators at a
qualified nursing or medical school. This school would also lead a
literature review and a consensus conference and develop training
modules for care coordination as well as software that is compatible
with VA systems. H.R. 4041 would authorize appropriations of $1.2M to
carry out these elements of the bill and direct the Secretary to
subcontract for the development of care-coordination software. It would
also require VA to convene a conference for care coordinator tool
validation and to conduct a software pilot program. $1.2M would be
authorized to carry out these provisions. Section 2(d) would authorize
the qualified nursing or medical school to train 45 recovery
coordinators, and authorize $500,000 for this training for each of
fiscal years 2010, 2011, and 2012.
VA does not support H.R. 4041. VA has established measures in place
that address the goals of this legislation. The Federal Recovery
Coordination Program (FRCP) was created in 2007 in response to a
recommendation from the President's Commission on Care for America's
Returning Wounded Warriors. The program has been successfully
implemented in 13 sites around the country and there are currently 20
Federal Recovery Coordinators (FRCs) Newly hired FRCs come to VA's
Central Office for intense training and orientation. During this
training, subject-matter experts provide in-depth reviews of topics
frequently encountered by FRCs in the course of assisting their
clients. Topics range from Social Security Disability Insurance to the
Department of Defense (DoD) disability evaluation system. After
completion of orientation, the new FRCs return to their station where
they complete all necessary training and paperwork unique to their host
facility. They also engage in a mentor/mentee relationship with another
more experienced FRC, which helps with process questions and resource
identification. Weekly supervisor calls also provide a structured
review of cases and one-on-one problem solving is available during the
week if needed. In addition to the initial orientation, FRCs also
receive quarterly training (4 weeks total) and have standard
educational requirements for the program and to meet their state
license standards. Training topics are identified by the FRCs for these
events to maximize their learning around specific information needed to
assist clients.
The language of section 2(b) of H.R. 4041 would require recovery
coordinators to be trained at a nursing or medical school; however, it
is unclear what that training would add to the current content-focused
training provided by subject matter experts. Moreover, this section
would also require the school to lead a literature review and develop
evidence-based guidelines for recovery coordination. A structured
evidence-based review is unlikely to produce much insight or definition
as there is a lack of supporting data. The cost of implementing this
section is estimated to be $1.2 million.
Section 2(c) of the bill would require the development of a care
coordination software tool and a program piloting the software. It is
unclear whether this tool is intended to be used for training or for
functional data management. FRCP already has a functional data
management tool that is sufficiently flexible to meet the growing needs
of the program. It is contained within the Veterans Tracking
Application (VTA) and iterative enhancements to the system over the
past 2 years have provided increasingly easier data entry and report-
writing capabilities. Through a related effort, FRCP is also part of an
information sharing initiative which will improve efficiency and
accuracy by enabling information transfer among facilities. It is
estimated that the software and pilot required by this section would
cost $1.2 million. We note that the word ``subcontractor'' in section
2(c)(1) should be ``contractor.''
Section 2(d) of H.R. 4041 would authorize training for 45
coordinators. We do not understand the rationale for this specific
number. Current staffing is based on the need for additional personnel
through monitoring of referrals to the FRCP program. As discussed
above, there are currently 20 coordinators in the system and we are in
the process of hiring an additional five FTE's to serve in facilities
in CA, TX, VA, and Washington D.C. The cost of section 2(d) is
estimated to be $500,000 in FY 2010, 2011, and 2012.
VA estimates the total cost of H.R. 4041 to be $3.9 million over 3
years.
H.R. 5428--``Injured and Amputee Bill of Rights''
H.R. 5428 would require the Secretary to establish a Bill of Rights
for injured and amputee Veterans that would be displayed prominently in
prosthetic and orthotics clinics throughout VA. H.R. 5428 would also
require the Veteran liaison at each medical center to collect
information relating to the alleged mistreatment of injured and amputee
Veterans. Each quarter this information would have to be reported to
the Department's Chief Consultant, Prosthetic and Sensory Aids who
would be required to investigate and address the alleged mistreatment.
We recognize the unique needs of injured and amputee veterans.
Across the country, VA clinics and Prosthetic and Orthotic Services
provide specialized care and treatment to these brave men and women. We
understand that injured and amputee veterans have clinical and medical
needs that set them apart from other patients at VA facilities--but
they are not set apart in their rights. The basic tenets of patient
care should not vary based either on the condition or injury
experienced by a Veteran or the type of medical services a Veteran
receives. VA does not support H.R. 5428, because this legislation would
confer unique rights upon a limited group of Veterans. Giving special
rights to amputee patients that are not available to other enrolled
Veterans would result in inconsistent and inequitable treatment among
our Veteran-patients.
VA adheres to strict standards of patient treatment. VA regulations
require that a comprehensive list of patient's rights be posted
prominently in all VA facilities. Patients who are concerned about the
quality of their care have a number of options already available for
addressing these issues. Every VA medical center has a patient advocate
dedicated to addressing the clinical and non-clinical complaints and
concerns of our Veterans and their families. Many facilities also
include a ``Letter to the Director'' drop box where Veterans can
communicate directly with the Director and raise issues and concerns.
In addition, VA's Prosthetic and Sensory Aid Service maintains a Web
site that offers Veterans and family members an opportunity to ask
questions or raise concerns directly with VA Central Office Staff. The
Department also works closely with Veterans Service Organizations to
identify and respond to any concerns with quality and access to care.
If extended to the entire patient population, the Department would
support the majority of ``rights'' that are included in this `Bill of
Rights,' e.g., the right to receive appropriate treatment, the right to
participate meaningfully in treatment decisions, etc. However, a few of
the ``rights'' raise serious concerns. Specifically, the Veteran's
``right to select the practitioner that best meets his or her orthotic
and prosthetic needs, including a private practitioner with specialized
expertise,'' is not sound from a medical perspective. VA's
practitioners are highly qualified, and VA is able to continually
monitor their performance through its rigorous quality management
programs. As part of those programs, VA has an extensive credentialing
and privileging program, which surpasses those found in the private
sector. VA, generally, does not have ready and efficient access to
Veterans' non-VA medical records, as few private providers, if any,
employ an electronic medical record. Were these Veterans permitted to
choose their own private providers, VA could not oversee the quality of
their care, ensure their private providers possess adequate
qualifications, and ensure they receive a continuum of services. One
must also bear in mind that VA's legal privacy and confidentiality
requirements exceed those applicable to the private sector.
In short, VA has the needed expertise in managing Veterans' unique
issues, including unparalleled expertise in managing and caring for
amputee patients, particularly those wounded in combat. What we cannot
provide through our own clinics and Prosthetic and Orthotic Services,
we readily purchase through contractual arrangements with more than 600
vendors and providers who are approved by the Department. Although our
Prosthetics and Orthotics Service labs are top-notch and very
successful in timely meeting Veterans' needs, we actively evaluate our
programs to identify any areas in need of improvement. With respect to
our contractor-prosthetists, we conduct quality-management programs to
oversee their performance, thereby protecting our Veterans and assuring
they receive quality services. These efforts would be significantly
hindered were Veterans permitted to self-refer to private prosthetists
and practitioners. Veterans could become a vulnerable marketing target
by those holding themselves out as having special expertise in this
field.
Moreover, including that ``right'' in a ``bill of rights'' would be
misleading. Congress has very carefully limited our authority to pay
for non-VA care and services. Stating that a Veteran has the ``right''
to choose one's own provider would still not make the Veteran eligible
for private care at VA-expense if he or she does not otherwise meet the
eligibility terms of 38 U.S.C. 1703. This ``right'' could mislead
Veterans into believing they are entitled to seek prosthetic or
orthotic care or services from a non-VA provider at VA-expense. As a
result, some could incur private medical expenses for which they would
be personally liable.
There would be no additional costs associated with enactment of
H.R. 5428.
H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of
2010''
H.R. 5516 would amend the definition of ``preventive health
services'' in 38 U.S.C. 1701 to specifically include immunizations.
This bill would further amend section 1701 to include the term
``recommended adult immunization schedule'' and define it to mean the
schedule established by the Advisory Committee on Immunization
Practices (ACIP). H.R. 5516 would also amend section 1706 of title 38,
to require the Secretary to develop quality measures and metrics to
ensure that Veterans receive immunizations on schedule. These metrics
would be required to include targets for compliance and, to the extent
possible, should be consistent and implemented concurrently with the
metrics for influenza and pneumococcal vaccinations. Moreover, the bill
would require that these quality standards be established via notice
and comment rulemaking. H.R. 5516 would also require that details
regarding immunization schedules and quality metrics be included in the
annual preventative services report required by 38 U.S.C. 1704
beginning in January of 2011.
VA does not support H.R. 5516. VA currently conducts ongoing
initiatives that address the goals of this legislation. The current
definition of ``preventive health services'' at 38 U.S.C. 1701 includes
immunization against infectious disease. Moreover, these immunizations
are specifically included in VA's medical benefits package. VA is an
ex-officio member of the ACIP and develops its clinical guidance on
immunizations in accordance with ACIP recommendations. All ACIP-
recommended vaccines, which include hepatitis A, hepatitis B, human
papillomavirus, influenza, measles/mumps/rubella, meningococcal,
pneumococcal, tetanus/diphtheria/pertussis, tetanus/diphtheria,
varicella, and zoster, are currently available to Veterans (as
clinically appropriate) at VA medical facilities.
The delivery of preventive care, which includes vaccinations, has
been well-established in the VA Performance Measurement system for more
than 10 years with targets that are appropriate for the type of
preventive service or vaccine. VA updates these performance measures to
reflect changes in medical practice over time. Requiring that the
quality metric, including targets for compliance, be established via
notice and comment rulemaking would limit VA's ability to respond
quickly to new research or medical findings regarding a vaccine.
Moreover, because the clinical indications and population size for
vaccines vary by vaccine, blanket monitoring of performance of all
vaccines could be cost prohibitive and may not have a substantial
positive clinical impact at the patient level.
Accurately costing this bill is difficult as it will depend on the
current use of individual vaccines and the specific performance
measures that would be established by VA for those vaccines. If H.R.
5516 results in a 10 percent increase in the use of vaccines by VA than
we estimate the cost of H.R. 5516 would be $5 million in 2012, $32.3
million over 5 years, and $90.7 million over 10 years.
H.R. 5543--``Collective Bargaining Regarding Compensation Other Than
Rates of Basic Pay''
H.R. 5543 would amend 38 U.S.C. 7422 by replacing the word
``compensation'' in sections (b) and (d) with the words ``rates of
basic pay.''
VA has serious concerns with this bill as it would repeal the
prohibition on collective bargaining with respect to compensation of
title 38 employees.
VA would like to stress to the Committee that we deeply value the
contributions of our employees, and enjoy a collaborative, positive
working relationship with unions across the country. We hold retention
of employees as a critically important goal, and encourage the
management teams of VA facilities to offer professional development
opportunities and encourage personal growth.
Currently, 38 U.S.C. 7422(b) and (d) exempt ``any matter or
question concerning or arising out of . . . the establishment,
determination, and adjustment of [title 38] employee compensation''
from collective bargaining. This bill would replace the word
``compensation'' with the phrase ``rates of basic pay.'' This change
would apparently make all matters relating to the compensation of title
38 employees (physicians, dentists, nurses, et al.) over which the
Secretary has been granted any discretion subject to collective
bargaining. In order to provide the Secretary with the flexibility
necessary to administer the title 38 system, Congress has granted the
Secretary significant discretion in determining the compensation of
VA's health care professionals. When Congress first authorized title 38
employees to engage in collective bargaining with respect to conditions
of employment, it expressly exempted bargaining over ``compensation''
in recognition of the U.S. Supreme Court's ruling in Ft. Stewart
Schools v. FLRA, 495 U.S. 641 (1990). In that case the Court held that
the term ``conditions of employment,'' as used in the Federal Service
Labor-Management Relations Statute (5 U.S.C. 7101), included salary, to
the extent that the agency has discretion in establishing,
implementing, or adjusting employee compensation. Id. at 646-47. Thus,
Congress sought to make clear in 38 U.S.C. 7422(b) that title 38
employees' right to bargain with respect to ``conditions of
employment'' did not include the right to bargain over compensation.
Over the years, Congress has authorized VA to exercise considerable
discretion and flexibility with respect to title 38 compensation to
enable VA to recruit and retain the highest quality health care
providers.
The term ``rates of basic pay'' is not defined in title 38.
However, the Agency has defined ``basic pay'' as the ``rate of pay
fixed by law or administrative action for the position held by an
employee before any deductions and exclusive of additional pay of any
kind.'' VA Handbook 5007, Part IX, par. 5. Such additional pay includes
market pay, performance pay, and any other recruitment or retention
incentives. Id. Accordingly, H.R. 5543 would subject many discretionary
aspects of title 38 compensation to collective bargaining. For example,
there are two discretionary components of compensation for VA
physicians and dentists under the title 38 pay system--market pay and
performance pay. Market pay, when combined with basic pay, is meant to
reflect the recruitment and retention needs for the specialty or
assignment of the particular physician or dentist in a VA facility.
Basic pay for physicians and dentists is set by law and would remain
non-negotiable under this bill, but the Secretary has discretion to set
market pay on a case-by-case basis. Market pay is determined through a
peer-review process based on factors such as experience,
qualifications, complexity of the position, and difficulty recruiting
for the position. In many cases, market pay exceeds basic pay. In those
situations, this bill would render a large portion or even the majority
of most physicians' pay subject to collective bargaining. The Secretary
also has discretion over the amount of performance pay, which is a
statutorily authorized element of annual pay paid to physicians and
dentists for meeting goals and performance objectives. Under this bill,
performance pay would also be negotiable. Likewise, pay for nurses
entails discretion because it is set by locality pay surveys. Further,
Congress has granted VA other pay flexibilities involving discretion,
including premium pay, on-call pay, alternate work schedules, Baylor
Plan, special salary rates, and recruitment and retention bonuses. The
ability to exercise these pay flexibilities is a vital recruitment and
retention tool. It is necessary to allow VA to compete with the private
sector and to attract and retain clinical staff who deliver health care
to Veterans. As described below, this flexibility would be greatly
hindered by the collective bargaining ramifications of H.R. 5543.
This bill would obligate VA to negotiate with unions over all
discretionary matters relating to compensation, and to permit employees
to file grievances and receive relief from arbitrators when they are
unsatisfied with VA decisions about discretionary pay. If VA were
obligated to negotiate over such matters, it could be barred from
implementing decisions about discretionary pay until it either reaches
agreements with its unions or until it receives a binding decision from
the Federal Service Impasses Panel. This potential barrier could
significantly hinder our ability and flexibility to hire clinical staff
as needed to meet patient care needs both qualitatively and in a timely
manner. Additionally, VA may be required to pay more than is necessary
to recruit and retain title 38 employees.
Moreover, any time an employee was unsatisfied with VA's
determination of his or her discretionary pay, he or she could grieve
and ultimately take the matter to binding arbitration. This step would
allow an arbitrator to substitute his or her judgment for that of VA
and, with regard to physician market pay, to override peer review
recommendations. This bill would allow independent third-party
arbitrators and other non-VA, non-clinical labor third parties who lack
clinical training and expertise to make compensation determinations. VA
would have limited, if any, recourse to appeal such decisions.
Importantly, H.R. 5543 would result in unprecedented changes in how
the Federal Government operates. It would permit unions to bargain
over, grieve, and arbitrate a subject--employee compensation--that is
generally exempted from collective bargaining even under title 5.
Although Congress has built much more Agency discretion into the title
38 compensation system both to achieve the desired flexibility and
because the system is unique to VA, permitting title 38 employees to
negotiate the discretionary aspects of their compensation would simply
be at odds with how other Federal employees are generally treated.
Further, collective bargaining over discretionary aspects of pay is
unnecessary. VA's retention rates for physicians and dentists are
comparable to private sector retention rates, while retention rates for
VA registered nurses significantly exceed those of the private sector,
strongly suggesting that the lack of bargaining ability over
discretionary aspects of pay has minimal impact on VA's ability to
retain title 38 employees.
We are not able to estimate the cost of H.R. 5543 for two reasons.
First, if VA is required to negotiate over compensation matters, and if
the Agency is unable to reach agreements with the unions, the final
decisions on pay will ultimately rest with the Federal Service Impasses
Panel. The Panel has discretion to order VA to comply with the unions'
proposals. Second, if pay issues become grievable and arbitrable, the
final decisions on pay will rest in the hands of arbitrators.
On the whole, our efforts to recruit and retain health care
professionals have been widely successful, notwithstanding the
exclusion of matters concerning or arising out of compensation from
collective bargaining. We would be glad to share applicable data with
the Committee and brief the members on our continuing efforts in this
area.
H.R. 5996--``Prevention, Diagnosis, Treatment and Management of Chronic
Obstructive Pulmonary Disease''
Subject to the availability of appropriations, H.R. 5996 would
require the Secretary to develop treatment protocols and related tools
for the prevention, diagnosis, treatment, and management of Chronic
Obstructive Pulmonary Disease (COPD) as well as to improve biomedical
and prosthetic research programs on this disease. Moreover, in
conjunction with the Centers for Disease Control and Prevention (CDC),
the Indian Health Service, and the Health Resources and Service Agency,
VA would be required to develop a pilot program to demonstrate best
practices for the diagnosis and management of COPD. The bill also
specifies that the Secretary and the CDC shall develop improved
techniques and best practices for assisting individuals with COPD in
quitting smoking.
VA supports the intent of H.R. 5996 as it has significant potential
to improve the health care outcomes of Veterans, but it already has the
authority to develop the treatment protocols and related tools and to
improve the research programs on this disease. COPD is currently the
4th leading cause of death in the United States, and it currently
impacts more than 500,000 Veterans. The primary cause of COPD, smoking,
also remains prevalent among Veterans. More than 30 percent of Veterans
are active smokers, and among those diagnosed with COPD, the rate of
active smoking is approximately 50 percent.
VA has long maintained smoking cessation as a major focus for
health promotion and disease prevention. VA's national performance
measure on tobacco use requires that all Veterans seen in outpatient
settings be screened once a year for smoking; if they are currently
using tobacco, they are provided with brief counseling, offered
prescriptions for nicotine replacement therapy and other smoking-
cessation medications, and provided with referrals to VA smoking
cessation programs. VA has also been working with DoD to identify areas
for collaboration to establish tobacco use cessation programs that
would provide a seamless transition in care and reduce the impact of
smoking-related illnesses among both Servicemembers and Veteran
populations.
VA supports the bill's focus on the special needs of COPD patients
who struggle with their smoking addictions. The knowledge gained would
benefit the population at large. VA believes this focus would
particularly improve care and outcomes for Veterans with COPD, improve
rates of smoking cessation among patients with COPD, and reduce the
risk and incidence of other smoking-related illnesses (e.g., lung
cancer, heart disease).
The cost of this bill is estimated to be $25.9 million over 5
years.
Draft Bill 1--Improvements in Programs for Homeless Veterans
Section 2 of the draft bill would amend 38 U.S.C. 2061 to grant VA
permanent authority to offer capital grants for homeless Veterans with
special needs on the same basis as the grants currently made to
homeless Veteran providers under the VA Homeless Grant and Per Diem
(GPD) Program pursuant to 38 U.S.C. 2011. Veterans with special needs
are: those who are women, including women who have care of minor
dependents; frail elderly; terminally ill; or chronically mentally ill
homeless veterans. Section 2 would further amend section 2061 by
removing the requirement that VA make grants to VA health care
facilities.
Section 3 of the draft bill would amend 38 U.S.C. 2012 to change
grant payments for furnishing services to homeless Veterans from a per
diem basis to the annual cost basis. It would also remove the
prohibition on VA providing a rate in excess of the rate authorized for
State domiciliaries and grant the Secretary the discretion to set a
maximum amount payable to grant recipients. Section 3 would also direct
the Secretary to adjust the rate of payment to reflect anticipated
changes in the cost of furnishing services and take into account the
cost of services in different geographic areas. It would also make the
requirement that the Secretary consider other available sources of
funding discretionary. Section 3, paragraph E would require the
Secretary to make quarterly payments based on the estimated annual
basis and would further require recipients to declare the actual amount
paid by quarter for services provided and repay any outstanding
balances if the amount spent by the recipient is less than the
estimated quarterly disbursement. Similarly, if recipients spend more
than the estimated amount, determined on a quarterly basis, the
Secretary would be required to make an additional payment equal to that
sum. Payment to recipients would be limited to the amount of the annual
grant payment as determined by the Secretary. Finally, section 3 would
allow grant recipients to use VA grants to match other payments or
grants from other providers.
While there are some similarities between this draft bill and a
recent VA legislative proposal, VA needs additional time to evaluate
this bill in conjunction with the Administration's focus on permanent
housing models for the homeless. We will provide views and costs as
soon as they are available.
Draft Bill 2--``Miscellaneous Health Care Provisions''
Annual Meeting of the Association of Military Surgeons in the United
States
Section 3 would permit the Under Secretary for Health to assist the
Association of Military Surgeons of the United States in organizing and
hosting the annual meeting of the Association. The military services
are able to assist the Association with its annual meeting due to
Public Law 39 (enacted January 30, 1903), which incorporated the
Association of Military Surgeons of the United States. That law made
the Secretaries of Treasury, War, and Navy and the Surgeons General of
the Army, Navy, and Marine--Hospital Service ex officio members of the
Association. VA would like an authorization to also assist with the
annual meetings. These meetings are valuable to VA because they permit
sharing with other Federal health-care entities and provide learning
opportunities for VA employees through lectures, panel discussions, and
poster discussions.
The cost associated with enactment of this section will be
insignificant.
Hospital Care and Medical Services in Non-Department Facilities
Section 4 would grant VA increased flexibility in entering into
fee-basis arrangements to obtain hospital care and medical services for
eligible Veterans. These arrangements would be authorized when VA is
unable to furnish economical hospital care or medical services due to
geographical inaccessibility, or when VA facilities are unavailable to
furnish needed care or services. The statute as currently written
states that these arrangements be accomplished by ``contracts'' with
non-VA ``facilities.'' This bill would expressly provide that VA,
notwithstanding any other law, may ``purchase, enter into a contract,
provide individual authorization or act in such other manner as the
Secretary determines appropriate'' with non-VA facilities in order to
furnish hospital and outpatient care to eligible Veterans.
VA supports section 4. There are no costs associated with this
section as it would be consistent with VA's current practice under
current law.
Extension of the Advisory Committee on Homeless Veterans
Section 5 would amend 38 U.S.C. 2066 to extend Congressional
authority to continue the Advisory Committee for Homeless Veterans for
an additional 3 years until December 30, 2014.
This Committee was Congressionally mandated by Public Law 107-95.
The mission of the Committee is to provide advice and make
recommendations to the Secretary on issues affecting homeless Veterans
and determine if the Department of Veterans Affairs (VA) and other
programs and services are meeting those needs. It has proven valuable,
and VA has implemented many of the Committee's recommendations through
policy and regulatory changes to enhance access and services for
homeless Veterans.
