GERALD M. CROSS, MD, FAAFP
PRINCIPAL DEPUTY UNDER SECRETARY FOR HEALTH
SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
March 3, 2009
Good Morning Mr. Chairman and Members of the Subcommittee. Thank you for inviting me here today to present the Administration’s views on four bills (one of which is in draft form) that would affect Department of Veterans Affairs (VA) programs that provide veterans benefits and services. With me today is Walter A. Hall, Assistant General Counsel. We appreciate the opportunity to discuss the bills on today’s agenda.
H.R. 784 Quarterly Report on Vacancies
H.R. 784 would require the Secretary to submit quarterly reports to Congress on any vacancies in mental health professional positions (i.e., psychiatrists, psychologists, social workers, marriage and family therapists, and licensed professional mental health counselors) at any VA medical facility. These reports would have to identify the Veterans Integrated Service Network (VISN) in which the medical facility is located and would be submitted to Congress not later than 30 days after the last day of a fiscal quarter. This reporting requirement would terminate after December 31, 2014.
VA does not support H.R.784 because it is unnecessary. VA has been working diligently to enhance mental health services throughout our system. We have done this, in part, by increasing our core staff to date by 4,000 positions, and we plan again this year to continue increasing the number of mental health professionals in the field to ensure sustained operations of this vital service line at our medical centers and clinics. Our commitment to ensuring that veterans receive needed mental health services necessarily demands that we do our utmost to ensure that staffing levels at VA points of access are sufficient. This data is best collected and controlled, however, at the local level. This is because staffing and workloads are inescapably dependent on local factors related to the local veteran population, usage rates, veterans’ particular health care needs, and local employment factors. We achieve oversight by holding the VISN managers accountable to senior leadership. Given that the current model is effective, we think the value in creating a quarterly reporting requirement at the national level is limited, particularly given it would necessitate the creation of a new complex data infrastructure to meet the bill’s requirements and have no accurate or helpful context once removed from local factors. We would be pleased to brief the Committee at any time on our efforts.
We estimate the cost of H.R. 784 to be $188,000 in Fiscal Year 2010; $1 million over a five-year period; and just over $1 million over a 10-year period.
H.R. 785 Pilot Program to Provide Outreach and Training to College and University Mental Health Centers
The key provisions of H.R. 785 would require VA to conduct a 4-year pilot to provide outreach and training services related to the mental health needs of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) to certain college or university counseling centers, student health centers, and student service centers. Educational institutions covered by the bill would be those that have a large population of enrolled OEF and OIF veterans. Specifically, VA would be required to:
VA supports the intent of the bill’s drafters. While costs are not prohibitive for such a pilot project, we believe more effort needs to go into identifying the precise scope and intended objectives of the pilot program before we can analyze whether H.R. 785 constitutes an effective means of achieving those ends. We are also concerned that the pilot program not dilute or duplicate our ongoing outreach efforts targeted at this veteran population and, more importantly, not detract from our ability to provide direct patient care to these and other veterans.
That said, however, we are committed to doing more in this area. We have already developed a comprehensive training course for suicide awareness that focuses particularly on this cohort of veterans. (This training is mandatory for certain VHA staff.) We have already shared the training module with the Department of Defense, and we will next direct each VA medical facility to offer it to the clinical and administrative staff at local community colleges, 4-year colleges, and universities. The advantage to this training module is that it is targeted at veteran-patients, is self-taught, and is accessible electronically on-line or in hard copy.
Additionally, we have developed some excellent Public Service Announcements relevant to the bill’s concerns. We will ensure these are also made available to colleges and universities for broadcast on campus stations. Included in such materials will be our advertisements and outreach materials on the Department’s suicide prevention hotline and safe-driving initiative. We will also take immediate steps to establish liaisons with colleges and universities at the local level as well as enhance our existing associations with affiliated educational institutions by, for instance, inviting their staff to attend conferences at the local VA medical facilities relating to the health needs of OEF/OIF veterans.
We welcome the opportunity to meet with the Subcommittee to discuss these initiatives further.
We estimate the cost of the pilot project to be $828,000 in Fiscal Year 2010 and just over $3 million over the 4-year duration of the pilot program.