The cost of the Advisory Committee on Homeless Veterans was
$141,000 in FY 2009 and VA estimates that this cost will increase by
three to 5 percent for the additional 3 years of operation and is
estimated to be $.5 million.
Authority to Recover Medical Care Costs from Third Party Providers
Section 6 would amend section 1729(f) of title 38, United States
Code, to make clear that the absence of a participating provider
agreement or other contractual arrangement with a third party may not
operate to prevent, or reduce the amount of, any recovery or collection
by the United States under this section. Subsection (b) would amend
section 1729(i)(1)(A) of title 38, United States Code, to clarify the
definition of a ``health-plan contract'' by specifying health
maintenance organizations, competitive medical plans, health care
prepayment plans, preferred or participating provider organizations,
individual practice associations, and other medical benefit plans are
included. These amendments would apply only to care and services
furnished under chapter 17 of title 38, United States Code, on and
after the date of the enactment.
There are no direct costs associated with this section, other than
administrative costs associated with collecting revenue. VA supports
this provision and estimates the adoption of this section would
increase collections beginning in fiscal year 2012 by $87.7 million and
$1.04 billion over a 10-year period.
Health Professionals Educational Assistance Programs
Section 7 would amend 38 U.S.C. 7675 to impose on full-time student
participants in the Employee Incentive Scholarship Program (EISP) who
leave VA employment prior to completion of their education program the
same liability as is currently imposed on part-time students. The
current statute clearly limits part-time student participants'
liability for breach of the EISP agreement. This proposal would make
both full- and part-time students liable for breach of the EISP
agreement. Currently, all other employee recruitment/retention
incentive programs have a service obligation and liability component.
VA supports this provision and estimates enactment would result in
savings of approximately $36,000 in fiscal year 2010 and a total
approximate savings of $189,000 over a 4-year period.
On-Call Pay for VHA IT Specialists
Section 8 would amend 38 U.S.C. 7457 and authorize the Secretary to
pay on-call pay to Information Technology (``IT'') Specialists whose
primary responsibilities are to perform services incident to direct
patient-care services at VHA health care facilities. Prior to 2006,
title 5 IT staff working in VA health care facilities were employed by
the Veterans Health Administration (``VHA'') and were authorized to
receive on-call pay under title 38. In 2006, the Department's Office of
Information and Technology (``OI&T'') was reorganized as a separate
staff office and, as a result, title 5 IT staff were transferred out of
VHA, and lost their authorization for on-call pay. On-call coverage is
needed because the Department is unable, given staffing availability
and cost, to staff OI&T on a 24-hour basis. This proposal would allow
the Department to properly support patient care operations on a 24-hour
basis. This is crucial, as VHA's delivery of health care is dependent
upon the electronic health record.
VA estimates the cost of this section to be $6.3 million for FY
2011, $37.3 million over 5 years, and $93.9 million over 10 years.
Pay for Physicians and Dentists Employed by the Office of Information
and Technology
Section 9 would amend 38 U.S.C. 7431 to authorize the Secretary to
pay physicians and dentists employed by the Department's Office of
Information and Technology (``OI&T'') in accordance with title 38 pay
authorities. Prior to 2006, physicians and dentists who served in
information technology (``IT'') positions providing support to the
Veterans Health Administration (``VHA'') worked in VHA units and were
covered by title 38 pay authorities. In 2006, OI&T was reorganized as a
separate Department staff office and, as a result, IT personnel were
transferred out of VHA, and lost their authorization for title 38 pay.
This provision would allow VA to recruit and retain physicians and
dentists in OI&T leadership positions by inserting a new subsection
into section 7431. Title 38 pay authorities are specifically designed
to allow VA to recruit and retain highly qualified health care
personnel for Veterans. The ability to offer title 38 pay to physicians
and dentists within OI&T is crucial in maintaining the Department's
position as a world leader in health care information technology
because it would allow the Department to recruit and retain senior IT
executives who, because of their experience as physicians and dentists,
possess intimate knowledge and expertise in both health care processes
and information technology.
While VA believes that 25 positions would be sufficient, this draft
bill would permit 100 positions at any time. To be eligible, a
physician or dentist must be board-certified. The Secretary would
ensure that the authority is used only for physicians and dentists
serving in key executive positions in which experience as a physician
or dentist is critical to accomplishment of the Department's mission.
Covered physicians and dentists must be paid using the pay schedules
established for executives in the Veterans Health Administration whose
primary duties are to manage personnel and programs rather than perform
clinical duties as a physician or dentist--currently, Pay Table 6 for
Executive Assignments, which has three tiers: Tier 1: $145,000-
$265,000, Tier 2: $145,000-$245,000, and Tier 3: $130,000-$235,000.
Section 9 includes conforming amendments to title 5 that make clear
that physicians and dentists receiving rates of basic pay under title
38, including those covered by proposed section 7431(i), are not
covered by the provisions governing the General Schedule and the Senior
Executive Service. Section 9 also amends 5 U.S.C. 5371 (OPM's statutory
authority to provide title 38 pay authority to other agencies) so that
OPM may authorize other agencies to apply title 38 pay provisions to
employees who would otherwise be in the Senior Executive Service.
The Department estimates the cost of the 100 employees allowed for
in the bill to be $13.7 million in FY 2011, $71.9 million over 5 years,
and $153.23 million over 10 years. If VA employed 25 of these
employees, the costs are estimated to be $3.4 million in FY 2011,
$17.96 million over 5 years, and $38.3 million over 10 years.
Extension of the Joint Incentives Program
Section 10 would change the termination date for the DoD-VA Joint
Incentives Program from September 30, 2015 to September 30, 2020,
enabling both agencies to contribute to the Joint Incentive Fund, which
fund funds creative coordination and sharing initiatives at the
facility, intraregional, and nationwide levels. VA supports this
extension. There are no costs associated with this provision.
Use of the Franchise Fund to Expedite Collection of Erroneous Payments
Section 11 would amend the paragraph under the heading ``Franchise
Fund'' in title I of the Departments of Veterans Affairs and Housing
and Urban Development, and Independent Agencies Appropriations Act,
1997 (Public Law 104-204), which was amended by section 208 of title II
of the Military Quality of Life and Veterans Affairs Appropriations
Act, 1996 (Public Law 109-114), to authorize the VA Franchise Fund to
use amounts available to cover its operating expenses to correct
erroneous or improper payments made by Franchise Fund employees.
The Government Management Reform Act (GMRA) of 1994 (Public Law
103-356) and the Departments of Veterans Affairs and Housing and Urban
Development, and Independent Agencies Appropriations Act, 1997 (Public
Law 104-204) authorize VA to provide certain common administrative
services to VA and other government agencies on a fee-for-service
basis. One such service is payment processing. As a service provider,
the VA Franchise Fund acts as an agent for its customers by processing
payments on their behalf. The Franchise Fund has service level
agreements (SLAs) with VA customers to pay vendor invoices using the
customer's appropriated funds. Occasionally, the Franchise Fund makes a
payment error, e.g., payment issued to an incorrect vendor. Currently,
customers provide additional funds to the Franchise Fund to make the
correct payment, pending recovery of the improper payment.
This section would authorize the customer involved with the
improper payment to establish a refund receivable from the Franchise
Fund and immediately recover the related budget authority. The Fund
would in turn establish a refund receivable from the vendor and record
it in its accounting records. The budget authority would not accrue to
the VA Franchise Fund until funds are recovered from the vendor.
Under this approach, the customer's appropriation would remain
whole. The Franchise Fund, acting as the agent, would set up a refund
receivable and use resources from the Fund to immediately refund the
corrected payment to its customers. This would occur while the Fund is
pursuing recovery of the improper payment from the vendor. VA supports
this provision. The VA Franchise Fund has established effective
processes to recover funds through bills of collection, payment
offsets, the Treasury Offset Program, or civil court collection. The
Franchise Fund's collection experience demonstrates a high percentage
of collections and a low risk for loss of improper payments.
There are no costs associated with this provision.
Mr. Chairman, this concludes my prepared statement. I would be
pleased to answer any questions you or any Members of the Committee may
have.
Statement of American Federation of Government Employees, AFL-CIO,
and AFGE National Veterans Affairs Council
Mr. Chairman and Members of the Subcommittee:
The American Federation of Government Employees (AFGE) and the AFGE
National VA Council (NVAC) appreciate the opportunity to submit a
statement for the record on H.R. 5543.
AFGE and NVAC represent nearly 200,000 employees in the Department
of Veterans Affairs (VA), more than two-thirds of whom are employees of
VA's world class health care system. They are proud of the care they
provide to veterans every day. They also take great pride in the
Veterans Health Administration's (VHA) best practices and state-of-the-
art health care information technology that was developed through the
joint input of labor and management.
Sadly, in 2003, the highly effective joint labor-management
agreement on bargaining rights of VA's Title 38 health care
professionals was nullified. In its place, the VA implemented a new
policy that deprives Title 38 clinicians of basic rights to grieve and
negotiate over matters related to compensation, patient care and peer
review.
Seven years and many, many wasted VA health care dollars later, it
is urgent that this unfair treatment of VA's Title 38 clinicians cease
and that the VA return to a bargaining rights policy that resolves
labor-management disputes more efficiently. As a first step, AFGE and
NVAC urge the Committee to approve H.R. 5543 to restore equal rights to
bargain over compensation matters. This bill will restore Congressional
intent in enacting Title 38 bargaining rights in 1991 and will also
allow these clinicians to enforce their rights under important VA
recruitment and retention laws over the past decade.
Under current VA policy, Title 38 clinicians--including physicians,
dentists, registered nurses (RN), physician assistants, chiropractors,
optometrists and podiatrists--face work environments plagued by
arbitrary and unfair pay policies. Many of these clinicians bring to
the VA invaluable experience as military personnel providing care on
the battlefield. Yet, they are singled out for unfair treatment. They
cannot challenge management pay policies that violate Federal law or VA
regulations simply because they are ``pure Title 38 employees''
appointed under Section 7401(1) of Title 38, instead of ``Hybrid Title
38 employees'' appointed under Section 7401(3) with full Title 5
bargaining rights.
As a result, a Title 38 RN has no recourse if she or he is denied
overtime pay, while a Hybrid Title 38 licensed practical nurse can file
a grievance over the same issue. Similarly, the union cannot negotiate
over retention pay criteria for a Title 38 psychiatrist, but can
negotiate over the implementation of similar pay policies for a Hybrid
Title 38 psychologist.
If these Title 38 health care professionals decide to leave the VA
to work at a another Federal facility, such as a military hospital or a
Federal prison clinic, they will acquire full collective bargaining
rights under Title 5.
Thus, the choice is clear: if the VA wants to be an employer of
choice in today's health care market and compete effectively for health
care professionals in short supply, it must provide equal compensation
bargaining rights to its Title 38 clinicians.
H.R. 5543 offers a very modest change to Section 7422, the
bargaining rights provision of Title 38. It simply clarifies that, like
all Federal employees, VA Title 38 clinicians can bargain over the
implementation of pay laws and regulations, but that only Congress and
the VA Secretary can set basic rates of pay.
The narrow scope of H.R. 5543 addresses opponents' assertions that
employees will try to bargain over Federal pay scales. The language of
this bill limits bargaining to compensation issues other than basic
rates of pay that Congress has specifically addressed in legislation to
help the VA recruit and retain health care personnel such as RN
locality pay and physician and dentist market pay and performance pay.
H.R. 5543 would also protect Title 38 clinicians from violations of
routine pay laws that all public and private sector registered nurses
count on, such as the right to additional pay for working evenings and
weekends.
AFGE and NVAC note that the VA has never offered this Committee an
example of an employee's attempt to use bargaining rights to set
Federal pay rates, and that there is not a single Undersecretary of
Health ``7422'' case involving such an attempt.
To address another concern raised by some opponents, the
recommendations of the recent ``7422 workgroup'' that are pending
before the Secretary are no substitute for legislative change. Yes,
they have the potential to improve Title 38 labor-management relations
to some extent and we appreciate the Secretary's willingness to review
current policy. However, even if the recommendations are adopted, they
cannot take the place of legislation that clarifies the scope of the
law. These recommendations very modest in scope, and would not provide
Title 38 clinicians with equal bargaining rights. Also, they lack the
force of law; Courts and arbitrators will continue to defer to the
Secretary's discretion under Title 38 absent legislation. Finally, as
we saw in 2003, policies issued during one administration can be easily
tossed out by the next. If the VA is to effectively compete with other
health care employers, it must assure current and prospective hires
that they can count on fair treatment and the ability to enforce pay
laws and regulations.
VA's current policy on compensation bargaining rights has weakened
critical legislation that Congress passed in recent years to recruit
and retain a strong health care workforce. For example, Congress
enacted legislation in 2004 to use local panels of physicians to set
market pay that would be competitive with local markets (P.L. 108-445).
The USH ruled that AFGE's national grievance over the composition of
the pay panels was barred by the ``compensation'' exception. (Decision
dated 3/2/07). Currently, VA physicians in numerous facilities are
unable to challenge unfair performance pay criteria that penalize them
for hospital-wide performance even though P.L. 108-445 specifically
refers to ``individual achievement.''
Finally, how dangerous can this simple clarification in the law be?
The VA has already agreed to full bargaining rights for new Title 38
clinicians at the new joint VA-Navy facility at North Chicago. Section
1703 of Public Law 111-84 provides that Navy civilian health care
professionals who are transferring to the VA workforce after completion
of this facility merger will retain full Title 5 collective bargaining
rights for 2 years in matters related to compensation, as well as
patient care and peer review. AFGE and NVAC look forward to working
with the VA to implement this 2 year pilot project when it begins next
month.
Thank you for the opportunity to share the views of AFGE and NVAC
on this important legislation for maintaining a strong VA health care
workforce.
Statement of Hon. Steve Buyer, Ranking Republican Member,
Full Committee on Veterans' Affairs, and a Representative
in Congress from the State of Indiana
Upon introduction of H.R. 5641, I made the following introductory
statement:
``Today, I am introducing H.R. 5641, a bill to allow the Department
of Veterans Affairs (VA) to enter into contracts with adult foster
homes to provide life-long care to veterans unable to live
independently.
Adult foster homes are designed to provide non-institutional long-
term care to veterans who prefer a more personalized, familial setting
than traditional nursing homes are able to provide.
VA has been helping to place veterans in adult foster homes since
2002 and over time more than 600 veterans in need have paid to receive
such care. As we speak, 219 veterans are living in these special homes.
The need for long term care is increasing as veterans from past
conflicts get older, and it will continue to grow as wounded warriors
return home from Iraq and Afghanistan with severe injuries that require
life-long assistance. While nursing homes will always be a valuable
tool for providing lasting care, for some the individualized, home-like
atmosphere of an adult foster home is a much more attractive
alternative than the prospect of moving into a traditional nursing
home.
The advantages of adult foster homes are clear. Veterans who opt
for foster home care will move into a home owned or rented by their
chosen foster home caregiver. The caregiver--who has passed a VA
screening, Federal background check, and home inspection and agreed to
undergo annual training- resides with the veteran and provides them
with 24-hour supervision and personalized care. For as long as that
veteran resides in the home, VA adult foster home coordinators and
members of a VA Home Care Team will make both announced and unannounced
visits at least three times every month to ensure the veteran is safe
and the home and caregiver are in compliance with VA's high quality
standards.
Additionally, the Home Care Team will provide veterans with
comprehensive, interdisciplinary primary care and provide the
caregivers with supportive education and training.
Many veterans who choose to reside in an adult foster home would
otherwise be in need of nursing home care and would qualify for VA
benefits to receive it. However, because VA is not authorized to
provide veterans with assisted living benefits, these veterans must pay
for the care they receive in adult foster homes out of their own
pockets.
Twenty-four percent of veterans who have received care in a Medical
Foster Home qualify for VA's highest priority group due to having
disabilities rated 50 percent or more service connected or having
otherwise been found unemployable due to service connected conditions.
Given that many of the veterans who are benefitting from this
individualized, non-institutional care are disabled, afflicted with
chronic disease, often elderly, and frequently 70 percent or more
service connected, placing the entire cost burden for adult foster
homes on their backs is no way to thank them for their valiant years in
service. What's more, it creates an inequity of benefits between those
who can afford to pay for such care and those that cannot.
The legislation I am introducing today would give VA the authority
to enter into a contract with a certified adult foster home to pay for
care for certain veterans already eligible for VA paid nursing home
care. By doing so, it would ensure more veterans have the option to
choose a treatment setting that best suits their needs free of
financial constraints.
Our veterans in need of life-long care have earned the right to
decide which long-term care environment would make them feel most at
home. And, I encourage my colleagues to join with me in cosponsoring
this legislation to make that decision easier.
Thank you and I yield back the balance of my time.''
Further, upon introduction of H.R. 6127, I made the following
introductory statement:
``Today I am introducing a bill, H.R. 6127, the Extension of Health
Care Eligibility for Veterans who Served at Qarmat Ali Act, to extend
the VA health care enrollment period for certain veterans who served in
the Qarmat Ali region of Iraq.
Soon after the conflict in Iraq began in 2003, Army National Guard
units from my home state of Indiana as well as units from Oregon, West
Virginia, and South Carolina and National Guardsmen mobilized as
individual augmentees from across the Nation were called up and tasked
with guarding the Qarmat Ali water treatment facility.
For 6 months--from April to September--these National Guardsmen
from across the Nation bravely guarded the plant, located just outside
Basra. Their mission was to secure the facility and provide protective
services for the independent contractors who were working throughout
the region to restore Iraqi oil production.
Recently, they have been notified of their possible exposure to a
toxic chemical known as sodium dichromate and are being asked to come
forward, be evaluated, and enroll in VA's Gulf War Registry. Health
problems associated with such exposure include respiratory issues, skin
lesions, and burns. Contact may cause increased rates of lung cancer
and other ear, nose, throat, and skin disorders.
The men and women of these National Guard units completed their
mission--and served our country--well. It was hard for me to discover
that despite their safe return, their service may continue to be put
them at risk. In particular, I am very sensitive to the Hoosiers who
may have been injured.
Under current law, combat veterans who served on active duty in a
theater of combat operations during a period of war after the Persian
Gulf War or in combat against a hostile force during a period of
``hostilities'' after November 11, 1998 are eligible to enroll in the
VA health care system, notwithstanding sufficient evidence of service-
connection, for 5 years following separation from service.
This includes members of the National Guard and Reserve who were
activated and served in combat support or direct operations as long as
they meet certain requirements.
When Congress established the 5 year period of open enrollment for
VA health care it was with the understanding that some wounds of war
may not manifest themselves until years after a veteran leaves military
duty.
But despite our best intentions, we are finding that some veterans
are faced with combat-related health problems that were not apparent
even 5 years after the veteran re-entered civilian life. This creates a
gap in services that unfairly penalizes these men and women for
conditions out of their control.
I commend the VA for their efforts to contact these veterans and
create the Qarmat Ali Registry to aggressively track and treat veterans
exposed to this toxic chemical as part of the Gulf War Registry.
However, it is also important for them to have immediate access to
VA's high quality health care system. The use of VA health care will
help to identify potential medical conditions, and provide counseling,
immunizations, and medications to prevent illness. Appropriate
preventative care can substantially improve health outcomes and the
quality of life for our honored heroes.
But, some of the Qarmat Ali veterans who separated from service
following their deployment in 2003 may no longer be eligible to enroll
in VA health care under the 5-year open enrollment period. As a result,
they must first file a claim and seek a service-connected disability
rating before enrolling in the VA health care system and gaining access
to the comprehensive medical care VA provides.
Unfortunately, the claims process can be both time-consuming and
daunting. It is unacceptable that the Qarmat Ali veterans, already
subjected to harmful toxins during service to our country, must now
await the outcome of a lengthy and sometimes adversarial claims
processing system before they can enroll in VA health care.
The VA was established expressly to care for veterans like these
who willingly left their homes, families, and lives to protect and
defend our Nation and may find themselves sick or injured as a result
of such selflessness
H.R. 6127 would correct this unintended gap in services by
extending the enrollment eligibility period for Qarmat Ali veterans by
5 years from the date of notification. This would allow them to
immediately begin receiving services at VA medical facilities for any
and all of their health care needs.
Breaking down barriers to needed care is the very least we, as a
grateful Nation, can do for the men and women who fight for our
freedoms, in Qarmat Ali and around the world.
I urge my colleagues to join me in supporting H.R. 6127 and these
brave American heroes. Thank you, and I yield back the balance of my
time.''
Statement of Hon. Bob Filner, Chairman,
Full Committee on Veterans' Affairs, and a Representative in Congress
from the State of California
Chairman Michaud, thank you for the opportunity to testify before
the Subcommittee on Health on H.R. 5428, a bill of rights for injured
and amputee veterans and H.R. 5543, a collective bargaining rights bill
for VA clinicians.
We are all too familiar with the wide-spread use of improvised
explosive devices (IEDs) in Operation Enduring Freedom and Operation
New Dawn. Many of our servicemembers are returning home with
amputations as a direct result of blast injuries and this is why I have
introduced H.R. 5428.
H.R. 5428 directs VA to display and educate VA employees about the
injured and amputee veterans' bill of rights at each VA prosthetics and
orthotics clinic. In addition, my bill requires VA to monitor and
resolve complaints from injured and amputee veterans alleging
mistreatment.
I believe that this bill will go a long way in not only protecting
the rights of our injured and amputee veterans, but will also play an
important role in ensuring consistency in the quality of orthotic and
prosthetic care that our veterans receive throughout the VA health care
system.
Next, I would like to discuss H.R. 5543, a bill which would allow
collective bargaining over compensation related labor-management
disputes. Examples of such disputes include locality pay, overtime pay,
shift differential pay, and performance pay.
I would like to emphasize that my bill continues to protect the
basic rates of pay so that VA employees cannot bargain over the Federal
pay scales. However, I have heard stories where a VA nurse's overtime
pay is miscalculated but there is no recourse for addressing this
inaccuracy.
H.R. 5543 would also help VA with their recruitment and retention
efforts since prospective employees would have the assurance that they
will be treated fairly when it comes to the enforcement of pay laws and
regulations.
Thank you again for the opportunity to share my thoughts with you,
and I hope that I can count on your support for H.R. 5428 and H.R.
5543.
Independence Through Enhancement of Medicare and Medicaid Coalition
September 24, 2010
The Honorable Bob Filner
Chairman, House Veterans Affairs Committee
United States House of Representatives
Washington, DC 20515
RE: Support for H.R. 5428; the Injured and Amputee Veterans Bill of
Rights
Dear Chairman Filner:
The undersigned members of the Independence Through Enhancement of
Medicare and Medicaid (ITEM) Coalition write to strongly support your
legislation, H.R. 5428, the Injured and Amputee Veterans Bill of
Rights, and ask that you help pass this legislation in this Congress as
expeditiously as possible.