Draft Bill to Expand Eligibility for Reimbursement for non-VA Emergency Care
This draft bill would expand the benefit available under 38 U.S.C. § 1725 related to the payment or reimbursement of expenses incurred by a veteran who received unauthorized emergency treatment from a non-VA provider for a non-service connected disability. Currently, to be eligible for reimbursement of such expenses, a veteran must meet a number of criteria, including that he or she not have “other contractual or legal recourse against a third party that would, in whole or in part, extinguish such liability to the provider.” 38 U.S.C. § 1725(b)(3)(C). The draft bill would amend that particular eligibility criterion to require that the veteran have no other contractual or legal recourse against a third party that would in whole extinguish the veteran’s liability to the private provider.
The draft bill would further provide for the coordination of benefits when a veteran has other legal or contractual recourse against a third party responsible for only partial payment of the veteran’s financial liability for the non-VA emergency treatment. In such cases, the draft bill would require VA to be a secondary payer, but it would limit VA’s financial liability to the difference between the amount already paid by the third party (excluding copayment or deductible amounts owed by the veteran) up to the amount VA would be authorized to pay under the program, i.e. 70 percent of the Medicare rate. That is, the VA-allowable amount would be offset by the amount already paid by the responsible third party. For example, if a non-VA provider billed a veteran $100 for the emergency treatment covered under section 1725, the third party paid $50 on the claim, and the VA-allowable amount for such treatment is $80, then VA would be responsible for paying $30 to the non-VA provider under the draft bill. Payment by the Secretary would then extinguish the veteran’s liability to the non-VA provider for the expenses of the emergency treatment at issue. VA’s payment could not include co-payments or similar payments owed by the veteran. All of these amendments would apply to non-VA emergency treatment furnished on or after October 8, 2007.
VA supports the draft bill. Under current law, VA is a payer of last resort. Consequently, a veteran who would otherwise be eligible for reimbursement or payment of private emergency medical expenses is ineligible for the benefit because a third party makes partial payment toward the veteran’s emergency treatment expenses pursuant to other contractual or legal recourse available to the veteran. In these cases, veterans are often left with sizeable medical debts for which they are personally liable. We understand the purpose for the legislation is to remedy this limited situation. Payment by the Secretary as secondary payer would fully extinguish the veteran’s liability to the private provider who furnished the emergency treatment.
It is not feasible to cost this proposal without extensive data on veterans’ personal liability for non-VA emergency care expenses following partial payments made by third parties under various personal injury protection policies. Those data are not available. We have therefore estimated the cost of the draft bill based on the average payment made by the Secretary for unauthorized non-VA emergency treatment of veterans’ non-service connected disabilities. We estimate the cost of implementing this draft bill to be $500,000 for Fiscal Year 2010, $3 million over a 5-year period, and $7.8 million over a 10-year period.
H.R. 1211“Women Veterans Health Care Improvement Act”
The last bill on today’s agenda is the “Women Veterans Health Care Improvement Act,” which contains a number of provisions that I will address individually.
Section 101 would require VA to contract with a qualified independent entity or organization to carry out a comprehensive assessment of the barriers encountered by women veterans seeking comprehensive health care from VA, building on the VA’s own “National Survey of Women Veterans in Fiscal Year 2007-2008” (National Survey). Many requirements related to sample size and the scope of the survey would apply to the conduct of the assessment. Section 101 would also require the contractor-entity to conduct research on the effects of the following concerns on the study participants:
● The perceived stigma associated with seeking mental health care services.
● The effect of driving distance or availability of other forms of transportation to the nearest appropriate VA facility on access to care.
● The availability of child care.
● The acceptability of integrated primary care, or with women’s health clinics, or both.
● The comprehension of eligibility requirements for, and the scope of services available under, such health care.
● The perception of personal safety and comfort of women veterans in inpatient, outpatient, and behavioral health facilities of the Department.
● The gender sensitivity of health care providers and staff to issues that particularly affect women.
● The effectiveness of outreach for health care services available to women veterans.
● The location and operating hours of health care facilities that provide services to women veterans.
● Such other significant barriers identified by the Secretary.
Additionally, section 101 would require the Secretary to ensure that the heads of the Center for Women Veterans and the Advisory Committee on Women Veterans review the results of the comprehensive assessment and submit their own findings with respect to it to the Under Secretary for Health and other VA offices administering women-veterans health care benefits.