This bill would establish a written list of rights that all injured
and amputee veterans have access to high quality orthotic and
prosthetic (O&P) care. O&P care, consisting of orthopedic braces,
artificial limbs, and the clinical services necessary to treat the
patient, is vital to veterans who have lost limbs or have sustained
injuries or disorders of the arms, legs, back and neck.
The rights created by this legislation are currently available to
veterans but are inconsistently applied throughout the VA health
system. This inconsistency leads to a lack of access to appropriate O&P
care in different areas of the country. This legislation would make
veterans aware of their right to high quality care provided by
qualified practitioners, to appropriate technology to meet their
specific needs, and to a second opinion regarding treatment options.
Veterans also have a right to a continuum of care when transferring
from the Department of Defense to the VA, and to a functional spare
prosthesis or orthosis if necessary, to name a few.
With the national spotlight on injured and amputee veterans in the
wake of the Iraq and Afghanistan wars, veterans often receive the care
they need. But when the spotlight dims, it is critical that veterans'
rights to high quality O&P care are well established and well
understood by veterans themselves. To help enforce these rights, the
Veterans Administration would be required to post this ``Bill of
Rights'' in every VA O&P Clinic across the country, to post it on the
VA Web site, and to create a complaint mechanism where disputes can be
resolved.
The ITEM Coalition urges Congress to pass the Injured and Amputee
Veterans Bill of Rights to give all veterans access to consistent, high
quality orthotic and prosthetic care. We thank you for your leadership
in introducing this important bill and look forward to working with you
and your staff to enact H.R. 5428 into law this year.
For more information, please contact Peter Thomas, ITEM Coalition
Counsel, at (202) 466-6550.
Sincerely,
Advanced Medical Technology Association
American Academy of Physical Medicine and Rehabilitation
American Association of People with Disabilities
American Association on Health and Disability
American Congress of Rehabilitative Medicine
American Medical Rehabilitation Providers Association
American Music Therapy Association
American Therapeutic Recreation Association
Amputee Coalition of America
Association of Assistive Technology Act Programs
Association of Rehabilitative Nurses
Blinded Veterans Association
Brain Injury Association of America
Christopher and Dana Reeve Foundation
Disability Health Access, LLC
Disability Rights Education and Defense Fund
Easter Seals
Harris Family Center for Disability and Health Policy
Hearing Loss Association of America
Helen Keller National Center
National Association for the Advancement of Orthotics and
Prosthetics
National Association of County Behavioral Health and Developmental
Disability Directors
National Association of State Head Injury Administrators
National Council on Independent Living
National Disability Rights Network
National Down Syndrome Society
National Multiple Sclerosis Society
National Rehabilitation Hospital
National Spinal Cord Injury Association
Paralyzed Veterans of America
Rehabilitation Engineering and Assistive Technology Society of
North America
Spina Bifida Association
TASH
United Spinal Association
VetsFirst
Cc: The Honorable Nancy Pelosi
The Honorable Steny Hoyer
The Honorable John Boehner
The Honorable Steve Buyer
Statement of National Coalition for Homeless Veterans
Chairman Michaud, Ranking Member Brown, and distinguished Members
of the Subcommittee:
Thank you for the opportunity to present this statement to the U.S.
House Committee on Veterans' Affairs, Subcommittee on Health. The
National Coalition for Homeless Veterans (NCHV) is honored to do so and
pleased to convey its support and recommendations for the draft
legislation on homelessness to amend title 38, United States Code, to
make certain improvements in programs for homeless veterans
administered by the Secretary of Veterans Affairs, and for other
purposes.
NCHV proudly represents over 2,300 community- and faith-based
homeless veteran service providers nationwide. These groups, whom U.S.
Department of Veterans Affairs (VA) Secretary Eric Shinseki calls ``the
real creative geniuses'' in ending veteran homelessness, are largely
responsible for the drastic reduction in homeless veterans over the
past 6 years--from 250,000 on any given night in 2004 to 107,000 in
2010, according to annual VA CHALENG reports.
VA reaches an incredible number of homeless veterans through its
Homeless Providers Grant and Per Diem Program (GPD)--a transitional
housing program that is the foundation of VA and community
partnerships. In 2005, the department introduced the ``grant program
for homeless veterans with special needs,'' as it is called in statute,
into the GPD in order to serve four critical demographics:
Women, including those with dependent children
Frail elderly
Terminally ill
Chronically mentally ill
The draft legislation in question would directly affect the GPD and
the special needs grant program.
Background
On Oct. 1, 2009, NCHV President and CEO John Driscoll testified
before this Subcommittee on the need for four bills: H.R. 2504, H.R.
2559, H.R. 2735 and H.R. 3073. An amended version of the third bill,
H.R. 2735, became wrapped into Section 3 of H.R. 4810, the End Veteran
Homelessness Act of 2010. That language appears identical to Section 3
of the current draft legislation, ``Improvement of Payments for
Providing Services to Homeless Veterans.'' H.R. 4810 passed in the
House by a 413-0 vote and was referred to the Senate.
Improving Grant and Per Diem Payments
GPD grantees are reimbursed for providing transitional housing and
supportive services based on the reimbursements provided to state
veterans' homes. Depending on the amount of other Federal funding that
service providers receive, these rates--which peak at $35.84 per
veteran, per day--may be reduced. This policy is outdated considering
the cost of comprehensive services that individuals need to rebuild
their lives. By striking ``per diem'' from current statute and
inserting ``annual cost of furnishing services,'' this bill would
enable organizations to better serve homeless veteran clients with
serious mental illness, substance abuse issues, histories of
incarceration and disabilities.
Community-based organizations serving these populations need round-
the-clock clinical staff, medications handlers, security personnel and
unique facility safety enhancements. Our concern is that without this
provision, community-based organizations will continue to struggle to
provide transitional housing and supports for these hard-to-serve
homeless veterans.
Section 3 of the draft legislation would allow providers to use GPD
funds to match other Federal funding sources. Other Federal service
grants not only allow but encourage cross-agency collaboration.
Penalizing GPD providers--who currently cannot draw GPD funds in
anticipation of allowable, budgeted program expenses--by reducing per
diem payments based on other income is counterproductive and impairs
the delivery of services to homeless veterans. If service providers are
going to end veteran homelessness in the next 4 years, they must be
afforded every opportunity to make their projects work.
VA deserves commendation for its increased investment in the GPD.
However, since its inception the program has undergone significant
changes in complexity, scope of services and targeted populations. This
draft legislation would provide several modifications needed to advance
the program's success preparing homeless veterans for transition to
permanent housing and independent living.
Expanding the Special Needs Grant Program
The other major section of this draft bill, Section 2,
``Enhancement of the Grant Program for Homeless Veterans with Special
Needs,'' would modify and expand VA's special needs grant program. The
program is currently limited to GPD recipients and authorized at $5
million through fiscal year (FY) 2011. This legislation would open the
program to new eligible public or nonprofit entities, and increase its
authorization to $21 million by FY 2013.
NCHV recognizes this as an opportunity to widen the availability of
services to homeless veterans whom the VA and its community partners
have identified as needing specialized care. Women veterans, the
fastest-growing subgroup of the homeless veteran population, will
particularly benefit from these changes to the GPD. By VA's estimates,
women will account for about 15 percent of the Nation's veterans within
10 years. Although we do not yet know the full service needs of the
latest generation of servicemembers returning from operations in Iraq
and Afghanistan, we do know that specialized care will be required for
single-parent homeless families and those at high risk of homelessness
due to health and economic challenges.
Despite NCHV's overall support for this bill, we recommend Sec. 2
(g) (5)--which requires special needs grant recipients ``to seek to
employ homeless veterans and formerly homeless veterans in positions
created for purposes of the grant for which those veterans are
qualified''--be removed.
The meaning of this provision is not clear. The VA Special Needs
Grants are primarily to provide transitional housing and supportive
services to homeless veterans in specialized settings, but are not
specifically designed to ensure employment. Most organizations that
receive GPD funds from the VA provide employment preparation, job
search and placement assistance, but those are funded through
Department of Labor programs, including the Homeless Veterans
Reintegration Program, and the Disabled Veterans Outreach Program and
Local Veterans Employment Representatives at all one-stop career
centers across the Nation. This provision seems to go against the
universal objective of avoiding costly duplication of services.
In Summation
The Health Subcommittee has provided leadership for the most
significant pieces of homeless veterans legislation advanced in the
111th Congress. Its members and staffs have played a powerful role in
the newfound campaign to end veteran homelessness in 5 years. With one
of those years already behind us, there is an even greater sense of
urgency for action: We must ensure that our programmatic approaches are
adaptable so that service providers' efforts are not stunted by
outdated policies.
From the House Committee on Veterans' Affairs to the thousands of
community- and faith-based organizations NCHV represents across this
Nation, we share a common goal of ending veteran homelessness. We are
honored to be a part of this historic undertaking, and we look forward
to continuing to work with this Subcommittee in order to achieve that
reality.
National Association for the Advancement of Orthotics and
Prosthetics
Washington, DC.
September 24, 2010
The Honorable Bob Filner The Honorable Michael Michaud
Chairman Chairman
House Veterans Affairs Committee House VA Health Subcommittee
U.S. House of Representatives U.S. House of Representatives
Washington, DC 20515 Washington, DC 20515
RE: Testimony for the Written Record: Strong Support for H.R. 5428, the
Injured and Amputee Veterans Bill of Rights
Dear Chairman Filner and Chairman Michaud:
The National Association for the Advancement of Orthotics and
Prosthetics (``NAAOP'') strongly supports H.R. 5428, the Injured and
Amputee Veterans Bill of Rights. We thank you for your leadership on
this important issue and look forward to working with you to enact this
key legislation this year for all veterans with amputations and other
orthopedic injuries who require orthotic and prosthetic (``O&P'') care.
As servicemembers return from the conflicts of the past decade with
amputations and musculoskeletal and neuromuscular injuries, they are
joining many other veterans who receive services from the Veteran's
Administration (``VA'') health care system who require artificial limbs
and orthopedic braces. In order to ameliorate the impact of these
potentially debilitating injuries and to ensure consistent access to
O&P patient care, the VA should establish a written set of standards
that outline the expectations that all veterans should have with
respect to their prosthetic and orthotic needs.
The Injured and Amputee Veterans Bill of Rights, H.R. 5428,
accomplishes this by proposing the establishment of a written ``Bill of
Rights'' for recipients of VA health care who require orthotic and
prosthetic care. This Bill of Rights will help inform and ensure that
veterans across the country have comparable access to the highest
quality O&P care regardless of their geographic location. It will
ensure that veterans know they are entitled to the most appropriate O&P
technology provided by a skilled practitioner of their choosing
(whether or not that practitioner has a formal contract with the VA).
They will know they have the right to a second opinion with respect to
treatment decisions and to continuity of care when being transferred
from the Department of Defense health program to the VA health system,
as well as other rights and protections.
Overall, the VA has provided quality orthotic and prosthetic care
to veterans over the years, whether or not their underlying impairment
has been service-connected. But there are many areas where
inconsistencies across the country are apparent and require
improvement. As the national focus on those injured by war begins to
wane in the coming years, we are concerned that these inconsistencies
will intensify across the country. That is why enactment of this
legislation in the 111th Congress is so important.
Your bill proposes a straightforward mechanism for ``enforcement''
of this ``Bill of Rights,'' an explicit requirement that every O&P
clinic and rehabilitation department in every VA facility throughout
the country be required to prominently display this Bill of Rights. The
VA Web site is also required to post the Bill of Rights. In this
manner, veterans with amputations and other injuries across the country
will be able to read and understand what they can expect from the VA
health care system. And if a veteran is not having their orthotic or
prosthetic needs met, they will be able to avail themselves of their
rights and work through the VA system to access the care they require.
The Bill of Rights would help educate injured and amputee veterans
of their rights with respect to O&P care, and would allow them an
avenue to report violations of that set of standards to the VA central
office. In this manner, Congress would have easy access to the level of
compliance with this Bill of Rights across the country and could target
particular regions of the country where problems persist.
Again, we thank you for your leadership on this important issue and
look forward to working with you to enact this legislation by the end
of the 111th Congress.
Sincerely,
Thomas Guth, C.P.
President
Statement of National Nurses United
Thank you for the opportunity to comment for the record on H.R.
5543, a bill to improve the collective bargaining rights and procedures
for certain employees of the Department of Veterans Affairs. National
Nurses United, the Nation's largest nurse union, represents nurses at
22 VA facilities throughout the United States. However, this bill is
incredibly important not just to our nurses who work at the Department
of Veterans Affairs (VA), but to our entire 155,000 national
membership. Denying the most basic protections to one nurse is an
injustice to all nurses.
We thank Chairman Filner for introducing this important
legislation, and for his work on the broader legislation, H.R. 949. We
appreciate your commitment to fair treatment for all VA health care
workers. It's simply unacceptable that nurses would be treated as
second-class citizens for the purposes of collective bargaining.
This bill fixes one way in which nurses collective bargaining
rights are different than the rights of other clinicians at the VA and
other Federally employed nurses by allowing them to bargain over pay
issues not related to the setting of base pay.
One need only look to the disparate treatment of nurses at a newly
merged VA/Navy Hospital in Chicago to see how irrational it is to apply
more restrictive collective bargaining rights on the VA nurses who are
working side by side with the Navy nurses. It begs the question of what
the difference is between the care given to active duty members of the
United States Navy and veterans. Members of the armed services of the
United States should and do receive excellent health care, and they get
it from nurses with collective bargaining rights that all nurses should
have, at a minimum.
National Nurses United is confident that if private employers and
other Federal employers can negotiate with nurses without the
restrictions in 38 U.S.C. 7422, it should be well within the capacity
of the VA to manage basic collective bargaining rights for its nurses.
We appreciate the formation of a working group to address the
grievances that nurses have had with the Department's interpretation of
section 7422. We hope that this workgroup will help to demonstrate the
reality that when leadership of any organization is willing to bring
workers to the table, everybody wins. However, such a working group can
only hope to resolve worker complaints about the system as long as the
Administration decides to honor their end of the bargain. Without a
legislative solution, any future Administration can roll back such an
agreement with impunity.
The collective bargaining process is entirely consistent with the
concept of ``patient centered medicine''. Nurses, as the front line
workers in the health care system, have a right and a duty to be
patient advocates. As such, they are quite motivated and well qualified
to advocate for the highest quality care available for the heroic men
and women who have laid their lives and health on the line in defense
of our Nation.
Delivering the best quality care means providing nurses and other
health care workers the support that they need so that they can spend
their time advocating for patients. When that's not the case, everyone
loses. For example, a nurse in Buffalo, New York recently volunteered
to give up home and family time to work through the weekend to provide
flu shots to veterans. Her contract clearly stated that she was to be
paid premium pay for those overtime hours. However, in addition to
never receiving the compensation she was entitled to, she was told that
she could also not file a grievance through her union for that overtime
pay, because of the exemptions in section 7422. Most rational observers
would make the determination that the pay exemptions in 7422 would only
apply to the setting of salary levels, not filing grievances over
violations of an existing employment contract.
Passing H.R. 5543 would mean that a nurse like the one in Buffalo
would be able to focus on taking care of patients rather than arguing
with the boss over her paycheck. That is good for nurses and the heroes
they heal.
We ask that the Committee work to pass H.R. 5543 to ensure that
hard-working front line nurses at the VA are treated fairly--not only
in comparison with other government nurses and VA clinicians--but with
the respect due any worker. Nurses choose to devote their careers to
helping the sick and the wounded, and to preventing illness. This is
not a choice made out of greed, cynicism, or self-concern. Once made,
this choice leads a practicing nurse to bear witness to pain and
suffering, but also hope and triumph the likes of which are nearly
impossible to describe in a few pages of Congressional testimony. It is
simply remarkable that anyone would choose to characterize their desire
for adequate representation for themselves and their patients as self-
interested and harmful to patient care. That is why the broader
bargaining rights in H.R. 949 have the support of the Disabled American
Veterans, Paralyzed Veterans of America, and Vietnam Veterans of
America. If the veterans who have come to rely on VA nurses can back
our rights to advocate for ourselves and our patients, then so should
the VA, and so should Congress.
Statement of Michael O'Rourke, Assistant Director,
National Veterans Service, Veterans of Foreign Wars of the United
States
CHAIRMAN MICHAUD, RANKING MEMBER BROWN AND MEMBERS OF THE
SUBCOMMITTEE:
On behalf of the 2.1 million members of the Veterans of Foreign
Wars of the United States and our Auxiliaries, the VFW would like to
thank this Committee for the opportunity to present our views on
today's pending legislation.
H.R. 3843, To amend title 38, United States Code, to direct VA to
publish redacted medical quality-assurance records of the Department of
Veterans Affairs on the Internet Web site of the Department
VFW supports the Transparency for America's Heroes Act. This bill
would require VA to publish and make available inspection reports of VA
facilities thirty-days after completion of the review on its Web site.
Recent reports of contaminated instruments, unsupervised medical
procedures and adverse conditions at a Philadelphia long-term care
facility erode faith in the VA health care system. We believe that
having information easily available to patients and stakeholders renews
the emphasis on quality, accountability and sound health care
procedures provided by all staff in every VA facility.
By providing quality assurance records on VA's Web site you will
close the gap between patient, VA and quality health care. It also
offers a sense of accountability and willingness by VA to clarify
procedures within its health care system.
We would ask that resources and funding for VA's IT Department
remain at appropriate levels to ensure continued efforts are made
toward providing the information needed to implement this new effort
toward transparency.
H.R. 4041, To authorize certain improvements in the Federal
Recovery Coordinator Program, and for other purposes
VFW supports this bill as it would improve the current Federal
Recovery Coordinator Program (FRCP) by authorizing and funding forty-
five recovery care coordinators to be trained at qualified nursing and
medical schools selected by VA. It would also provide for the
development of evidence-based guidelines for care coordination and best
practices for models of care used as part of the FRCP.
The FRCP was established to assist recovering servicemembers and
their families by providing information with access to care, services
and benefits within VA and DoD.
In 2007, DoD and VA partnered to create a Federal Recovery
Coordination Program to coordinate clinical and nonclinical care for
the most severely injured and ill servicemembers. Today, the program is
up and running at six military treatment centers and two VA medical
centers, but predicting the total number of coordinators needed is
difficult. The program itself has struggled with referrals as it
depends on the number of eligible servicemembers and veterans enrolling
and their specifics needs.
VFW believes that utilizing nursing and medical schools to train
coordinators is a positive step forward and highlights the need for
fundamental changes in care management. Today's injured servicemembers
deserve greater coordination as they struggle with complex injuries
that often hinder their transition from military to civilian life.
Having someone trained properly to guide the way is only the first step
toward recovery.
H.R. 5428, To direct the Secretary of VA to educate certain staff
of the Department of Veterans Affairs and to inform veterans about the
Injured and Amputee Veterans Bill of Rights, and for other purposes
The VFW supports this legislation, which would require the display
of an injured and amputee veterans bill of rights. The display
reaffirms and clarifies the rights of these injured servicemen and
women, letting them know what they can expect from VA.
We believe that this bill would ensure consistency in the orthotic
and prosthetic (O&P) benefit program under the VA health care system.
It would also allow veterans to select the practioner that best meets
their needs, and provide them ample access to vocational
rehabilitation, employment and housing assistance. The bill also goes
one step further by requiring all VA O&P clinics to post the bill of
rights and create a mechanism of enforcement by establishing a
complaint system so that veterans can report mistreatment or a lapse in
care.
H.R. 5516, The Access to Appropriate Immunizations for Veterans Act
of 2010
VFW supports legislation that would improve health outcomes for
veterans by expanding VA performance measures to cover vaccines
recommended by the Center for Disease Control and Prevention (CDC). The
recommended adult immunization schedule is periodically reviewed and
revised so that vaccinations are scheduled at the time in which they
are needed most.
Currently VA only administers the influenza and pneumococcal
vaccinations. Congressman Stearns' legislation would authorize VA
performance measures to cover all vaccinations recommended by VA and
CDC so veterans, especially those in ``high risk'' categories, would
receive timely access to vaccines that may help prevent diseases and
long-term hospital stays. By following suggested vaccine protocols, we
see a win-win in the delivery of health care and improved health care
outcomes within VA.
H.R. 5543, A bill to alter collective bargaining rights of VA
employees
This bill would permit VA employees to contest aspects of their
pay. Under this legislation, employees would be able to file grievances
and negotiate all compensation that is not considered basic pay, to
include bonuses, merit pay, and other compensable items. It would still
bar VA employees from petitioning for a basic pay structure that
differs or is inconsistent with the General Schedule or other Federal
basic pay structures; it would merely give them the option to file a
grievance with respect to additional pay. The VFW has no position on
this legislation.
H.R. 5641, Legislation that would authorize the Secretary of
Veterans Affairs to enter into contracts to transfer veterans that are
unable to live independently into adult foster homes.
The VFW supports this bill, which would add language to Section
1720 of Title 38 to allow veterans who receive VA care and require a
protracted period of nursing home care to transfer into an adult foster
home. Under the bill, such homes must have the goal of providing non-
institutional, long-term, supportive care. VA currently has the
authority to reimburse institutional care facilities such as nursing
homes for long-term domiciliary care, but veterans living in adult
foster homes must do so at their own expense. To grant VA authority to
reimburse adult foster homes would provide veterans with an additional
residency choice and improve the quality of life for those who would
prefer this option.
The language protects veterans who may wish to reside in such a
setting by requiring caregivers to reside on premises, to receive
annual training, and to provide 24-hour care. The adequacy of their
living conditions would be ensured through language that would grant
needed devices in the home, such as lifts or closed captioning devices.
As part of the contracting process, adult foster homes would be
required to accept announced and unannounced visits, and the caregivers
who run them would be screened by the VA in addition to being required
to pass a Federal background check.
We believe this language defines what and who can serve veterans
through an adult foster home in an adequately narrow way, while also
responsibly providing the chance to live in a family setting that will
be more beneficial for the physical and mental health of veterans of
all ages.
H.R. 5996, Legislation to direct the Secretary of Veterans Affairs
to take a more aggressive posture in its treatment of Chronic
Obstructive Pulmonary Disease.
The VFW supports this effort. Chronic Obstructive Pulmonary Disease
(COPD) affects our veterans at a rate approximately three times higher
than their civilian counterparts, and it is the fourth most common
diagnosis among hospitalized veterans. And among veterans age 65-74, it
is the most common diagnosis leading to hospitalization.
This legislation would improve our response to COPD by requiring VA
to develop treatment protocols to prevent, diagnose, treat and manage
the disease and also to improve biomedical and prosthetic research. It
also requires the VA to develop pilot programs to gain a better
understanding of best practices in this area of medicine. Finally, the
bill contains provisions that require VA to develop better smoking
cessation programs to improve techniques and best practices to assist
veterans who want to improve their health outlook by successfully
quitting smoking.
H.R. 6123, To amend title 38, United States Code, to improve the
provision of rehabilitative services for veterans with Traumatic Brain
Injury
The VFW supports this legislation, as it would make significant
improvements to Chapter 17 of Title 38 by expanding the plan for
rehabilitation and reintegration of TBI patients to account for the
individual's independence and quality of life.
It expands objectives for the rehabilitation of veterans suffering
from a TBI to include behavioral and mental health concerns. As a
result of this bill, the phrase `rehabilitative services' vice
treatments would be an overarching theme in Chapter 17, thereby
conforming the code to the prevailing wisdom that TBI patients deserve
more than mere treatment of their injuries--rather, they deserve
ongoing evaluation and additional intervention where necessary to
ensure a full recovery. We believe the changes in this bill would make
it easier for veterans struggling with the aftermath of a TBI to
receive such coverage.
Finally, this bill would also support TBI patients by associating
sections of the law related to TBI rehabilitation and community
reintegration to a broader definition of the term `rehabilitative
services' in Title 38 that comprises a range of services such as
professional counseling and guidance services. Our veterans deserve an
optimal chance to lead productive lives, and this bill would help to
ensure our response to Traumatic Brain Injuries consists of more than
just healing the physical wounds of war.
H.R. 6127, A bill to provide for the continued provision of health
care services to certain veterans who were exposed to sodium dichromate
while serving as a member of the Armed Forces at or near the water
injection plant at Qarmat Ali, Iraq, during Operation Iraqi Freedom.
Over the course of the last several months, information has
surfaced revealing that approximately 800 servicemembers were exposed
to harmful chemicals while guarding sensitive infrastructure in Iraq
during the first half of 2003. These servicemembers, Guardsmen and
women from a number of different states, were not exposed to a quantity
of contaminant considered to be causal to any harmful effects; however,
the VFW fully supports taking extraordinary precautions in this case.
This legislation would extend enrollment eligibility into the VA
health care system for all veterans exposed to sodium dichromate at
Qarmat Ali by 5 years from the day they were notified of their
exposure. We have been assured that the VA is reaching out to inform
those exposed of their options for care and to advise them on VA
recommended examinations and treatments, and the VFW appreciates this
effort on their behalf. We support this legislative effort to give them
every reasonable opportunity to seek VA health care as a result of
their sacrifice and selfless service to our country.
Draft bill, To amend title 38, United States Code, to make certain
improvements in programs for homeless veterans administered by the
Secretary of Veterans Affairs and for other purposes.
VFW supports draft legislation that would enhance many homeless
veterans programs. This bill greatly increases funding for various
homeless programs and expands the availability of resources needed by
homeless veterans, while including provisions that encourage treatment
facilities providing care to homeless veterans to use the available
funding effectively.
The bill also addresses the shortfall in funding for aiding
homeless veterans. Prior to this bill funding for health care
facilities for treatment of homeless veterans was $5 million a year.
With this bill funding would increase in FY 2011 to $10 million, $15
million in FY 2012, and top out at $21 million in FY 2013. The increase
in funding is needed and would help to expand services across the board
for homeless veterans programs.
The VFW commends the Committee for taking a step in the right
direction; however, we are concerned that the structure of this
temporary increase does not adequately reflect the needs of our
veterans. Thousands of Iraq and Afghanistan veterans are returning home
to tough economic conditions, often having to give up homes and housing
to support the mission, and we believe there is a clear preponderance
of data that demonstrates the need for scrutiny of these programs in
addition to this supplemental funding. All veterans should have access
to every resource they are entitled to when they are in need, and the
VFW is convinced that in order to meet that need, funding levels should
not be reduced to levels prior to FY 2011.
The VFW recognizes the many challenges our Nation faces in
addressing homelessness among our veterans. For many, the road to
homelessness is littered with complications related to medical
conditions such as post-traumatic stress disorder, traumatic brain
injury, or drug and alcohol addiction. The provision of temporary
housing and/or job placement is only a treatment of some of the
symptoms of homelessness, and is far from a cure.
By striking the term ``health care facilities'' and amending it to
read ``eligible entities for the purpose of establishing programs, or
expanding or modifying programs that provide assistance to homeless
veterans'' they would have at their disposal an improved array of
options. Specifically, rehabilitation facilities, work placement
services, and homeless shelters that do not necessarily provide medical
care would be authorized to receive funding in exchange for their
services. This multi-pronged approach represents a long overdue
tactical change that will help to combat homelessness among the veteran
population.
We also applaud the changes in Section 2061 that will institute
various safeguards to ensure that funding is used properly by approved
facilities. Proper use of funding and proper oversight--wise
stewardship of the taxpayer's dollar--should never be an ancillary
concern, particularly in this fiscally constrained environment. Making
sure that the funds available are spent wisely or be returned to the VA
encourages programs to use every available dollar to improve and expand
their services. With countless veterans suffering from both the visible
and invisible wounds of war completing their overseas tours and
separating from the military with bleak job prospects at home, we must
ensure an adequate safety net for those veterans who are experiencing
hard times.
Draft bill, To amend title 38, United States Code, to ensure that
health care professionals of VA provide veterans with information
concerning service-connected disabilities.
VFW supports draft legislation that would encourage VA health care
professionals to furnish information to veterans about benefits
provided by the Veterans Health Administration, including guidance on
how to apply for compensation relating to a service-connected
disability. Far too many veterans seeking health care services from VA
are not aware of the full range of their earned benefits or how to
acquire them. VA health care professionals should be providing needed
information, advice and assistance. We believe such a change would help
facilitate the acquisition of earned and needed compensation, pension,
and other benefits. We believe that this is an important opportunity
for VA to continue to improve upon their outreach services on behalf of
those who have worn the uniform and served our great Nation.
Thank you for the opportunity to present our views before this
Subcommittee.
Prepared Statement of Richard F. Weidman, Executive Director
for Policy and Government Affairs, Vietnam Veterans of America
Mr. Chairman, Ranking Member Brown, and distinguished members of
the House Veterans' Affairs Subcommittee on Health, Vietnam Veterans of
America appreciates the opportunity to present our views on nine bills
up for your consideration this morning.
H.R. 3843, the ``Transparency for America's Heroes Act,'' would
direct the Secretary of Veterans Affairs to publish on the VA Web site
redacted medical quality-assurance records and documents (but not
personal identifying information) created by the VA.
In general, despite lapses in care at individual medical centers,
the VA--actually, the Veterans Health Administration--provides good to
excellent care at medical centers and community-based outpatient
clinics for more than five million veterans annually. If the VA is to
achieve and retain the confidence of the veterans it serves, opening
for ease of public inspection quality-assurance records makes good
managerial sense. If passage of H.R. 3843 can help bring a measure of
transparency to what has, for the most part, been a cloistered process,
it has VVA's full endorsement.
H.R. 4041 would direct the Secretary of Veterans Affairs to provide
collaborative recovery coordinator training at a ``qualified'' nursing
or medical school, and would authorize said nursing or medical school
to train 45 recovery coordinators.
While this bill, on the surface, sounds important, and while it
addresses a very real need, VVA believes it is in the purview of the VA
Secretary to determine how best to set up recovery coordinator training
and train whatever number of recovery coordinators he deems fit.
At the same time, Congress needs to exercise its powers of
oversight to ensure that the VA does all that is necessary to
coordinate the treatment and recovery of badly wounded or injured
veterans. We do not believe that a prescriptive bill such as H.R. 4041
will necessarily be an effective way to get VHA to comply with its
national mandate, although we certainly understand your frustration
with the VHA on this and other issues that should be ``no-brainers''
for the VHA to accomplish.
We would respectfully point out that provisions in H.R. 4041,
specifically for the development of ``care coordination software,''
open the possibility of a boondoggle, and seem at odds with the
centralization of IT within the VA.
H.R. 5428 would direct the Secretary of Veterans Affairs to ensure
that an Injured and Amputee Veterans Bill of Rights is printed on
signage in accessible formats and displayed prominently and
conspicuously in each VA prosthetics and orthotics clinic. It would
require that VA employees who work at such clinics, as well as patient
advocates for veterans who receive care there, receive training on the
elements in said Bill of Rights. It also would direct the Secretary to
conduct outreach to inform veterans of this Bill of Rights.
The difficulty we have with this piece of legislation is elemental:
If Congress sees fit to enact a Bill of Rights for injured and amputee
veterans, why not enact a similar Bill of Rights for blinded veterans,
and one for homeless veterans, and one for women veterans? Or perhaps
one Bill of Rights for all veterans? (This latter VVA would heartily
endorse.)
We also quibble with the provision that would direct the Secretary
to conduct outreach to inform veterans of the provisions in an Injured
and Amputee Veterans Bill of Rights. The VA needs to do a far better
job in informing all veterans, and their families, about the health
care and other benefits earned by veterans by virtue of their service
in uniform, and about health conditions that may derive from a
veteran's time in service. Under the leadership of Secretary Shinseki,
the VA is finally moving in this direction, although it admittedly has
little expertise with marketing and advertising.
We would quibble, too, with the provision of submitting a quarterly
report to the VA's Chief Consultant of Prosthetics and Sensory Aids on
information collected relating to alleged mistreatment of injured and
amputee veterans. If this is to be done for one subgroup of veterans,
why not for all subgroups of veterans? Or, better yet, simply for all
veterans?
H.R. 5516, the ``Access to Appropriate Immunizations for Veterans
Act of 2010,'' would include within authorized preventive health
services available to veterans through the Department of Veterans
Affairs immunizations against infectious diseases on the recommended
adult immunization schedule established by the Advisory Committee on
Immunization Practices established by the Secretary of Health and Human
Services and delegated to the Centers for Disease Control and
Prevention.
This bill makes good sense insofar as it focuses on vaccinations
for infectious diseases with vaccines approved by the FDA. We would
hope, however, that it doesn't do for veterans what was done for
active-duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic over the
possibility that rogue enemies could somehow unleash these viruses on
an unsuspecting American military and public.
VVA also urges this distinguished Committee to take similar action
for all pharmaceutical treatments approved by the FDA, and
automatically list them on the VA formulary unless it is demonstrated
through open hearings that a product is not effective or potentially
harmful. The VA formulary process needs to be brought out into the
light of day, exposed to the sunshine, and codified in statute to end
the backroom deals in the ``dead of night'' non-transparent process
that the VA currently uses. This President has often emphasized his
Administration's commitment to ``Open Government.'' VVA lauds that
principle, and urges the Congress to bring that open government process
to listing of pharmaceuticals. Enacting a process that mirrors the DoD
formulary process into Title 38 for VA is appropriate, and should be a
high priority for the Congress to get done within the next year.
VVA supports the enactment of H.R. 5516.
H.R. 5543 would repeal the prohibition on collective bargaining
with respect to matters and questions concerning compensation of
employees of the Department of Veterans Affairs other than rates of
basic pay.
VVA sees no legitimate reason why VA clinicians and other health
care professionals are barred from bargaining over additional
compensation issues such as overtime pay and physician performance
bonuses. VVA sees no credible rationale why these professionals are not
accorded the same rights as are other Federal employees when it comes
to seeking redress in disputes with management.
Frankly, the VA nursing service has for far too long been plagued
by a destructive mind-set that favors ``nurse executives'' and is
disdainful of bedside nurses and other actual caregivers who actually
touch patients and are the heart of the provision of good medical care.
This inappropriate and ugly attitude manifests in the treating of the
staff members who provide actual ``hands-on'' care virtually as chattel
who should have no say in working conditions. This must end.
Because enactment of H.R. 5543 would bring a long-needed measure of
justice for health care professionals at VA medical facilities, VVA
strongly supports its passage.
H.R. 5641, dubbed the ``Heroes at Home Act,'' would authorize the
Secretary of Veterans Affairs to enter into contracts for the transfer
to non-Department adult foster homes for veterans who are unable to
live independently.
If such a veteran who is eligible to be transferred to a non-VA
nursing home prefers to be transferred instead to a home designed to
provide non-institutional, long-term, supportive care in a family
setting, VVA sees no reason why policy--and the legal foundation for
such policy--would not facilitate this. Nursing homes, even well run
facilities, can be oppressive places. Adult foster homes, with proper
oversight by the VA, can be attractive alternatives. As such, VVA
supports enactment of this legislation.
VVA also notes that much more attention overall needs to be paid to
our most vulnerable veterans, especially in regard to those with
guardians and whose funds are controlled by someone else who is
supposed to be looking out for those who cannot care for themselves. A
GAO report that examines all aspects of fiduciaries would be useful in
this regard.
H.R. 5996 would direct the Secretary of Veterans Affairs to improve
the prevention, diagnosis, and treatment of veterans with chronic
obstructive pulmonary disease ``subject to the availability of
appropriations provided for such purpose.''
While we have no problem with the intent of this legislation, the
only way it will realistically happen is if Congress does in fact
appropriate funds for its implementation. That said, Congress ought to
mandate the VA to develop techniques and strategies to encourage
veterans who smoke to cease smoking, whether they have developed COPD
or not, and to prioritize an anti-smoking campaign at the top of its
preventive health programs. If passed without specifically targeted
funding, H.R. 5996 will be little more than another item on a laundry
list of ``Things to Do'' at VA medical facilities.
VVA specifically notes that there are pharmacological treatments
and other treatment modalities available in the private sectors that
are difficult if not virtually impossible to get on the VA formulary.
We suspect that much of the problem here is the ``blame game'' that
goes ``It is his own fault he is sick, so we should not do much to help
him.'' That attitude has no place in veterans' health care.
H.R. 6123, the ``Veterans' Traumatic Brain Injury Rehabilitative
Services' Improvements Act of 2010,'' would in essence tweak Section
1710C of title 38 to more broadly define provisions for assisting
veterans afflicted with Traumatic Brain Injury (TBI), the ``signature
injury'' of the wars in Afghanistan and Iraq. VVA supports the intent
of this legislation.
H.R. 6127 would provide for the continued provision of health care
services to veterans who were exposed to sodium dichromate while
serving in the U.S. Armed Forces at or near the water injection plant
at Qarmat Ali, Iraq, during Operation Iraqi Freedom.
Toxic substances can be insidious; often their effects do not
manifest till health conditions develop years after a veteran's
exposure in the military. As Vietnam veterans, we know this to be the
case vis a vis exposure to dioxin, to Agent Orange, when we served in
Southeast Asia. Because we are still learning about the effects of
exposure to sodium dichromate to troops who were stationed at or near
Qarmat Ali, extending their eligibility for VA health care would be a
prudent investment in maintaining their health and treating maladies
that may have derived from their service in Operation Iraqi Freedom.
We would submit, however, that the VA has an obligation to track
the health status of all veterans thus exposed so as to better
determine what health conditions may, in fact, be attributed to
exposure to sodium dichromate. There may also be other toxins that
emanate from these same or similar sources, so VVA urges more complete
epidemiological tracking of health problems in returning warriors,
depending on when and where they served. Ensuring such tracking ought
to be an added provision of H.R. 6127.
H.R. 6188, the Veterans' Homelessness Prevention and Early Warning
Act of 2010, would amend paragraph (4) of subsection (a) of section
3732(a)(4)(A) of title 38, United States Code, to ensure that a case
manager develops a plan to provide alternate housing for the veteran in
the event that the veteran loses the veteran's home. VVA supports
enactment of this bill.
Draft legislation to make certain improvements in programs for
homeless veterans administered by the Secretary of Veterans Affairs
contains many very well-thought out facets that should assist Secretary
Shinseki and his staff in their efforts to end homelessness among
veterans by 2015.
Ending homelessness among veterans surely is a worthy goal. If
policies, processes, and practices by the VA and other entities of
three levels of government--local, state, and Federal--can function in
concert, to create a continuum of care, we would hope that homelessness
among veterans can continue to be reduced significantly, although some
veterans for whatever reasons will choose to live their life on the
streets, in flophouses, or out in the woods.
This legislation does contain some particularly important clauses.
For instance, it would direct grant recipients, as a condition of
accepting a grant, to ``maintain referral networks . . . for
establishing eligibility for assistance and obtaining services, under
available entitlement and assistance programs.''
We do believe, however, that the schedule of appropriations for
grants--$10 million for FY 2011, $15 million for FY 2012, and $21
million for FY 2013--perhaps ought to be reversed. Why? Because if the
programs and services currently in existence, and additional programs
and services as established by this and other legislation succeed in
achieving their stated purpose, there will be fewer veterans to avail
themselves of these programs and services. Hence, we would suggest that
appropriations be at a constant level, e.g., $15 million for each of
the next three fiscal years.
__________
It should be noted that VVA continues to urge that VA Homeless
Grant and Per Diem (HGPD) funding must be considered a payment rather
than a reimbursement for expenses, a key distinction that will enable
the community-based organizations that deliver the majority of these
services to operate more effectively.
This legislation attempts to make the funding provided to HGPD
providers more accessible by creating a vehicle to enable them to
better access reimbursement. If a provider is able to draw from the
available funds on a monthly basis with program expenditures for
reconciliation on a quarterly basis, then VVA supports this language.
If funds are available on a ``short turnaround'' drawdown that is
directly deposited into provider accounts, monies would be more
immediately available. The current method of voucher submissions
through local medical centers creates a lag in payment for weeks. With
the monthly drawdown, a non-profit agency would not have to utilize its
line of credit (if it even has one) to make payroll or pay program
expenses. Also, the fees associated with this practice cannot be
charged back as an expense to the program.
VVA also supports allowing greater than quarterly expenditures in
any given quarter if a need for these additional expenses exists.
Community non-profit providers, most of them small, that serve
homeless veterans cannot survive if they are permitted to draw down
from the quarterly amount only on a quarterly basis. Creditors,
purveyors, utilities, and the like must be paid monthly. Non-profits
held to a quarterly payment method would be hard-pressed to meet their
financial obligations in a timely fashion. If bill language means that
the providers can only draw down from the quarterly amount on a
quarterly basis, then VVA must oppose this provision.
VVA also supports the submission of future anticipated expenses
rather than past spent program expenses.
One of the most effective front-line outreach operations funded by
VA HGPD is the Day Service Center, sometimes referred to as a Drop-In-
Center. Few even remain in the HGPD system because of limited per diem
funding support. These service centers are an indispensable resource
for VA outreach. They can reach deep into the homeless veteran
population on the streets and in the shelters of our cities and towns.
They are the portal from the streets and shelters to substance abuse
treatment, job placement, job training, VA benefits, VA medical and
mental health care and treatment, homeless domiciliary placement, and
transitional housing. They are the first step to independent living.
They can be the first step to ending homelessness. But this can only
happen if they are able to operate in an effective environment.
Under the VA HGPD program, non-profits receive per diem at rates
based on an hourly calculation per diem (one-eighth of the allowable
per diem for residential programs) for the time that the homeless
veteran is physically in the center. While this may cover the cost of
the coffee and food that the veteran receives, it does not come close
to paying for the professional staff that must provide the assistance
and comprehensive services long after that veteran leaves the facility,
and the demands on staff require a significant amount of time, energy,
and manpower in order to be effective and, hence, successful.
It is unfortunate that the current per diem funding model is simply
not sufficient to sustain the operations of many community-based
service centers. Many have either closed or never opened after being
funded by VA HGPD. The VA acknowledges and understands that this
situation exists.
At the very least, VVA hopes that Service Centers are also included
in the annual set-aside program funding available monthly with
quarterly reconciliation. If not, we believe that it is necessary to
create ``Service Center Staffing/Operational'' grants, much like the VA
``Special Needs'' grants that were previously legislated, although this
is hardly an optimal solution, particularly with regards to funding
programs that work with some of the hardest to place and most chronic
of our homeless veteran population.
Draft legislation to ensure that the Secretary of Veterans Affairs
provides veterans with information concerning service-connected
disabilities at health care facilities makes sense insofar as it goes.
However, it does not go far enough.
VVA would like to see Congress orient a major outreach campaign to
all veterans, not only to those veterans who already use VA health care
facilities. Seven out of ten veterans do not obtain health care at VA
facilities, and far too many of them are unaware not only of the
benefits to which they are entitled by virtue of their service to this
Nation, but of health conditions that may derive from their time in
service because of exposure to toxic substances.
The VA needs to conceptualize and coordinate an outreach and
information campaign that avails itself of public service announcements
featuring real veterans as well as recognizable stars like Gary Sinise
and Dennis Franz; signage on billboards; point-of-purchase displays in
hardware stores, sporting emporiums, doctors' offices, and other places
patronized by veterans and their families (because more often than not
veterans are reached through their families).
Thanks you for the opportunity to appear here this morning to
express the views of VVA. I will be pleased to answer any questions,
Mr. Chairman.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
October 4, 2010
Mr. Jacob B. Gadd
Deputy Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Mr. Gadd:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health legislative
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R.
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on
Homelessness, and Draft Legislation on VA Health care Provisions, which
took place on September 30, 2010.
Please provide answers to the following questions by Monday,
November 15, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. In their testimony, DAV questioned whether making quality
assurance medical records available on a VA Web site would be easily
understandable and meaningful for our veterans and their families to
make informed decisions. Do you share this concern? Do you have any
specific recommendations on ways to improve this bill so that the
quality assurance medical records that VA posts on their Web site are
meaningful and useful?
2. Many of the witnesses on the second panel emphasized the need
to balance confidentiality and transparency. In fact, VA explains that
it is precisely the confidential nature of the quality-assurance
program that allows providers to report and examine patient safety
events without fear of recrimination or liability. What specific
barriers and challenges must VA overcome before they can make quality
assurance records available to the public without compromising patient
confidentiality?
3. In your written testimony, you recommended enhanced
communication between national, state and local levels to ensure
maximum awareness of benefits that are available. Could you expand on
this point and provide more detailed recommendations on ways to enhance
communication?
4. Some have raised concerns about limiting the bill of rights to
injured and amputee veterans. What are your thoughts on a bill of
rights for all veterans which encompasses rights for injured and
amputee veterans?
5. PVA raised concerns with H.R. 5428 ignoring veterans who may
be in need of special equipment who suffer from a specific disease and
not a physical injury. Do the other witnesses of this panel share this
concern? Why or why not?
6. VVA raises some caution with H.R. 5516 by stating that they
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic.'' Do you share
this concern? Why or why not?
7. VA explains that H.R. 5543 would ``result in unprecedented
changes in how the Federal Government operates. It would permit unions
to bargain over, grieve, and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
There was unanimous support for this bill by the witnesses on the
second panel. How do you respond to VA's concerns?
8. In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for our
veterans with TBI.
9. PVA recommends that a broader spectrum of veterans is targeted
instead of singling out the Qarmat Ali veterans for enrollment in H.R.
6127. Do the other witnesses of this panel share PVA's recommendation?
Why or why not?
10. In your testimony, you recommended that each VA medical center
create a VHA/VBA training liaison position to facilitate biannual
training and updates on VBA regulations for VHA providers. Which VHA
providers should participate in this training and should other, non-
providers who work at the VA medical centers partake in this training?
11. In your testimony, you identified the need for ``Congress and
VA to address the growing concern with homeless women veterans,
especially those with children.'' The draft homeless veterans bill is
targeted to the special needs population, which include women veterans
with children. In addition to the creation of a new capital grants
program as specified in the draft bill, what other programs and
services should VA provide to help women veterans with children?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 15, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
American Legion
Washington, DC.
November 15, 2010
Honorable Michael Michaud, Chairman
Veterans' Affairs Subcommittee on Health
U.S. House of Representatives
A335 Cannon Office Building
Washington, DC 20515-6335
Dear Chairman Michaud:
Thank you again for allowing The American Legion to testify at the
September 29th hearing regarding pending legislation affecting
veterans' health issues. This letter is in response to your Post-
Hearing Questions:
Question 1: In their testimony, DAV questioned whether making
quality assurance medical records available on a VA Web site would be
easily understandable and meaningful for our veterans and their
families to make informed decisions. Do you share this concern? Do you
have any specific recommendations on ways to improve this bill so that
the quality assurance medical records that VA posts on their Web site
are meaningful and useful?
Response: The American Legion has a number of concerns regarding
the publication of quality assurance medical records online. Even a
cursory examination of VA data security over the last several years
will show a troubling pattern of data breaches and compromised security
of veterans' personal information. Obviously, this would remain a
primary concern of the Legion, the protection of veterans' personal
information. While it is possible to redact this information towards
the end of protecting patient privacy, it is unclear as to whether this
redacted information could be of use. The American Legion does support
more clarity and transparency from VA in all aspects of quality
assurance, but to be of real benefit there would need to be more detail
concerning making this information useful to a layman such as a veteran
or their family. The most helpful information for veterans would be an
indication of what common errors and deficiencies are at a particular
medical institution.
Question 2: Many of the witnesses on the second panel emphasized to
balance confidentiality and transparency. In fact, VA explains that it
is precisely the confidential nature of the quality assurance program
that allows providers to report and examine patient safety events
without fear of recrimination or liability. What specific barriers and
challenges must VA overcome before they can make quality assurance
records available to the public without compromising patient
confidentiality?
Response: To begin with, The American Legion must reiterate that
data security has been a major issue for VA over the last several
years, and it will take time to rebuild confidence in data security. VA
can help with this by adopting even more transparency in the measures
they are taking to protect patient information. At the very least, all
potential identifying information must be stripped away to prevent
possible identification and exploitation of that information.
Question 3: In your written testimony, you recommended enhanced
communication between national, State and local levels to ensure
maximum awareness of the benefits that are available. Could you expand
on this point and provide more detailed recommendations on ways to
enhance communication?
Response: One of the largest concerns that The American Legion has
recognized through the System Worth Saving visits made annually to VA
medical facilities is that there is a lack of consistency from VISN to
VISN in the implementation of policy. More control through Central
Office to ensure standardization should be the starting point.
Following on from there, VA should target individual communities
through public awareness campaigns to let veterans know of the
resources in their area and the availability of these benefits. Rather
than worrying about how to reach veterans, VA should adopt the attitude
that veterans are an integral part of every community and simply seek
to reach out to the general public and increase awareness. Many
veterans may not know they can receive treatment at CBOC clinics or
pharmacy benefits, yet through public service advertising on TV and on
the Internet, veterans can be directed to VA Web sites and facilities
to determine the benefits to which they are entitled.
Furthermore, on numerous occasions The American Legion experienced
difficulties in contacting the Federal Recovery Coordinators (FRCs). As
a result, we would like to recommend increasing the FRC staff to one
coordinator in each state as opposed to only 25 coordinators throughout
the country. This effort should alleviate the workload and enhance
communication across the National and local levels.
Question 4: Some have raised concerns about limiting the bill of
rights to injured and amputee veterans. What are your thoughts on a
bill of rights for all veterans which encompasses rights for injured
and amputee veterans?
Response: The American Legion believes that the intent of this
legislation is to focus on a certain group of veterans with certain
life-altering conditions. Veterans with amputations and other severe
injuries face unique issues and barriers compared to veterans with
minor injuries. In essence, the Injured and Amputee Veterans' Bill of
Rights is to alleviate some of the barriers that these veterans
encounter. Therefore, the American Legion believes it should remain as
such.
Question 5: PVA raised concerns with H.R. 5428 ignoring veterans
who may be in need of special equipment who suffer from a specific
disease and not a physical injury. Do the other witnesses of this panel
share this concern? Why or why not?
Response: The American Legion stands by its position that the
Injured and Amputee Bill of Rights should focus on injured and amputee
veterans. However, we would like to emphasize that VA should continue
to provide the best quality of health care to our veterans. Simply
because one bill provides for a specific group of veterans does not
alleviate VA's responsibility of care for the rest of the veterans that
they serve.
Question 6: VVA raises some caution with H.R. 5516 by stating that
they hope the bill ``doesn't do for veterans what was done for active
duty troops in the all too recent past, who were forced to be
inoculated against smallpox and anthrax in a panic.'' Do you share this
concern? Why or why not?
Response: The American Legion fully supports VA's efforts to
provide for necessary immunization and vaccination. However, we do
believe that this effort should be voluntary and not mandatory. It
would impose on a patient's right to choose their treatment course if
they had no say in whether they were vaccinated or not. For an example
of how this is sensibly implemented, consider the current annual flu
shots, which are provided for those veterans who choose to partake in
them, yet are not required treatment in any way.
Question 7: VA explains that H.R. 5543 would ``result in
unprecedented changes in how the Federal Government operates. It would
permit unions to bargain over, grieve and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
There was unanimous support for this bill by the witnesses of the
second panel. How do you respond to VA's concerns?
Response: The American Legion has no position and therefore does
not support or oppose the legislation.
Question 8: In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for our
veterans with TBI.
Response: In addition to the provisions of H.R. 6123, The American
Legion would recommend that VA incorporate more holistic approaches as
a part of the rehabilitative care administered to veterans who suffer
from Traumatic Brain Injury. The holistic treatment can include more
herbal remedy instead of pharmaceutical drugs, as well as other avenues
such as massage therapy and meditation.
Question 9: PVA recommends that a broader spectrum of veterans is
targeted instead of singling out the Qarmat Ali veterans for enrollment
in H.R. 6127. Do other witnesses of the panel share PVA's
recommendation? Why or why not?
Response: The American Legion fully concurs with this
recommendation. As stated previously in testimony, The American
Legion's policy on Hazardous Environmental Exposure requires that all
veterans who were exposed to environmental hazards are afforded the
necessary health care and compensation due to the extent of any lasting
effects of the exposure.
Question 10: In your testimony, you recommend that each VA Medical
Center create a VHA/VBA training liaison position to facilitate
biannual training and updates on VBA regulations for VHA providers.
Which VHA providers should participate in this training, and should
other, non-providers who work at the VA medical centers partake in this
training?
Response: During the American Legion System Worth Saving site
visits, The American Legion found that veterans are not receiving
information from VHA providers about their rights to file claims
through VBA. Furthermore, during American Legion Quality Review visits
to VBA Regional Offices, it became apparent that communication of
information between medical centers and the offices processing
veterans' claims were vastly improved when there was a dedicated
individual set to facilitate this task. Based on these findings, The
American Legion recommends that VA hire a VHA/VBA Liaison within each
VA Medical Center to initiate biannual training to VHA primary care
providers so that they are educated on VBA regulations and can pass on
that information to their patients during their routine visits. In
addition, The American Legion recommends that the same VHA/VBA bi-
training also be provided to a single primary care provider at the
Community Based Outpatient Clinics (CBOCs) who will then train their
other staff members. Furthermore, enhanced communication between VBA
and those VHA staff responsible for Compensation and Pension
examinations is essential to ensure that VHA better understands the
information required to fairly adjudicate a claim, the applicable law
and how the examinations must be conducted, and any recent law changes
or court decisions which might alter the way that these examiners
conduct the exams. Often VHA C&P exam providers are unaware of what the
courts have found regarding veteran rights in these exams, and this
only contributes to inadequate exams which must be repeated and thus
add lengthy delays to the problem and contribute to the rising VA
backlog of claims.
Question 11: In your testimony, you identified the need for
``Congress and VA to address the growing concern with homeless women
veterans, especially those with children.'' The draft homeless
veterans' bill is targeted to the special needs population, which
includes women veterans with children. In addition to the creation of a
new capital grants program as specified in the draft bill, what other
programs and services should VA provide to help women veterans with
children?
Response: In addition to the provisions of the draft legislation,
the American Legion would like to urge VA to provide childcare to women
veterans with children. According to the VA, women veterans are one of
the fastest growing populations in the VHA system. A significant amount
of these women veterans are of child-bearing age and are utilizing the
VA on a more frequent basis than in the past. This is especially
necessary for the female veterans with mental health appointments as
children are not allowed to accompany their parents to these
appointments.
While this is obviously a benefit for those women veterans
receiving health care, enhancing shelter facilities for homeless
veterans to accommodate the needs of children is also essential, as
well as the provision of childcare for women veterans in the vocational
rehabilitation programs. The ability to know that children are being
safely cared for during job interviews and essential training to
enhance marketable job skills can be a difference maker for women
veterans seeking employment that can lead to a stable income and the
ability to provide for their own housing needs.
Again, The American Legion would like to thank you and the
Committee for the opportunity to expand on the views presented at the
hearing and further clarify the position of the nearly 2.5 million
members of the Nation's largest veterans' service organization. Thank
you for your continued commitment to America's veterans and their
families.
Sincerely,
Jacob Gadd
Deputy Director, National Veterans Affairs and Rehabilitation
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
October 4, 2010
Mr. Carl Blake
National Legislative Director
Paralyzed Veterans of America
801 18th Street, NW
Washington, D.C. 20006
Dear Mr. Blake:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health legislative
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R.
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on
Homelessness, and Draft Legislation on VA Health care Provisions, which
took place on September 30, 2010.
Please provide answers to the following questions by Monday,
November 15, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Many of the witnesses of this panel emphasized the need to
balance confidentiality and transparency. In fact, VA explains that it
is precisely the confidential nature of the quality-assurance program
that allows providers to report and examine patient safety events
without fear of recrimination or liability. What specific barriers and
challenges must VA overcome before they can make quality assurance
records available to the public without compromising patient
confidentiality?
2. Some have raised concerns about limiting the bill of rights to
injured and amputee veterans. What are your thoughts on a bill of
rights for all veterans which encompasses rights for injured and
amputee veterans?
3. VVA raises some caution with H.R. 5516 by stating that they
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic.'' Do you share
this thought? Why or why not?
4. VA explains that H.R. 5543 would ``result in unprecedented
changes in how the Federal Government operates. It would permit unions
to bargain over, grieve, and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
There was unanimous support for this bill by the witnesses on second
panel. How do you respond to VA's concerns?
5. In addition to the provisions of H.R. 6123, the TBI Improvement
Act, please share your insight on additional authorities that would be
helpful in ensuring better health outcomes for our veterans with TBI.
6. In your testimony, you raised concerns about the feasibility of
implementing the draft legislation on VHA outreach to veterans on VBA
benefits. Do you have specific recommendations on ways to improve this
draft bill so that we can more realistically expect VHA to implement
the provisions of this bill?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 15, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
Paralyzed Veterans of America
Washington, DC.
November 15, 2010
Honorable Michael Michaud
Chairman
House Committee on Veterans' Affairs
Subcommittee on Health
338 Cannon House Office Building
Washington, DC 20515
Dear Chairman Michaud:
On behalf of Paralyzed Veterans of America, I would like to thank
you for the opportunity to present our views pending legislation
considered by the House Veterans' Affairs Subcommittee on Health at the
hearing held on September 29, 2010. We appreciate the continued
emphasis that the Subcommittee places on the unique health care needs
of a diverse veterans population.
We have included with our letter a response to each of the
questions that you presented following the hearing. If you need
additional information, please feel free to contact us. Thank you very
much.
Carl Blake
National Legislative Director
__________
Question 1: Many of the witnesses of this panel emphasized the need
to balance confidentiality and transparency. In fact, VA explains that
it is precisely the confidential nature of the quality assurance
program that allows providers to report and examine patient safety
events without fear of recrimination or liability. What specific
barriers and challenges must VA overcome before they can make quality
assurance records available to the public without compromising patient
confidentiality?
Answer: As we stated in our testimony, in the case of VA quality-
assurance records, it only makes sense that transparency is critical to
veterans, and those who serve veterans such as Veterans Service
Organizations (VSO), and their understanding of how well VA is doing
its job. Requiring VA to publish redacted medical quality-assurance
records on the VA's Web site will provide users of the VA a better
understanding of the successes or failures of the VA in the quality of
care they provide our veterans. This may encourage greater efforts on
the part of VA employees, staff and leaders to ensure the best care is
provided to veterans while ensuring openness.
As we also stated, PVA's concern stems from the need for privacy in
health care records. As we have seen in recent years, carelessness and
bad decisions have led to the release of critical personal information
of millions of veterans, particularly as a result of mishandling of
information technology (IT) assets. As such, focused training for the
VA personnel responsible for publishing this information will be
essential to ensure that seemingly simple mistakes do not lead to the
disclosure of a veteran's personal information. The VA must
specifically prescribe to its staff what information is suitable for
public viewing and what information must be redacted from records.
Additionally, safeguards should be locked in to the VA's IT system to
ensure that personal information cannot be accessed through outside
sources.
Question 2: Some have raised concerns about limiting the bill of
rights to injured and amputee veterans. What are your thoughts on a
bill of rights for all veterans which encompasses rights for injured
and amputee veterans?
Answer: As we stated in our testimony, PVA supports H.R. 5428 which
seeks to better educate injured and amputee veterans on their rights as
well as the VA staff who work at prosthetics and orthotics clinics or
who work as patient advocates for veterans. However, as we also
mentioned, PVA is concerned that this legislation's language seems to
ignore veterans who may be in need of special equipment who suffer from
a specific disease and not a physical injury. For example, many PVA
members face significant hardship associated with a diagnosis for
Multiple Sclerosis (MS). Similarly, veterans who have been diagnosed
with Amyotrophic Lateral Sclerosis (ALS) and Parkinson's disease face
similar problems. And yet, they are equally reliant on prosthetics and
sensory aids to function in as normal a manner as possible. We believe
that the legislation, as written, excludes veterans such as those
mentioned here who have significant limitations brought on by diseases,
and not just direct injuries or amputations.
PVA certainly supports the idea of a bill of rights for all
veterans. In fact, if such a legislative proposal is considered, we do
not believe any special mention is necessary for injured and amputee
veterans. Legislation should be all-encompassing so that veterans who
have experienced illness or disease or injury or amputation are
included.
Question 3: VVA raises some caution with H.R. 5516 by stating that
they hope the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic.'' Do you share
this thought? Why or why not?
Answer: PVA has no specific position on the concerns raised by
Vietnam Veterans of America in their official statement. As explained
in the PVA's statement to the Subcommittee, we support the legislation
as introduced.
Question 4: VA explains that H.R. 5543 would ``result in
unprecedented changes in how the Federal Government operates. It would
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective
bargaining.'' There was unanimous support for this bill by the
witnesses on the second panel. How do you respond to VA's concerns?
Answer: In trying to understand the concerns regarding labor
relations in the Department of Veterans Affairs (VA), PVA has reached
out to the various labor organizations that represent different
segments of the health care workforce. It seems that the VA is often
concerned about the expansion of bargaining rights under Title 38
hiring authorities, as they may be inconsistent with the rights
available to Federal employees under Title 5. However, the language
included in H.R. 5543 seems to be consistent with similar authorities
provided under Title 5.
The American Federation of Government Employees (AFGE) has also
informed us about the inconsistencies they see with the consolidation
of the workforce associated with the Department of Defense (DOD) and VA
joint health care facility in North Chicago. The Navy doctors, nurses,
and physician assistants who became Title 38 employees were granted
full bargaining rights (as though they were Title 5 employees) for 2
years as a part of the merger agreement with the VA. This simply makes
no sense as they will be working hand-in-hand with VA staff who do not
have the same rights. Moreover, it demonstrates that the VA does not
ultimately believe there is any real harm to the provision of health
care services by granting these employees rights. Simply put, if it is
good enough for one group of health care professionals, it seems that
it would be good for another.
Lastly, we have been told by the AFGE that the VA may be working
towards some solutions to ease labor-management relations. In fact, in
September, the VA Secretary approved a recommendation that allows
bargaining over violations of VA directives about nurse overtime and
premium pay, physician market pay and performance pay and other pay
rules in VA directives and handbooks. We hope that this signals a move
towards better labor-management relations across the VA which will only
benefit the veterans who depend on the VA health care system for their
care.
Question 5: In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for our
veterans with TBI.
Answer: As stated in our testimony, PVA supports H.R. 6123, the
``Veterans' Traumatic Brain Injury Rehabilitative Services' Improvement
Act of 2010.'' In recent testimony, PVA has raised continuing concerns
about servicemembers who do not have the immediate outward signs of TBI
getting appropriate care. The military has implemented procedures to
temporarily withdraw individuals from combat operations following IED
attacks for an assessment of possible TBI, creating a significant
military impact, but believing it necessary for soldier health even if
it reduced combat forces.
Because all the impacts of TBI are still unknown, this legislation
to expand services and care, providing for quality of life and not just
independence, and emphasizing rehabilitative services, is important to
the ongoing care of TBI patients. It is imperative that a continuum of
care for the long term be provided to veterans suffering from TBI. PVA
believes this legislation is a step toward ensuring that care.
Additionally, as referenced in The Independent Budget for FY 2011,
PVA believes greater emphasis needs to be placed on research into the
long-term consequences of brain injury and the development best
practices in its treatment. Moreover, this research should include
veterans of past military conflicts who may have experienced brain
injury that has gone undetected, undiagnosed, or untreated.
The impact on the family of a veteran who has experienced a brain
injury also cannot be overstated. And yet, in many cases immediate
family members will become the lifelong caregivers of these
significantly disabled veterans. As such, it will be imperative that as
the VA implements the caregiver provisions of P.L. 111-163, the
``Caregivers and Veterans Omnibus Health Services Act of 2010,'' that
the difficulties these families will face be considered. Any training
provided to the caregivers will most certainly require specialized
focus on the unique needs of veterans with traumatic brain injury and
associated mental health problems. We encourage the Subcommittee to
continue to monitor the progress of implementation of P.L. 111-163 to
ensure that the VA is addressing this concern.
Question 6: In your testimony, you raised concerns about the
feasibility of implementing the draft legislation on VHA outreach to
veterans on VBA benefits. Do you have specific recommendations on ways
to improve this draft bill so that we can more realistically expect VHA
to implement the provisions of this bill?
Answer: PVA expressed no real concerns about the implementation of
the legislation in our written statement. However, we must emphasize
the need to ensure that correct and consistent information is provided
when a veteran seeks benefits information at a VA medical facility.
As we mentioned in our statement, we would also hope that VA will
direct veterans seeking benefits information to veterans service
organizations who have service programs to benefit these men and women.
PVA maintains a highly skilled and well-educated service officer staff
at many VA medical facilities around the country who can assist
veterans with certain health care concerns as well as the broad range
of benefits available. It certainly makes sense for the VA to tap into
this resource.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
October 4, 2010
Mr. Adrian M. Atizado
Assistant National Legislative Director
Disabled American Veterans
807 Maine Avenue, SW
Washington, DC 20024
Dear Mr. Atizado:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health legislative
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R.
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on
Homelessness, and Draft Legislation on VA Healthcare Provisions, which
took place on September 30, 2010.
Please provide answers to the following questions by Monday,
November 15, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Many of the witnesses of this panel emphasized the need to
balance confidentiality and transparency. In fact, VA explains that it
is precisely the confidential nature of the quality-assurance program
that allows providers to report and examine patient safety events
without fear of recrimination or liability. What specific barriers and
challenges must VA overcome before they can make quality assurance
records available to the public without compromising patient
confidentiality?
2. Some have raised concerns about limiting the bill of rights to
injured and amputee veterans. What are your thoughts on a bill of
rights for all veterans which encompasses rights for injured and
amputee veterans?
3. PVA raised concerns with H.R. 5428 ignoring veterans who may be
in need of special equipment who suffer from a specific disease and not
a physical injury. Do you share this concern? Why or why not?
4. VVA raises some caution with H.R. 5516 by stating that they
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic.'' Do the rest
of the witnesses on this panel share this thought? Why or why not?
5. VA explains that H.R. 5543 would ``result in unprecedented
changes in how the Federal Government operates. It would permit unions
to bargain over, grieve, and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
There was unanimous support for this bill by the witnesses on second
panel. How do you respond to VA's concerns?
6. In addition to the provisions of H.R. 6123, the TBI Improvement
Act, please share your insight on additional authorities that would be
helpful in ensuring better health outcomes for our veterans with TBI.
7. PVA recommends that a broader spectrum of veterans is targeted
instead of singling out the Qarmat Ali veterans for enrollment in H.R.
6127. Do you share PVA's recommendation? Why or why not?
8. In your testimony, you raised concerns about the feasibility of
implementing the draft legislation on VHA outreach to veterans on VBA
benefits. Do you have specific recommendations on ways to improve this
draft bill so that we can more realistically expect VHA to implement
the provisions of this bill?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 15, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
POST-HEARING QUESTIONS FOR ADRIAN M. ATIZADO
OF THE DISABLED AMERICAN VETERANS FROM THE
COMMITTEE ON VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH
UNITED STATES HOUSE OF REPRESENTATIVES
SEPTEMBER 29, 2010
Post-hearing questions for the record from House Subcommittee on
Health's legislative hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R.
5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220,
and Draft Legislation, held September 29, 2010.
Question 1: Many of the witnesses of this panel emphasized the need
to balance confidentiality and transparency. In fact, VA explains that
it is precisely the confidential nature of the quality-assurance
program that allows providers to report and examine patient safety
events without fear of recrimination or liability. What specific
barriers and challenges must VA overcome before they can make quality
assurance records available to the public without compromising patient
confidentiality?
Answer: We again ask as we did in our written testimony whether the
release of all the information contained in quality assurance records
in redacted form addresses the following pertinent questions, and if
so, at what cost.
The central question in the particular case of the events
surrounding the Department of Veterans Affairs (VA) Philadelphia
Community Living Center is the appropriate notification of the public,
including Congress, when substandard VA care is identified, and why
such care was not identified by routine inspections. Other essential
questions include whether different metrics are used in routine health
care inspections and quality management programs, and if so, why.
As to the Subcommittee's question, if redacted quality assurance
records are to be made public, the VA must revisit its quality
assurance program to sustain its effectiveness by emphasizing
prevention--not punishment, which is essential for VA to continue
receiving candid reports on adverse events and/or close calls from
which it could then learn and undertake improvement and prevention
efforts. As indicated in DAV's written testimony, ``[t]he Institute for
Healthcare Improvement (IHI) has found that all employee reporting
programs (voluntary and mandatory) result in substantial
underreporting. Several studies have shown that computer monitoring
strategies have identified many times more potential adverse events
than were reported through employee reporting mechanisms. The IHI's
`Trigger Tools' are also used to identify adverse events and detect
safety problems. Moreover, not having specific facility and patient
information has caused frustration when VA Central Office and oversight
bodies have requested Veterans Health Administration (VHA) data
regarding adverse events. Facility patient safety managers have also
had to create secondary, duplicative systems in order to capture the
patient information needed for effective reviews and reports.'' \1\
---------------------------------------------------------------------------
\1\ http://www.dav.org/voters/documents/statements/
Atizado20100929.pdf.
---------------------------------------------------------------------------
We consider information from VA quality assurance records as raw
data that VA or some other entity will need to make into a format that
is readable, understandable, and meaningful to the target audience.
Also, accommodations should be provided so individuals may gain access
by telephone or mail requests, and during personal onsite visits.
Finally, and equally important, VA should encourage wide public
awareness of the availability of such information, how and where to
access it, and appropriate limitations on its use.
On a broader scale, if such transparency through release of
redacted quality assurance records are deemed by Congress to carry such
weight as to overcome the concern by DAV and others that such actions
may jeopardize VA's quality and safety activities, Congress must also
address the circular deference problem between the Health Insurance
Portability and Accountability Act (HIPAA) and the Freedom of
Information Act (FOIA) and other Federal and state open records laws in
which determination of which statute controls the public nature of the
health care related information.
There are existing rules, policies, and laws that favor closure of
quality assurance records. The HIPAA Privacy Rule defines in eighteen
criteria the type of information that would identify a patient
(personally identifiable information) and offers standards of
protection of the privacy of individually identifiable health
information created or maintained by health care providers who engage
in certain electronic transactions, health plans, and health care
clearinghouses. The HIPAA Security Rule sets national standards for the
security of electronic protected health information; and the
confidentiality provisions of the Patient Safety Rule, which protect
identifiable information being used to analyze patient safety events
and improve patient safety.
Other Federal law protects health care quality assurance
information of the Department of Veterans Affairs \2\ and of the
Department of Defense \3\ from both public disclosure under the FOIA
and from discovery in litigation. In addition, the courts interpret the
FOIA exemptions to protect from public disclosure information that
would be exempt from discovery. All of these protections reflect a
general Federal policy that protects health care quality assurance
information from disclosure.
---------------------------------------------------------------------------
\2\ 38 U.S.C. Sec. 5705--Confidentiality of medical quality
assurance records.
\3\ 10 U.S.C. Sec. 1102--Confidentiality of medical quality
assurance records: qualified immunity for participants.
---------------------------------------------------------------------------
In addition to these laws favoring protection of quality assurance
records from disclosure, Recommendation 6.1 in the Institute of
Medicine's 2000 report, To Err is Human: Building a Safer Health
System, recommended reporting systems for quality of care and health
care errors should be privileged. It states: ``Congress should pass
legislation to extend peer review protections to data related to
patient safety and quality improvement that are collected and analyzed
by health care organizations for internal use or shared with others
solely for purposes of improving safety and quality.'' \4\
---------------------------------------------------------------------------
\4\ http://www.nap.edu/openbook.php?record_id=9728.
---------------------------------------------------------------------------
On the other hand, there are rules, policy, and laws favoring
disclosure of quality assurance records. FOIA embodies the notion that
citizens of this Nation have a right to access documents created by the
government. This right however is not unconditional, evidenced by
including exemptions to the FOIA, state open record laws and Federal
Governments. Such exemptions signify that not all government documents
should be public for several reasons, including the principle that some
government functions will be harmed by disclosure.
In this vein, however, the courts have read the exemptions
narrowly. The courts holding in Anderson v. Health & Human Services,
907 F.2d 936, 941 (10th Cir. 1990) is that ``[t]he FOIA is to be
broadly construed in favor of disclosure and its exemptions are to be
narrowly construed,'' and that ``The Federal agency resisting
disclosure bears the burden of justifying nondisclosure.''
This burden on Federal agencies is buttressed by Executive Order
13410, ``[h]ealth care programs administered or sponsored by the
Federal Government promote quality and efficient delivery of health
care through the use of health information technology, [and]
transparency regarding health care quality.'' Its purpose also includes
making relevant information available to program beneficiaries,
enrollees, and providers in a readily useable manner and in
collaboration with similar initiatives in the private sector and non-
Federal public sector. \5\
---------------------------------------------------------------------------
\5\ http://edocket.access.gpo.gov/2006/pdf/06-7220.pdf.
---------------------------------------------------------------------------
If Congress concurs, or rather defers, to the Department of Health
and Human Services' (HHS) interpretation implementing HIPAA in the
preamble of the 2000 regulations, then FOIA should control access to a
record covered by HIPAA and FOIA. \6\ If left unaddressed then we urge
this Subcommittee to continue to oversee VA's actions to make system
and/or policy changes to ensure the issue of why the Department's
quality management failed to identify substandard care and timely
notifying the public. Furthermore, we ask the Subcommittee to ensure VA
addresses the need for transparency of quality assurance records in the
disability claims process described in our written testimony.
---------------------------------------------------------------------------
\6\ Standards for Privacy or Individually Identifiable Health
Information, 65 Fed. Reg. 82,462, 82,482 (December 28, 2000).
Question 2: Some have raised concerns about limiting the bill of
rights to injured and amputee veterans. What are your thoughts on a
bill of rights for all veterans which encompasses rights for injured
---------------------------------------------------------------------------
and amputee veterans?
Answer: With regards to the provision of comprehensive VA health
care services, DAV has a National Resolution, which I have included
below, which will most likely be our primary guide on a veterans bill
of rights:
RESOLUTION NO. 036
SUPPORT THE PROVISION OF COMPREHENSIVE DEPARTMENT OF
VETERANS AFFAIRS HEALTH CARE SERVICES TO ENROLLED VETERANS
WHEREAS, it is the policy of the Disabled American Veterans that
veterans should be afforded quality and timely health care services by
the Department of Veterans Affairs (VA) because of their honorable
service to our Nation; and
WHEREAS, it is the conviction of the Disabled American Veterans
that quality health care for veterans is achieved when health care
providers are given the freedom and resources to provide the most
effective and evidence-based care available; and
WHEREAS, the Veterans Health Administration plays a critical
role in the delivery of health care services to our Nation's sick and
disabled veterans, is the largest direct Federal provider of health
care services, the largest clinical training ground for the health
professions, and a leader in medical research; and
WHEREAS, although the veterans' health care system is provided
an advance appropriation for medical care, it is still at the
discretion of Congress to provide sufficient funding; and
WHEREAS, in the past, because of restricted appropriation
levels, VA has been forced at times to restrict, ration and deny access
to health care implicitly promised in connection with veterans'
military service; and
WHEREAS, the VA health care system must be provided sufficient
funding to ensure, at a minimum, the following standards are met:
Promote and ensure health care quality and value, and
protect veterans' safety in the health care system;
Guarantee access to a full continuum of care, from
preventive through hospice services;
Receive adequate funding through appropriations for
care of all enrolled veterans;
Fairly and equitably distribute resources to treat the
greatest number of veterans requiring health care;
Furnish the gender-specific, quality and quantity of
services necessary to meet the needs of a growing population of women
veterans;
Provide all medications, supplies, prosthetic devices
and over-the-counter medication necessary for the proper treatment of
service-connected disabled veterans;
Preserve VA's mission and role as a provider of
specialized services in areas such as blindness, burns, amputation,
spinal cord injury and dysfunction, mental illness, and long-term care;
Maintain the integrity of an independent VA health care
delivery system as representing the primary responsible entity for the
delivery of health care services to enrolled veterans;
Modernize its human resources management system to
enable VA to compete for, recruit and retain the types and quality of
VA employees needed to provide comprehensive health care services to
sick and disabled veterans;
Maintain a strong and veteran-focused research program;
NOW
THEREFORE, BE IT RESOLVED that the Disabled American Veterans in
National Convention assembled in Atlanta, Georgia, July 31-August 3,
2010, supports legislation that embodies the concepts and principles
enumerated above and establishes certainty to clearly defined VA health
care services for enrolled veterans.
Question 3: PVA raised concerns with H.R. 5428 ignoring veterans
who may be in need of special equipment who suffer from a specific
disease and not a physical injury. Do you share this concern? Why or
why not?
Answer: PVA's written testimony states, ``As expressed in previous
testimony on this topic, PVA is concerned that this legislation's
language seems to ignore veterans who may be in need of special
equipment who suffer from a specific disease and not a physical
injury.''
As inferred in the Subcommittee's previous question above and the
statement to the Subcommittee from the sponsor of the bill, \7\ the
veteran patient population the bill is intended to primarily serve is
the Operation Enduring Freedom and Operation New Dawn who suffer from
blast injuries due to the widespread use of improvised explosive
devices (IEDs) by ensuring veterans in need of an assistive device or
prosthetic gets the highest quality item available and in a timely
manner.
---------------------------------------------------------------------------
\7\ http: / / www.veterans.house.gov / hearings /
Testimony_Print.aspx?newsid=625&Name=The_
Honorable_Bob_Filner
---------------------------------------------------------------------------
Moreover, not all treatment for all diseases and injuries require
VA's Prosthetics and Sensory Aids Service. While DAV supports VA's
Amputee System of care, we would generally agree the measure seems to
ignore other veteran patients who seek care at VA.
Question 4: VVA raises some caution with H.R. 5516 by stating that
they hope that the bill ``doesn't do for veterans what was done for
active-duty troops in the all too recent past, who were forced to be
inoculated against smallpox and then anthrax in a panic.'' Do the rest
of the witnesses on this panel share this thought? Why or why not?
Answer: The possibility exists, however improbable. It would depend
on how VA would implement the bill's requirement if passed by Congress.
Question 5: VA explains that H.R. 5543 would ``result in
unprecedented changes in how the Federal Government operates. It would
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective
bargaining.'' There was unanimous support for this bill by the
witnesses on second panel. How do you respond to VA's concerns?
Answer: DAV does not have an approved resolution from our
membership on this specific VA labor-management dispute, but we believe
labor organizations that represent employees in recognized bargaining
units within the VA health care and benefits systems have an innate
right to information and reasonable participation that result in making
VA a workplace of choice, and particularly to fully represent VA
employees on issues impacting working conditions and ultimately patient
care.
The issue at hand is an imbalance between VHA and its title 38
employees, which is undermining Congress' intent when it passed section
7422 of title 38, United States Code, in 1991. In granting specific
bargaining rights to labor in VA professional units, Congress
recognized such rights promote effective interactions and negotiation
between VA management and its labor force representatives concerned
about the status and working conditions. In providing this authority,
Congress granted to VA employees and their recognized representatives a
right that already existed for all other Federal employees appointed
under title 5, United States Code. Nevertheless, Federal labor
organizations have reported that VA has severely restricted the
recognized Federal bargaining unit representatives from participating
in, or even being informed about, human resources decisions and
policies that directly impact conditions of employment of the VA
professional staffs within these bargaining units.
We are advised by labor organizations that when management actions
are challenged, VA officials (many at the local level) have used
subsections (b), (c) and (d) of section 7422 as a statutory shield to
obstruct any labor involvement to correct or ameliorate the negative
impact of VA's management decisions, even when management is allegedly
not complying with clear statutory mandates (e.g., locality pay surveys
and alternative work schedules for nurses, physician market pay
compensation panels, etc.).
Facing VA's refusal to bargain, the only recourse available to
labor organizations is to seek redress in the Federal court system.
However, recent case law has severely weakened the rights of title 38
appointees to obtain judicial review of arbitration decisions. Title 38
employees also have fewer due process rights than their title 5
counterparts in administrative appeals hearings.
The alternative for labor organizations is to seek legislative
action in the absence of reasonable compromise. DAV is sensitive to the
realities of VA's human resource challenges on which this issue has a
direct impact. Certainly retention rates are important, but this is
only one factor that must be considered in determining whether the
current status of this particular issue is sustainable.
VHA is facing the challenge of an increasing percentage of workers
becoming eligible for retirement. VHA has identified registered nurses
(RNs) as its top occupational challenge because 40.7 percent of the
current registered nurse (RN) workforce will be eligible or will take
retirement by 2014. VA also reports that by FY 2014, approximately 40.7
percent of the current workforce will be eligible for (or will take)
retirement.
With respect to turnover for VHA nurses, the lowest rates occur in
the VA Central Office among nurses who perform administrative, policy,
and management functions. The highest rates occur along the Pacific
coast and in the Appalachian region along the Atlantic coast. Many RNs
resign early in their VHA careers. For example, in FY 2006, 16.3
percent resigned in the first year of employment, compared with VA
physicians, 13.2 percent of whom departed the VHA in their first year
of employment. Overall in VHA, 12.9 percent of newly hired personnel
resign in their first year.
According to the American Federation of Government Employees, in
2007, 77 percent of all RN resignations within VA occurred in the first
5 years of employment, and the average VA-wide cost of turnover is $47
million per year for nurses. Given the loss of productivity, risks to
patient care, and waste represented by such early departures from VA
employment, VA simply cannot afford to ignore the concerns of its
nurses in the areas of job satisfaction, compensation, and other
conditions of employment. It appears that the often hostile environment
consequent to these disagreements diminishes VA as a preferred
workplace for many of its health care professionals. Likewise, veterans
who depend on VA and who receive care from VA's physicians, nurses and
others can be negatively affected by that environment.
VA has recently given Federal labor organizations some indication
of additional flexibility in negotiating labor-management issues such
as some features of compensation, and we are hopeful that this change
signals a new trend in these key relationships that directly affect
sick and disabled veterans. As VHA is indeed a unique system wherein
its employees are driven first and foremost by their commitment to
serve our Nation's disabled veteran, we hope that VA and Federal labor
organizations can find a sustained basis for compromise.
Question 6: In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for veterans
with TBI.
Answer: One additional specific authority that we believe would
prove helpful to the most severely injured TBI cases and their
immediate family members would be the provision of off-site long-term
therapeutic residential facilities that would be near but clearly
separated from the intensity found in the polytrauma rehabilitation
centers themselves. DAV testified on this matter before the
Subcommittee at its July 22, 2010 hearing. We ask that your
professional staff review our testimony and further consider the merits
of this proposal, as well as other concerns DAV expressed about VA's
TBI programs during that particular hearing.
Question 7: PVA recommends that a broader spectrum of veteran is
targeted instead of singling out the Qarmat Ali veterans for enrollment
in H.R. 6127. Do you share PVA's recommendation? Why or why not?
Answer: Yes. In our written testimony we stated, ``We also ask for
the Subcommittee's consideration to afford the same eligibility to
those veterans who were exposed to toxic substances as a result of
disposing a poisonous mixture of plastics, metals, paints, solvents,
tires, used medical waste and asbestos insulation in open-air trash
burn pits in Iraq and Afghanistan. Tests on the burn pits in the war
zones have shown that the fires released dioxins, benzene and volatile
organic compounds, including substances known to cause cancer.''
Question 8: In your testimony, you raised concerns about the
feasibility of implementing the draft legislation on VHA outreach to
veterans on VBA benefits. Do you have specific recommendations on ways
to improve this draft bill so that we can more realistically expect VHA
to implement the provisions of this bill?
Answer: Our key concern in implementing the provisions of this bill
is that correct and consistent information is provided to a veteran
seeking assistance at VA medical facilities on their claim or filing a
claim for VA disability compensation, pension, and other ancillary
benefits.
We believe serious consideration must be given to a single-point-
of-entry into the Veterans Benefits Administration at VA medical
facilities to carry out the provisions of this bill. The individual(s)
located at a VA medical facility charged with assisting veterans in
this regard should have the necessary tools to discharge his or her
responsibility by receiving proper training and testing, appropriate
time if other than a part-time duty, authority, responsibility, and
accountability.
Any signage that provides cursory information about submitting a
claim for compensation, establishing service connection for a
disability, and contact information (including address, telephone
number, and Internet Web site address) of the appropriate offices that
may offer assistance with respect to service-connected disabilities
should include the single-point of entry at that VA medical facility.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
October 4, 2010
Ralph Ibson
Senior Fellow for Policy
Wounded Warrior Project
1120 G Street, NW, Suite 700
Washington, DC 20005
Dear Mr. Ibson:
Thank you for your testimony at the U.S. House of Representatives
Committee on Veterans' Affairs Subcommittee on Health legislative
hearing on H.R. 3843, H.R. 4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R.
5641, H.R. 5996, H.R. 6123, H.R. 6127, H.R. 6220, Draft Legislation on
Homelessness, and Draft Legislation on VA Healthcare Provisions, which
took place on September 30, 2010.
Please provide answers to the following questions by Monday,
November 15, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. Many of the witnesses of this panel emphasized the need to
balance confidentiality and transparency. In fact, VA explains that it
is precisely the confidential nature of the quality-assurance program
that allows providers to report and examine patient safety events
without fear of recrimination or liability. What specific barriers and
challenges must VA overcome before they can make quality assurance
records available to the public without compromising patient
confidentiality?
2. Mr. Ibson, you note that the Federal Recovery Coordinators
``may need specialized education and training. However it is not clear
that VA needs legislation to mount such training.'' If not for this
legislation, what suggestions do you have to encourage VA to enhance
the training that FRCs receive?
3. Some have raised concerns about limiting the bill of rights to
injured and amputee veterans. What are your thoughts on a bill of
rights for all veterans which encompasses rights for injured and
amputee veterans?
4. PVA raised concerns with H.R. 5428 ignoring veterans who may
be in need of special equipment who suffer from a specific disease and
not a physical injury. Do you share this concern? Why or why not?
5. VA explains that H.R. 5543 would ``result in unprecedented
changes in how the Federal Government operates. It would permit unions
to bargain over, grieve, and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
There was unanimous support for this bill by the witnesses on second
panel. How do you respond to VA's concerns?
6. Mr. Ibson, WWP believes that H.R. 5428 does not go far enough
in ``converting amputees' expectations into reality''. There are
provisions in this bill that require follow-up action so that the Chief
Consultant of Prosthetics and Sensory Aids must investigate and address
the reported complaints and allegations. Doesn't this ensure that the
bill of rights goes beyond posting a piece of paper at VA medical
centers? What other changes would you make to translate the bill of
rights into reality for our injured and amputee veterans?
7. VVA raises some caution with H.R. 5516 by stating that they
hope that the bill ``doesn't do for veterans what was done for active-
duty troops in the all too recent past, who were forced to be
inoculated against anthrax and smallpox in a panic''. Do you share this
thought? Why or why not?
8. In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for our
veterans with TBI.
9. PVA recommends that a broader spectrum of veterans is targeted
instead of singling out the Qarmat Ali veterans for enrollment in H.R.
6127. Do you share PVA's recommendation? Why or why not?
10. In your testimony, you raised concerns about the feasibility
of implementing the draft legislation on VHA outreach to veterans on
VBA benefits. Do you have specific recommendations on ways to improve
this draft bill so that we can more realistically expect VHA to
implement the provisions of this bill?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 15, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Subcommittee on Health
House Veterans Affairs Committee
September 29, 2010--Legislative Hearing
Wounded Warrior Project
Responses to Questions for the Record
Question 1: Many witnesses emphasized the need to balance
confidentiality and transparency. In fact, VA explains that it is
precisely the confidential nature of the quality assurance program that
allows providers to report and examine patient safety events without
fear of recrimination or liability. What specific barriers and
challenges must VA overcome before they can make quality assurance
records available to the public without compromising patient
confidentiality?
WWP Response: The issue, in our view, is not solely or even
principally a matter of ensuring against breaches of patient
confidentiality. VA is required by law (38 U.S.C. sec. 7311) to conduct
a quality-assurance program, that is, a comprehensive program to
monitor and evaluate the quality of health care furnished by the
Veterans Health Administration. In establishing that requirement,
Congress adopted a widely accepted principle (reflected in section 5705
of title 38, protecting the confidentiality of quality-assurance
records) that in order to evaluate adverse or potentially adverse
events in health care, discussions must be frank, open, and complete,
and must be conducted under circumstances that support such
discussions. It is difficult to imagine that VA could gain the level of
trust and participation of clinicians needed to operate an effective
quality assurance program if those records (even redacted) were to
become readily accessible.
Question 2: You note that the Federal Recovery Coordinators ``may
need specialized education and training. However it is not clear that
VA needs legislation to mount such training.'' If not for this
legislation, what suggestions do you have to encourage VA to enhance
the training FRC's receive?
WWP Response: WWP agrees that by virtue of their responsibilities,
Federal Recovery Coordinators (FRC's) require specialized skills. It
has not been our experience, however, that there is any apparent
systemic deficit in the educational background or experience of FRC's,
or the training VA provides those selected to carry out these important
responsibilities.
Question 3: Some have raised concerns about limiting the bill of
rights to injured and amputee veterans. What are your thoughts on a
bill of rights for all veterans which encompasses rights for injured
and amputee veterans?
WWP Response: WWP does not find fault with legislation that focuses
on remedying problems encountered by injured and amputee veterans. Our
concern regarding H.R. 5428 is with its heavy reliance on a ``bill of
rights'' which appears likely to fall short of being as effective a
remedial mechanism as the term ``rights'' suggests. Given our concern
regarding the limitations of the proposal, we would not recommend
expanding the bill to provide for a ``bill of rights'' addressing all
veterans. In addition, VA regulations (at 38 C.F.R. sec. 17.33) already
establish patients' rights regulations applicable to all VA patients.
Question 4: PVA raised concerns with H.R. 5428 ignoring veterans
who may be in need of special equipment who suffer from a specific
disease and not a physical injury. Do you share this concern?
WWP response: Given the population it serves, WWP has not
encountered such problems. But it is understandable that proposing a
``bill of rights'' as a partial remedy for problems encountered by
veterans with amputations might spark advocates' concerns regarding
other disabled veterans who are not covered by such legislation.
Question 5: WWP believes that H.R. 5428 does not go far enough in
``converting amputees' expectations into reality.'' There are
provisions in the bill that require follow-up action so that the Chief
Consultant of Prosthetics and Sensory Aids must investigate and address
the reported complaints and allegations. Doesn't this ensure that the
bill of rights goes beyond posting a piece of paper at VA medical
centers? What other changes would you make to translate the bill of
rights into reality for our injured and amputee veterans?
WWP response: The bill does propose establishment of a mechanism
for monitoring and complaint-resolution. But, as drafted, the bill
raises questions regarding the nature and number of complaints that VA
would actually investigate and address. Specifically, the bill calls
for investigating and addressing information ``relating to the alleged
mistreatment of injured and amputee veterans.'' The term
``mistreatment'' could be read to cover only the most serious kinds of
allegations, such as patient neglect or abuse. (See ``Elder
Mistreatment: Abuse, Neglect, and Exploitation in an Aging America,''
The National Academy of Sciences, http://www.nap.edu/
openbook.php?isbn=0309084342.) It is not clear from the language that
the term would apply to a complaint of failure to provide access to a
practitioner of one's choice or to a second opinion or to comparability
of benefits with DoD, for example. Since the bill would not appear to
establish enforceable ``rights'' in law, VA could reasonably conclude
that its failure to meet veterans' expectations would not amount to
``mistreatment.''
WWP recommends that the Committee give consideration to amending
the bill in a manner that imposes more substantial requirements on VA.
Rather than directing simply that a ``bill of rights'' be posted, the
legislation could direct VA to amend its patient rights' regulations to
establish certain fundamental aspects of prosthetics care as
substantive, enforceable veterans' rights. So, for example, it would be
reasonable to direct VA to amend that regulation to provide with
respect to veterans who have suffered an amputation (1) a right to the
most appropriate technology, (2) a right to be fully informed of, and
to participate fully in decisions regarding, all applicable prosthetic
treatment options; and (3) a right to receive both a primary prosthesis
and a functional spare. Other issues raised by the bill that are more
difficult to enforce as ``rights'' might better be addressed in a
different manner. An amended bill might direct the VA to (1) develop
and implement a plan (to be submitted to Congress) to improve the level
of expertise of its prosthetics and orthotics staff, (2) establish and
implement standards for timeliness of prosthetics and orthotics care;
and (3) establish and enforce requirements to ensure that veterans
receive comparable benefits relating to prosthetic and orthotic
services in transitioning from DoD to VA care. An amended bill could
also clarify that the proposed complaint resolution process covers
complaints regarding any of the issues addressed in the bill (vs.
``mistreatment'').
Question 6: In addition to the provisions of H.R. 6123, the TBI
Improvement Act, please share your insight on additional authorities
that would be helpful in ensuring better health outcomes for veterans
with TBI.
WWP Response: While H.R. 6123 would close the gaps in law that
appear to limit veterans with severe traumatic brain injury from
getting needed rehabilitative services, Congress could certainly take
additional steps to foster improved care and better health outcomes for
these veterans. For example, while numbers of VA facilities have
received additional staffing, equipment and training to improve TBI
care, there appears to be a relative dearth of state-of-the-art
clinical expertise--in VA and nationally--in treating serious
behavioral-health effects experienced by some who have suffered severe
TBI. These behavior changes can include impulsivity, impaired judgment,
inability to control anger, lack of inhibition, etc. Given the profound
implications these troubling TBI consequences have for the wounded
warrior and family, there is urgency to closing the knowledge and
expertise-gap. Scholars have recognized this need, but medicine has yet
to move in this direction. As discussed in ``The Integration of
Neurology, Psychiatry, and Neuroscience in the 21st Century'' (American
Journal of Psychiatry, 159: 695-704, May 2002), there is a clear need
for more practitioners with extensive experience integrating neurology
and psychiatry. As its author, Dr. Joseph Martin of Harvard Medical
School, writes, scientific advances have made it clear that there is no
scientific basis for the separation of neurology and psychiatry, and
that it is counterproductive for these fields to continue to follow the
divergent paths they have taken. Yet, he notes, there are very few
training programs that foster collaboration and integration. Finally,
Dr. Martin observes in writing about the role of U.S. medical schools,
a ``major concern for academic leaders in neurology and psychiatry is
the paucity of interest among medical students and residents in
pursuing careers in the clinical neurosciences. . . . At a time when
neuroscience research promises so much to our understanding of the
brain in its normal and abnormal conditions, it comes as a shock that
we have failed to instill more excitement in our students'' to pursue
residency programs in neurology and psychiatry.
VA can do more for those veterans struggling with behavioral-health
changes associated with a severe traumatic brain injury. Through the
affiliations between its medical centers and major medical schools, VA
plays a major role in training American physicians. As such, VA is
ideally situated to help foster the development of clinical-
neuroscience teaching programs--particularly at polytrauma centers--
whose aims would include achieving better outcomes for TBI patients.
Congress could, and should, provide incentives to spur that needed
development.
Question 7: PVA recommends that a broader spectrum of veterans is
targeted instead of singling out the Qarmat Ali veterans for enrollment
in H.R. 6127. Do you share PVA's recommendation? Why or why not?
WWP Response: WWP recommends that given the potential range of
toxic substances to which veterans might have been exposed in Iraq and
Afghanistan, rather than legislating on an incident-by-incident basis,
consideration be given to a systematic approach to addressing toxic
exposures.
Question 8: VVA raises some caution with H.R. 5516 by stating that
they hope that the bill ``doesn't do for veterans what was done for
active-duty troops in the all too recent past, who were forced to be
inoculated against anthrax and smallpox in a panic.'' Do you share this
thought? Why or why not?
WWP Response: While WWP has no position on H.R. 5516, we do not
read this legislation as opening a door to forced inoculations,
particularly in light of the requirement for full and informed patient
consent in 38 U.S.C. section 7331 and 38 C.F.R. section 17.34.
Question 9: VA explains that H.R. 5543 would ``result in
unprecedented changes in how the Federal Government operates. It would
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective
bargaining.'' There was unanimous support for this bill by the
witnesses on the second panel. How do you respond to VA's concerns?
WWP response: WWP, a participant on the second panel, respectfully
expressed no position on H.R. 5543 or on a number of other bills on the
agenda that addressed issues wounded warriors and their families have
simply not encountered.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
October 4, 2010
Hon. Eric K. Shinseki
Secretary
U.S. Department of Veterans' Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Shinseki:
Thank you for the testimony of Robert L. Jesse, Principal Deputy
Under Secretary for Health, and Walter A. Hall, Assistant General
Counsel, at the U.S. House of Representatives Committee on Veterans'
Affairs Subcommittee on Health legislative hearing on H.R. 3843, H.R.
4041, H.R. 5428, H.R. 5516, H.R. 5543, H.R. 5641, H.R. 5996, H.R. 6123,
H.R. 6127, H.R. 6220, Draft Legislation on Homelessness, and Draft
Legislation on VA Healthcare Provisions, which took place on September
30, 2010.
Please provide answers to the following questions by Monday,
November 15, 2010, to Jeff Burdette, Legislative Assistant to the
Subcommittee on Health.
1. In light of recent lapses in certain medical centers using
dirty reusable medical equipment, why does VA oppose H.R. 3843? What
steps has VA taken to inform bring transparency to the patient safety
lapses at certain VA medical centers?
2. VA opposes H.R. 4041. How can VA ensure that the current
training provided to FRCs is evidence-based and will yield positive
outcomes for our veterans who receive assistance from FRCs?
3. DAV identified a number of continuing gaps that exist in the
FRC program. This includes integration of IT access across VA and DOD,
manageable caseload, and a multilayer bureaucracy of VA and DOD staff.
How do you respond to DAV's concerns? What steps has VA taken to
address these gaps?
4. VA has serious concerns with a few of the ``rights'' in H.R.
5428. This includes the right to select the practitioner that best
meets the veterans' needs and the right to receive comparable services
and technology at any VA medical facility. Do you have recommendations
on ways to modify these ``rights'' so that they are not problematic for
the VA?
5. VA does not support H.R. 5516 because ``clinical indications
and population size for vaccines vary by vaccine, blanket monitoring of
performance of all vaccines could be cost prohibitive and may not have
a substantial positive clinical impact at the patient level''. It is my
understanding that VA has seen positive health outcomes as a result of
increased vaccinations for influenza and pneumococcal vaccinations.
Additionally, a recent article in the New York Times highlighted the
importance of adult vaccinations explaining that C.D.C. recommends
adults ages 19 and older receive immunizations against as many as 14
infectious diseases. In light of this information, why would VA oppose
efforts to increase and monitor vaccinations among our veterans?
6. VA has serious concerns with H.R. 5543 because it would
subject many discretionary aspects of title 38 compensation to
collective bargaining. This bill is intended to allow collective
bargaining over compensation related labor-management disputes such as
locality pay, overtime pay, shift differential pay, and performance
pay. I have heard stories of VA nurses who have no recourse if they are
denied overtime pay, which may negatively impact VA's retention
efforts. Does VA have administrative solutions for dealing with these
issues if not through H.R. 5543? Please explain.
7. VA explains that H.R. 5543 would ``result in unprecedented
changes in how the Federal Government operates. It would permit unions
to bargain over, grieve, and arbitrate a subject--employee
compensation--that is generally exempted from collective bargaining.''
However, it is my understanding that H.R. 5543 makes modest changes by
allowing VA clinicians the same rights as the rest of Federal employees
so that they can bargain over the implementation of pay laws and
regulations. How do you respond to this disconnect?
8. I understand that VA is in the process of developing the
Department's views on H.R. 5641, which would allow veterans to be
placed in medical foster homes. In the meanwhile, could you comment on
the number of veterans who currently pay out of pocket to be placed in
medical foster homes? What is your understanding of the need or demand
for medical foster homes among our veterans?
9. H.R. 5996 addresses the prevention, diagnosis, and treatment
of veterans with Chronic Obstructive Pulmonary Disease. What treatment
protocols does VA currently have in place and what tools do VA
clinicians currently have? What gaps in treatment protocols and tools
need to be addressed?
10. VVA explains that ``there are pharmacological treatments and
other treatment modalities available in the private sectors that are
difficult if not virtually impossible to get on the VA formulary.'' How
do you respond to these concerns?
11. Section 4 of the draft legislation on general health care
matters would provide additional authority beyond simple contracts for
services at non-VA facilities. Would you explain what additional
authorities are needed by providing some concrete examples?
Thank you again for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 15, 2010.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
The Honorable Michael Michaud, Chairman
House Committee on Veterans' Affairs, Subcommittee on Health
``Health Legislative Hearing''
September 29, 2010
Question 1: In light of recent lapses in certain medical centers
using dirty reusable medical equipment, why does VA oppose H.R. 3843?
What steps has VA taken to inform, bring transparency to the patient
safety lapses at certain VA medical centers?
Response: Had they been in effect, the provisions of H.R. 3843
would not have prevented a VA medical center from failing to precisely
follow manufacturers' sterilization or disinfection instructions. VHA
is openly and candidly identifying the causes for these regrettable
lapses. Further, where significant events occur, administrative
investigations are conducted which are subject to the Freedom of
Information Act, and therefore publicly available. It appears that H.R.
3843 would supersede the Freedom of Information Act, creating a
standard for disclosure for VA that is not applied to other agencies or
entities throughout the government. The impact and interaction of this
bill with the Freedom of Information Act would need to be further
explored by all relevant committees of jurisdiction.
In addition, VA is concerned about the impact of this legislation
on the willingness of employees to bring forward concerns regarding the
quality of care provided by VA. VHA's quality assurance programs work
as well as they do because we strive to maintain a culture where
employees at all levels feel free, if not obligated, to report even
potential lapses in quality so fact-finding and remediation can occur.
We discovered the sterilization and disinfection problems precisely
because of this culture and specifically because our employees came
forward with their concerns.
VHA is opposed to H.R. 3843 because it would repeal almost all of
the quality assurance and peer review disclosure protections in current
38 U.S.C. 5705 and require posting of all VHA quality assurance
documents on the Internet. Confidentiality is critical to the
protection of Veterans' private information on which quality assurance
depends. In addition, long experience in clinical quality improvement
programs has taught the entire medical community that confidentiality
in reporting and internal fact-finding is critical to establishing a
culture where errors and close calls are openly identified,
acknowledged and addressed. All 50 states protect their hospitals and
health systems from disclosure of quality improvement or peer review
proceedings through state statutes similar to current 38 U.S.C. 5705 or
by judicial precedent. The effect of H.R. 3843 would change VHA's
current culture of openness and potentially diminish error reporting.
VHA publicly posts\1\ its standards for transparency about its
clinical lapses. Forthright and open disclosure is required as a
routine part of medical care. When an individual patient is involved,
providers disclose directly to their patient. When serious injury or
death occurs, medical center leadership makes a formal disclosure to
the patient, his or her personal representative, or designated family
members and, if requested, their lawyer. When a large number of
patients are involved, we disclose a medical lapse to all potentially
affected patients unless the clinical risk is insignificant (defined as
fewer than 1 in 10,000 patients) and there are no ethical or
institutional principles which warrant disclosure). If there is a
question whether we should disclose, we err on the side of Veterans'
safety and make the disclosure.
---------------------------------------------------------------------------
\1\ VHA Directive 2008-002, ``Disclosure of Adverse Events to
Patients,'' http://www1.va.gov/vhapublications/
ViewPublication.asp?pub_ID=1637.
---------------------------------------------------------------------------
A recent article in the New England Journal of Medicine notes that
large scale adverse events are not uncommon in the industry. What
appears to be ``a notable exception'' is VHA's approach to being
transparent about those mistakes. The article suggests that VHA's
policy of ``disclosure should be the norm, even when the probability of
harm is extremely low.'' \2\
---------------------------------------------------------------------------
\2\ Dudzinski DM, et. al, The Disclosure Dilemma--Large-Scale
Adverse Events, N Engl J Med 2010; 363:978-986; http://www.nejm.org/
doi/full/10.1056/NEJMhle1003134.
---------------------------------------------------------------------------
VHA is known as an industry leader in systemic programs that reduce
the number of medical mistakes that occur such as the issuance of the
``Hospital Quality Report Card.'' The Hospital Quality Report Card
provides a snapshot of the quality of care provided at all VA health
care facilities. The report includes information about waiting times,
staffing levels, infection rates, surgical volumes, quality measures,
patient satisfaction, service availability and complexity,
accreditation status, and patient safety. Repealing the confidentiality
provisions of 38 U.S.C. 5705 would jeopardize the current culture of
openness that drives VHA's ability to identify errors and their causes
and, more importantly, prevent future occurrences.
VHA is willing to work with the sponsors of H.R. 3843 to identify
alternatives to the effective repeal of Sec. 5705 while at the same
time enhancing VHA's ability to make meaningful quality improvement
information more available to the public.
Question 2: How can VA ensure that the current training provided to
FRCs is evidence-based and will yield positive outcomes for our
Veterans who receive assistance from FRCs?
Response: The term ``evidence-based'' generally refers to the
practice of medicine. It involves using evidence to make clinical
decisions about the care and treatment of an individual patient. The
Federal Recovery Coordination Program (FRCP) does not provide direct
medical care or treatment. Instead, Federal Recovery Coordinators
(FRCs) coordinate the delivery of services and serve as a resource for
Servicemembers, Veterans and their families.
Care coordination removes the barriers between organizations and
systems of care. It is a recognized step in the movement toward a truly
integrated system. Currently, there is no body of evidence that
identifies best practices for this approach.
FRCs are Masters-prepared registered nurses and licensed social
workers who bring to the position strong educational and practical
backgrounds. The additional training provided to FRCs is based on the
knowledge and skills they require to assist clients. This includes in-
depth training on VA, DoD, other governmental benefits, and private
sector services for this population. FRCs also receive training on
current medical treatment and management of a variety of medical
conditions, such as traumatic brain injury, PTSD, spinal cord injury,
amputee care and rehabilitation, as well as how to access health care
in the Military or VA health systems and the private sector. FRCP uses
subject matter experts in delivering this training to the FRCs in a
variety of ways (quarterly training, on-line educational opportunities,
conferences, weekly staff meetings, and orientation).
FRCP recently conducted its first (baseline) satisfaction survey.
The overall satisfaction score across all clients and caregivers was 79
percent positive, indicating that most respondents rated the overall
quality of care and services provided by FRCP as very good. Many of the
respondents stated they found FRCs to be resourceful, knowledgeable,
and strong advocates for their clients.
Question 3: DAV identified a number of continuing gaps that exist
in the FRC program. This includes integration of IT access across VA
and DoD, manageable caseload, and a multilayer bureaucracy of VA and
DoD staff. How do you respond to DAV's concerns? What steps has VA
taken to address these gaps?
Response: The integration or interoperability of IT systems across
VA and DoD is a recognized challenge, involving technological, clinical
and organizational complexity. To address the need for improved
information sharing, particularly among case/care management/
coordination programs, FRCP has been a driving force behind an effort
to develop business requirements for an IT solution. These requirements
are now completed and ready for identification of a pilot project to
show feasibility. This project has been included under the Virtual
Lifetime Electronic Record (VLER) initiative at VA.
Having an appropriate tool that measures the time impact of an
injured or ill Servicemember or Veteran enrolled in FRCP is critical
for determining staffing requirements, appropriate caseloads and
measuring outcomes. Over time, using an intensity tool should also
provide a way to document outcomes for each client (if FRCP is
effective, the intensity of need should decrease with repeated
measurement). Development of this tool is a high priority for FRCP and
has the full support of VA. However, it is a complicated task that will
require time and iterative testing to ensure validity and reliability.
To coordinate each client's particular needs and goals, the FRCs
work with military liaisons, members of the Services Wounded Warrior
Programs, service recovery care coordinators, TRICARE beneficiary
counseling and assistance coordinators, VA vocational and
rehabilitation counselors, military and VA facility case managers, VA
Liaisons, VA specialty care managers, Veterans Health Administration
(VHA) and VBA OEF/OIF case managers, VBA benefits counselors, and
others. FRCs understand DoD and VA benefits, as well as access to
health care. They use this knowledge to assist their clients in
navigating the various transitions associated with recovery without
duplicating services.
Question 4: VA has serious concerns with a few of the ``rights'' in
H.R. 5428. This includes the right to select the practitioner that best
meets the Veteran's needs and the right to receive comparable services
and technology at any VA medical facility. Do you have recommendations
on ways to modify these ``rights'' so that they are not problematic for
the VA?
Response: VHA does not believe rephrasing the proposed rights in
H.R. 5428 will provide a higher level of flexibility or quality of care
than is already provided through VA's current processes and oversight
of care. Veterans are evaluated by a team of qualified practitioners
who are highly knowledgeable and have access to a complete medical
history and treatment plan. All VA Orthotic and Prosthetic (O&P)
Services and more than 600 contracted O&P providers are accredited by
one of two national accrediting bodies. All amputee Veterans receive
care at a nationally accredited O&P Service from practitioners that
meet the requirements of VHA's extensive credentialing and privileging
program. The Veteran, and as appropriate, their family, is part of the
decision-making and prescription process when receiving VA amputation
care services.
Altering the current process to allow Veterans to self-refer to a
prosthetist or orthotist poses many risks to our Veterans. Providers
whose credentials are unknown and not monitored through VA quality
management programs, and providers who do not have access to the
Veteran's medical information and cannot provide a team approach to the
care of the Veteran both pose significant risks. In addition, Veterans
could incur private medical expenses for which they would be personally
liable if not eligible for private care at VA expense under 38 U.S.C.
1703. Finally, although injured and amputee Veterans have needs that
set them apart from other patients at VA facilities, the basic tenets
of patient care should not vary based on the condition or injury
experienced by a Veteran.
Question 5: VA does not support H.R. 5516 because ``clinical
indication and population size for vaccines vary by vaccine, blanket
monitoring of performance of all vaccines could be cost prohibitive and
may not have a substantial positive clinical impact at the patient
level.'' It is my understanding that VA has seen positive health
outcomes as a result of increased vaccinations for influenza and
pneumococcal vaccinations. Additionally, a recent article in the New
York Times highlighted the importance of adult vaccinations explaining
that C.D.C. recommends adults ages 19 and older receive immunizations
against as many as 14 infectious diseases. In light of this
information, why would VA oppose efforts to increase and monitor
vaccinations among our Veterans?
Response: VA fully supports the provision of all recommended adult
vaccines to its patients. As noted, VA provides influenza and
pneumococcal vaccines to a high percentage of Veterans and has seen a
positive impact on health as a result. Those two vaccines are
recommended for all (influenza) or a large proportion (pneumococcal) of
our Veterans. Therefore, setting targets and tracking how well we are
doing in providing them is critically important.
Most of the other recommended adult vaccines are recommended for
smaller subsets of our Veteran population; some vaccines are
recommended for only a few patients who have specific conditions or
reasons for getting the vaccines. Setting targets for and tracking the
delivery of those vaccines is much more difficult because of the
variability in the indications for the vaccines. For example, the
varicella (chicken pox) vaccine is recommended for adults but only for
those who do not already have immunity to varicella (either from
previous vaccination or from having had the disease). Decisions about
these non-universally recommended vaccines should be made between
patients and their providers on a case-by-case basis.
Question 6: VA has serious concerns with H.R. 5543 because it would
subject many discretionary aspects of title 38 compensation to
collective bargaining. This bill is intended to allow collective
bargaining over compensation related labor-management disputes such as
locality pay, overtime pay, shift differential pay and performance pay.
I have heard stories of VA nurses who have no recourse if they were
denied overtime pay, which may negatively impact retention efforts.
Does VA have administrative solutions for dealing with these issues if
not through H.R. 5543? Please explain.
Response: Title 38 U.S.C. 7422 does not preclude unions or
employees from seeking redress, including filing a grievance, when VA
fails to follow its own policies or comply with regulatory or statutory
obligations regarding employee compensation. In addition, unions have
the right to request that the Under Secretary for Health provide a
written determination as to whether a specific issue is properly
excluded from bargaining or grieving under 38 U.S.C. 7422.
In connection with proposed legislation concerning section 7422, VA
and the unions formed a Work Group to work collaboratively to formulate
recommendations to improve knowledge, and correct misunderstanding,
misinterpretation, and inconsistent use of section 7422. Both of these
points are included in Work Group recommendations submitted to the
Secretary. In addition, VA has an Administrative Grievance Procedure
which generally permits employees to pursue disputes over perceived
misapplication of VA compensation statutes and regulations, including
those that might be covered by section 7422. H.R. 5543 is not necessary
to enable title 38 employees to pursue such disputes.
VA's concern with H.R. 5543 is that it is much broader than
allowing employees a means to resolve labor-management disputes
involving perceived misapplication of VA compensation statutes and
regulations. The bill would give title 38 employees and the unions that
represent them the right to grieve any decision made by the Department
relating to discretionary pay matters, not just disputes involving
regulatory or policy-related compensation issues. Title 38 has a number
of pay systems that have significant discretionary aspects. For
example, basic pay for physicians and dentists is set by law, but the
Secretary of Veterans Affairs has discretion to set market pay for
these positions above established basic rates based on factors such as
experience, qualifications, complexity of the position and difficulty
recruiting for the position. Pay for nurses is largely discretionary
because it is set by locality pay surveys in accordance with the
locality pay statute and its regulations.
Further, Congress has granted VA other pay flexibilities involving
discretion for nurses and certain other health care workers, including
premium pay, on-call pay, alternate work schedules, special salary
rates, and recruitment and retention bonuses. If VA was obligated to
negotiate with unions over discretionary pay, we would not be able to
implement decisions about discretionary pay until we either reach
agreements with our unions or until we receive a binding decision from
the Federal Service Impasses Panel. This could significantly delay our
ability to hire clinical staff.
Question 7: VA explains that H.R. 5543 would ``result in
unprecedented changes in how the Federal Government operates. It would
permit unions to bargain over, grieve, and arbitrate a subject--
employee compensation--that is generally exempted from collective
bargaining.'' However, it is my understanding that H.R. 5543 makes
modest changes by allowing VA clinicians the same rights as the rest of
Federal employees so they can bargain over the implementation of pay
laws and regulations. How do you respond to this disconnect?
Response: In general, Federal employees covered by title 5 pay
systems do not have the right to bargain or grieve over aspects of
their compensation. As noted, VA title 38 compensation has significant
discretionary aspects, in contrast to title 5 pay systems. The pay for
VA nurses, for example, is almost entirely discretionary because it is
based upon locality surveys. H.R. 5433 would give title 38 employees
the right to bargain or grieve over these discretionary aspects of
compensation. As a result, title 38 employees would be allowed to
bargain or grieve over significant aspects of their pay, which other
Federal employees cannot do. For that reason, negotiating over
compensation on such a large scale would be unprecedented in the
Federal Government. As discussed above, title 38 employees have the
same rights as other Federal employees to resolve labor-management
disputes involving perceived misapplication of compensation statutes
and regulations.
Question 8: I understand VA is in the process of developing the
Department's views on H.R. 5641, which would allow Veterans to be
placed in medical foster homes. In the meanwhile, could you comment on
the number of Veterans who currently pay out of pocket to be placed in
medical foster homes? What is your understanding of the need or demand
for Medical Foster Homes among our Veterans?
Response: As of August 30, 2010, there were 274 Veterans residing
in Medical Foster Homes. All Veterans residing in Medical Foster Homes
pay out of pocket to live there. Projections through 2019 from the VHA
demand model indicate that as many as 5,000 Veterans could meet the
requirements and potentially elect to reside in Medical Foster Homes.
Question 9: H.R. 5596 addresses the prevention, diagnosis, and
treatment of Veterans with Chronic Obstructive Pulmonary Disease. What
treatment protocols does VA currently have in place and what tools do
VA clinicians currently have? What gaps in treatment protocols and
tools need to be addressed?
Response: VHA has many treatment protocols and tools for the
diagnosis of Chronic Obstructive Pulmonary Disease (COPD). In 2007 VHA
and DoD published an update for the COPD evidence-based Clinical
Guideline and similar guidelines, such as the American Medical
Association COPD Guideline published by the National Quality Forum. The
VHA/DoD edition of this guidance is one of the most current available.
The guideline was accompanied by provider ``pocket cards,'' reference
materials available using online links, and patient education tools.
VHA also has many tools available for the treatment of COPD, including
extensive home oxygen guidelines that have proven their utility and
effectiveness under Joint Commission review.
Prevention of smoking is critical in patients with COPD. VHA has
implemented a number of evidence-based national initiatives, including
adoption of a population-health approach to smoking cessation;
increased access to nicotine replacement therapy and/or smoking
cessation medications; elimination of outpatient copayments for smoking
cessation counseling; clinical practice guidelines; and collaboration
with mental health and substance use disorder health care providers to
promote integration of smoking cessation into routine treatment of
psychiatric populations. VA has metrics regarding screening,
counseling, and offering of medication support as well as enrollment in
smoking cessation classes and support groups.
Historically, the prevalence of smoking and smoking-related
illnesses has been higher among Veteran patients in the Veterans Health
Administration (VHA) in comparison to that of the general population.
Although rates of tobacco use have remained high, smoking cessation
interventions continued to be greatly underutilized in VHA clinical
settings just as they have been nationally.
Moreover, VHA is implementing Patient Aligned Care Teams, expanding
access to care management for patients suffering from chronic diseases
such as COPD. A component of this effort will be the development and
implementation of metrics to trend and drive improvement. We will be
studying the use of externally developed models and metrics such as the
Ambulatory Care Sensitive Conditions (ACSC) model for COPD metrics as
well as internal development of metrics tailored to our Veteran
population. At this time, there are no identified gaps.
Question 10: VVA explains that ``there are pharmacological
treatments and other treatment modalities available in the private
sector that are difficult if not virtually impossible to get on the VA
formulary.'' How do you respond to these concerns?
Response: The VA believes that statement is an inaccurate and
misleading representation of the VA National Pharmacy program. While it
is true that not every commercially available drug is listed on the VA
National Formulary, the same can be said for virtually any formulary in
use in the United States today. VA is not unique in this regard.
What is unique about VA's formulary process is that if a VA
provider determines that a commercially available drug is medically
necessary, then the commercially available drug will be made available
via the VA National Formulary process for that individual patient,
regardless of whether it is a brand or generic drug, whether it is or
is not listed on the VA National Formulary, or whether it is costly or
inexpensive. By contrast, in private sector health plans, there are
numerous examples of drugs that a patient cannot get regardless of the
medical need.
The philosophy for VA's formulary management process is an
unwavering reliance on well-researched, well-documented clinical
evidence demonstrating that a specific drug can provide an expected,
cost-effective benefit for the Veteran population. According to an
analysis of the VA National Formulary (VANF) in 2001, the Institute of
Medicine (IOM) stated:
``The VA National Formulary and formulary system that enable the
VHA to make quality choices among drugs and negotiate favorable prices
should be maintained . . . . The VHA should continue to make careful
choices among drugs, based first on quality considerations but with an
understanding of cost implications, and should negotiate the best
prices possible using the leverage of committed use and the ability to
drive market share.''
VA's primary motivation in formulary management has always been and
always will be to ensure highest quality care for Veterans. Economic
considerations, though important, are secondary compared to safety and
efficacy. VA has often been criticized for not adding recently approved
medications to the VANF, or for unduly restricting medications, and has
been the subject of inquiries and investigations prompted by these
criticisms by the Institute of Medicine, the Government Accountability
Office and the Office of the Inspector General. To date, these external
reviews have only provided suggestions for some minor process
improvements, concluding that VA's processes were safe and cost-
effective and that formulary decisions were based on sound reviews of
the medical evidence.
Questions 11: Section 4 of the draft legislation on general health
care matters would provide additional authority beyond simple contracts
for services at non-VA facilities. Would you explain what additional
authorities are needed by providing some concrete examples?
Response: 38 U.S.C. 1703, as currently written, provides that fee-
basis arrangements will be accomplished by contracts with non-VA
facilities. The proposed language in Section 4 of the draft legislation
would make it clear that VA is able to furnish fee-basis care through
mechanisms other than contracts, such as an individual authorization
and other industry standard tools such as provider agreements (similar
to Center for Medicare and Medicaid (CMS) provider agreements)) for
authorizing services for veterans. An individual authorization is used
when services are sporadic in nature where contracting in accordance
with Federal acquisition law and regulation would be cumbersome and not
timely. Also, many providers, including many individual and small
practice groups, are unfamiliar with Federal acquisition regulations
which could adversely affect their interest in being a provider to VA
potentially impacting care to Veterans. Further, pricing could be
determined reasonable by other established rates such as Medicare as
opposed to competitive acquisitions.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
November 16, 2010
The Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Shinseki:
On Wednesday, September 29, 2010, Dr. Robert L. Jesse, Principal
Deputy Under Secretary for Health, Veterans Health Administration
testified before the Subcommittee on Health during a legislative
hearing on a number of bills relating to veterans health care,
including H.R. 5516 and H.R. 5996.
As a follow-up to the hearing, I request that Dr. Jesse respond to
the following questions in written form for the record.
H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of
2010''
1. The Department's testimony stated that ``. . . blanket
monitoring of performance of all vaccines could be cost prohibitive and
may not have a substantial positive clinical impact at the patient
level.'' However, VA currently has performance measures for influenza
and pneumococcal vaccines. How has implementing such performance
measures affected the rates of vaccination and hospitalization for
these two illnesses? Do you believe that adult immunizations are an
important way to prevent the spread of disease and are a cost-effective
way to preserve health?
2. A recent New York Times article on adult vaccinations rates
states that only 7 percent of Americans over age 60 have received the
herpes zoster vaccine, developed by VA researchers to prevent shingles.
How many VA patients have received the herpes zoster vaccine? Has VA
seen a corresponding decline in the number of veteran patients with
shingles?
3. The Department's testimony stated that H.R. 5516 would ``. . .
limit VA's ability to respond quickly to new research or medical
findings regarding a vaccine.'' However, the legislation requires VA to
use the immunization schedule established by the Center for Disease
Control (CDC) Advisory Committee on Immunization Practices. Is this
schedule inappropriate for veterans? Does VA believe that H.R. 5516
would prevent new vaccines from being added to the performance measures
if the CDC has not adopted them?
4. In the Department's statement, it is written that ``VA
currently conducts ongoing initiatives'' regarding vaccination rates.
What are these initiatives? How does VA ensure that all veterans have
access to vaccines and is such data reported? Will VA commit to
increasing immunization rates?
5. VA added the T-dap vaccine to the VA National Formulary as an
adult booster vaccine. However, in 2007 VA purchased less than 48,000
doses, enabling the vaccination of less than 1 percent of VA patients.
How did VA formulate this vaccine strategy? What is the target vaccine
rate for veterans with this vaccine?
6. When VA increased the rate for pneumococcal vaccinations,
pneumonia hospitalization rates decreased by about 50 percent, a
savings of about $117 for each vaccine administered. Does VA have any
estimate on how much money would be saved through preventing future
hospitalization? Do the costs that VA estimated for this bill include
any potential savings from diminishing hospitalization rates for
preventable diseases?
H.R. 5996--To direct the Secretary of Veterans Affairs to improve the
prevention, diagnosis, and treatment of veterans with chronic
obstructive pulmonary disease.
1. Various veteran service organizations (VSOs) testified to the
need and their support for improving the prevention, diagnosis and
treatment of veterans with chronic obstructive pulmonary disease
(COPD). The Paralyzed Veterans of America expressed some concern that
because this authorization is subject to appropriation, the Secretary
could choose not to implement the bill if enacted. Can we expect the VA
to implement this legislation if enacted?
2. In their written statement, the Department expressed support
for the intent of H.R. 5996. How could H.R. 5996 be adjusted to gain
the support of VA?
3. What COPD-related programs currently exist at VA?
4. The Department's statement references existing VA authority to
conduct treatment protocols and further research into COPD. Is VA
currently developing treatment protocols and related tools to improve
research programs on COPD, as mandated in H.R. 5996? If so, please
discuss this work.
5. How much of the Veterans Health Administration's budget is
allocated to COPD-related conditions?
6. How did VA estimate the cost of H.R. 5996?
The attention to these questions by the witness is much appreciated
and I request that they be returned to the Subcommittee on Health no
later than close of business Friday, December 17, 2010. If you have any
further questions, please call (202) 225-3527.
Sincerely,
Cliff Stearns
Republican Member
__________
Questions for the Record
The Honorable Cliff Stearns
House Committee on Veterans' Affairs, Subcommittee on Health
``Health Legislative Hearing'' September 29, 2010
H.R. 5516--``Access to Appropriate Immunizations for Veterans Act of
2010''
Question 1: The Department's testimony stated that ``. . . blanket
monitoring of performance of all vaccines could be cost prohibitive and
may not have a substantial positive clinical impact at the patient
level.'' However, VA currently has performance measures for influenza
and pneumococcal vaccines. How has implementing such performance
measures affected the rates of vaccination and hospitalization for
these two illnesses? Do you believe that adult immunizations are an
important way to prevent the spread of disease and are a cost-effective
way to preserve health?
Response: VHA exceeds other health care providers in the delivery
of influenza and pneumococcal immunizations (Trivedi A. et al. Medical
Care. E-pub November 2010). The implementation of performance measures
for these two immunizations contributed to VHA's high rate of use;
however, other implementation strategies, including clinical reminders
for providers, standing orders, immunization campaigns, and wellness
providers for patients, have also contributed to this success. VHA
agrees that adult immunizations are an important way to prevent the
spread of disease and are a cost-effective way to preserve health. Yet,
most of the adult immunizations other than influenza and pneumococcal
are recommended for smaller subsets of the Veteran population; some
vaccines are recommended for only a few patients who have specific
conditions or reasons for getting the vaccine. Setting targets for and
tracking the delivery of those vaccines is much more difficult because
of the variability in the indications for the vaccines.
Question 2: A recent New York Times article on adult vaccination
rates states that 7 percent of Americans over age 60 have received the
herpes zoster vaccine, developed by VA researchers to prevent shingles.
How many VA patients have received the herpes zoster vaccine? Has VA
seen a corresponding decline in the number of Veteran patients with
shingles?
Response: Data from VHA's Pharmacy Benefits Management shows that a
total of 193,917 doses of the herpes zoster vaccine have been purchased
since October 2007. VHA does not uniformly systematically record the
number of Veterans who have received the vaccine from their non-VA
providers. Validated data about the incidence or prevalence of shingles
in VA patients since the vaccine was released are not available.
Question 3: The Department's testimony stated that H.R. 5516 would
``. . . limit VA's ability to respond quickly to new research or
medical findings regarding a vaccine.'' However, the legislation
requires VA to use the immunization schedule established by the Center
for Disease Control (CDC) Advisory Committee on Immunization Practices.
Is this schedule inappropriate for Veterans? Does VA believe that H.R.
5516 would prevent new vaccines from being added to the performance
measures if the CDC has not adopted them?
Response: Overall, VHA supports the immunization schedule
established by the Advisory Committee on Immunization Practices (ACIP).
VHA Handbook 1120.05, Coordination and Development of Clinical
Preventive Services (http://www1.va.gov/vhapublications/
ViewPublication.asp?pub_ID=2095), requires that ``the evidence-based
recommendations of the . . . ACIP must be included [in VHA Clinical
Preventive Services Guidance Statements], unless there are reasons to
differ from these recommendations, such as: existing VHA policy, unique
characteristics of the VHA population, VHA specific implementation
issues, or more recent compelling evidence [emphasis added].'' VHA is
represented as an ex-officio member of the ACIP and several VHA staff
are members of various ACIP workgroups. So while VHA recognizes ACIP as
the authoritative source for immunization recommendations for the
general U.S. population, and participates in the development of its
recommendations, VHA requires the flexibility to adapt ACIP
recommendations as needed for its specific population of Veteran
patients.
Question 4: In the Department's statement, it is written that ``VA
currently conducts ongoing initiatives'' regarding vaccination rates.
What are these initiatives? How does VA ensure that all Veterans have
access to vaccines and is such data reported? Will VA commit to
increasing immunization rates?
Response: VHA promotes immunizations for its Veteran patients by
providing general information about immunizations on My HealtheVet and
on the VHA National Center for Health Promotion and Disease Prevention
Web site (http://www.prevention.va.gov/
Resources_Immunizations_Vaccines_for_Veterans_and _the_Public.asp).
Veterans who are ``in-person authenticated'' on My HealtheVet receive
electronic reminders about influenza and pneumococcal immunizations
when they are due. Every year, the Office of Public Health and
Environmental Hazards, through its award-winning multidisciplinary
``Infection: Don't Pass It On'' project, develops an influenza campaign
that promotes the use of influenza immunization to Veterans and
employees (http:/www.publichealth.va.gov/flu/index.asp); in addition to
influenza, campaign materials for pneumococcal immunization are
provided through this project. Many facilities have clinical reminders
about immunizations for staff in the electronic medical record, so that
when patients are seen for appointments, staff are prompted to discuss
appropriate immunizations with the patients. Nurses, social workers and
case managers play an important role in promoting use of vaccinations
with Veterans. Some VA medical centers have arrangements with local
Veteran Rehabilitation Centers to provide immunizations at the Centers.
The VHA Office of Rural Health has funded and established over 40 new
outreach clinics in rural communities and also 4 mobile health units,
which serve the states of Colorado, Maine, Washington, and West
Virginia, all of which provide primary care for rural Veterans,
including adult immunizations.
VA reports rates of influenza and pneumococcal immunization use,
compared with non-VA rates, on its Quality of Care Web site,
www.qualityofcare.va.gov. VA is committed to providing high quality,
appropriate preventive care, including immunizations, to all its
Veterans. The VHA National Center for Health Promotion and Disease
Prevention is developing an interactive public Web site that will allow
users to search for age-and gender-appropriate recommendations for
preventive care, including immunizations. Currently, the
www.prevention.va.gov site has a link to a questionnaire that helps
people determine which immunizations are recommended for them (http://
www.immunize.org/catg.d/p4036.pdf), based on their individual risk
factors and health status.
Question 5: VA added the T-dap vaccine to the VA National Formulary
as an adult booster vaccine. However, in 2007 VA purchased less than
48,000 doses, enabling the vaccination of less than 1 percent of VA
patients. How did VA formulate this vaccine strategy? What is the
target vaccine rate for Veterans with this vaccine?
Response: The ACIP recommendation for use of a single dose of T-dap
in adults ages 19-64 was published in the Morbidity and Mortality
Weekly Report (MMWR) in December 2006. The recommendation was to
replace the next booster dose of tetanus and diphtheria toxoids vaccine
(Td) for adults whose last dose of Td was 10 or more years earlier and
who had not previously received T-dap. The number of doses needed each
year is much less than the total number of VA patients and is based on
an estimate of the number who would be due for the vaccine that year
and who had not received it outside VA. The vaccine is not FDA-approved
for use in adults age 65 or older; nearly half of the population served
by VHA is in that age range. Only recently, at its latest meeting in
October 2010, the ACIP voted to recommend off-label use for older
adults. Since 2007, VA has purchased a total of 288,940 doses of T-dap,
enabling the vaccination of more than 10 percent of VA patients in the
target age group.
Question 6: When VA increased the rate for pneumococcal
vaccinations, pneumonia hospitalization rates decreased by about 50
percent, a savings of about $117.00 for each vaccine administrated.
Does VA have any estimate on how much money would be saved through
preventing future hospitalization rates for preventable diseases?
Response: The cost-effectiveness estimates for adult vaccinations
vary by vaccine, depending on the incidence of the vaccine-related
disease and the cost and effectiveness of the vaccine. While many adult
vaccines have been shown to be reasonably cost-effective under usual
circumstances, few are actually cost-saving (unlike childhood
immunizations, most of which are estimated to be cost-saving). VA has
not estimated any potential savings from prevention of hospitalizations
from the increased use of adult immunizations.
H.R. 5996--To direct the Secretary of Veterans Affairs to improve the
prevention, diagnosis, and treatment of Veterans with chronic
obstructive pulmonary disease.
Question 1: Various Veterans Service Organizations (VSOs) testified
to the need and their support for improving the prevention, diagnosis
and treatment of Veterans with chronic obstructive pulmonary disease
(COPD). The Paralyzed Veterans of America (PVA) expressed concern that
because this authorization is subject to appropriations, the Secretary
could choose not to implement the bill if enacted. Can we expect the VA
to implement this legislation if enacted?
Response: VA is committed to the continuous improvement of care to
our Nation's Veterans. The foundation work related to the
standardization of diagnosis and care for Veterans suffering from COPD
has been completed. The results are supported by existing initiatives
targeting smoking cessation and prevention. Operation of pilot sites as
prescribed by the bill was not included in the President's budget;
however, the overall intent of the bill could be met through a
continued focus on current initiatives.
Question 2: In their written statement, the Department expressed
support for the intent of H.R. 5996. How could H.R. 5996 be adjusted to
gain the support of VA?
Response: VA would offer full support of this bill if the bill were
crafted to allow more flexibility with the execution model and plans.
VA believes it is important to develop pilot programs within VA prior
to partnering with other agencies. Medicine is ever changing and the
need to have the flexibility to change with the advances in medicine is
crucial to success.
Question 3: What COPD-related programs currently exist at VA?
Response: COPD care is integrated into the Patient Aligned Care
Teams (PACT), the primary care system in the Veterans Health
Administration.
At the Pharmacy Benefits Management group, a clinical pharmacist
with experts from the field review current data regarding status of the
best medical therapy for COPD in addition to other pulmonary diseases.
Smoking and tobacco use cessation is organized through the Public
Health Office of the Veterans Health Administration (VHA). Smoking
continues to be the leading cause of preventable death and disease in
the United States (US). Quitting smoking is the most important public
health approach to minimize risk of emphysema and other smoking-related
illnesses, such as cardiovascular disease, in the aging Veteran
population. Smoking cessation care is currently provided at every VA
health care facility nationally, with access to first-line FDA-approved
smoking cessation medications. VA also has a national performance
measure that requires that all Veterans seen in outpatient primary care
and mental health settings be screened yearly for current tobacco use
and provided with brief counseling and offered assistance in the form
of medications and additional counseling. The rate of smoking cessation
care has increased and the prevalence of smoking among Veterans in care
has decreased from 33 percent in 1999, to 19.7 percent in 2008.
Question 4: The Department's statement references existing VA
authority to conduct treatment protocols and further research into
COPD. Is VA currently developing treatment protocols and related tools
to improve research programs on COPD, as mandated in H.R. 5996? If so,
please discuss this work.
Response: The Department of Veterans Affairs (VA) and The
Department of Defense (DoD) have developed guidelines for treatment of
COPD http:// www.healthquality.va.gov/
Chronic_Obstructive_Pulmonary_Disease_COPD.asp.
These guidelines include algorithms for the management of COPD and
for the management of acute exacerbations of COPD. The guidelines also
include tools to facilitate implementation; a pocket card for quick
reference and a summary in addition to the full guidelines.
Research Programs--The cooperative studies program (CSP) has as an
objective to initiate new multi-site clinical trials in chronic
disease. COPD and its relationship to bacterial infections,
environmental exposure, and rehabilitation are included in that
objective's priorities. VA investigators recognize that COPD is an
important chronic disease. VA and DoD have developed a joint Clinical
Practice Guideline (CPG) for COPD. This guideline This guideline was
updated in 2007 based on best practices and available clinical
research. VA and DoD continue to collaborate on revisions to this CPG.
VA has funded thirty-five research projects specific to COPD over
the last 2 years. These projects range from molecular investigation
through practical application of science in rehabilitating patients
with COPD.
VA has over 340 research publications on COPD over the last 3
years, which demonstrates VA's commitment to research and knowledge
sharing.
VA is pleased to announce that Dr. Christine M. Freeman, PhD, has
been nominated for the Presidential Early Career Award for Scientists
and Engineers (PECASE) Award for her work on the role of the immune
system in COPD. Dr. Freeman's work on immunologic mechanisms involved
in COPD pathogenesis holds great potential that could lead to novel
treatment approaches for this very common and devastating disease.
Question 5: How much of the Veterans Health Administration's budget
is allocated to COPD-related conditions?
Response: In FY 2010, VA provided Home Respiratory Care to 128,000
Veterans at a cost of more than $139 million. The VA spends
approximately $5693 (2004 data)/Veteran with COPD as a primary or
secondary condition. Approximately, 19 percent of Veterans are
afflicted with COPD. An estimate of expenditures for COPD for a
population of about 969,000 Veterans with COPD finds that the VA
commits $5,516,517,000 (2004 data).
Question 6: How did VA estimate the cost of H.R. 5996?
Response: The cost for H.R. 5996 was estimated based on funding a
person to build the COPD program in each VA medical center and
resources for a training program which would include two full time
national coordinators.
The cost of this bill is estimated to be $25.9 million over 5
years.