VA supports section 101 but notes that the results of our National Survey will not be available until later in the fiscal year. Consequently, we do not think it feasible to enter into a contract for the mandated assessment and research until we have first had a chance to complete and fully analyze the results of the National Survey. Only in this way can the assessment and research adequately build on the National Survey and reliably augment, rather than duplicate, VA’s efforts in this area. We estimate the cost of section 101 to be $3.5 million.
Section 102 of H.R. 1211 would require VA to enter into a contract with an entity or organization to conduct a very detailed and comprehensive assessment of all VA health care services and programs provided to women veterans at each VA facility. The assessment would have to include VA’s specialized programs for women with PTSD, homeless women, women requiring care for substance abuse or mental illnesses, and those requiring obstetric and gynecologic care. It would also need to address whether effective health care programs (including health promotion and disease prevention programs) are readily available to, and easily accessed by, women veterans based on a number of specified factors.
After the assessment is performed, the bill would require VA to develop an extremely detailed plan to improve the provision of health care services to women veterans, taking into account, among other things, projected health care needs of women veterans in the future and the types of services available for women veterans at each VA medical center. VA would then be required to report to Congress on the assessment and plan, including any administrative or legislative recommendations VA deems appropriate.
What is unclear in the bill is whether the contractor-entity conducting the assessment would also be required to develop the follow-up “plan,” as the terms of section 102 refer to the contractor’s conduct of ”studies and research” required by that section.
VA supports section 102 only if the development of the mandated plan would be conducted by a contractor-entity. We estimate the total costs of this section to be $4,354,000 during the period of Fiscal Year 2010 through Fiscal Year 2012.
Section 201 of H.R. 1211 would authorize VA to provide hospital care and medical services to newborns of women-veterans who receive their maternity care through the Department. This treatment authority would be limited to 14 days, beginning on the date of the child’s birth.
We appreciate and understand the Committee's interest in this issue. Before we can take a position on section 201, however, we first need to determine whether the time-frame of 14 days is appropriate. Additionally, we must complete the cost estimate for this provision. Once we complete these analyses, we will submit our views and cost estimate for the record.
Section 202 would require VA to carry out a program to provide graduate medical education, training, certification, and continuing medical education for mental health professionals who provide sexual trauma care and counseling services and care and counseling for Post-Traumatic Stress Disorder (PTSD). We do not support section 202 because it is unnecessary. Further, the training and continued medical education and training that VA currently requires of these mental health professionals far surpasses that which would be required by this provision.
We believe it is essential that our medical professionals across the system be able to effectively recognize and treat the manifestations of sexual trauma and PTSD. To that end, we train our mental health professions on evidence-based practices (EBPs) for PTSD and associated conditions that can result from sexual trauma, such as depression and anxiety. VA is also conducting two national training initiatives to educate therapists in two particular EBPs for PTSD. The first of these is Cognitive Processing Therapy (CPT), which began in 2006. Following didactic training, clinicians participate in clinical consultations to attain full competency in CPT. VA is also using new CPT treatment manuals, originally developed and tested in civilian settings for victims of rape and child sexual abuse, which had been adapted specifically for VA and the Department of Defense by inclusion of material on the treatment of issues arising from the experience of sexual trauma during military service. To date, VA has trained 1,484 VA clinicians in the use of CPT.
The second national initiative is an education and training module on Prolonged Exposure (PE) for treatment of PTSD, which began in 2008. As you are likely aware, there have been a number of studies supporting the use of exposure treatment for PTSD. Originally PE was developed to treat sexual-assault survivors, but it has been successfully adapted for the treatment of combat-related PTSD. To date, OMHS has trained 233 clinicians in the use of PE.
VA has also begun training its mental health professionals in Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT), which are evidence-based psychotherapies for anxiety and depression, two mental health conditions that can result from the experience of sexual trauma. Similar to the two PTSD-related training initiatives, this training program includes the use of didactic training materials adapted for the treatment of sexual trauma experienced during military service and clinical case studies involving women veterans. This training program began in 2008, and VA has already trained 151clinicians.
As our mental health professionals receive training under these two initiatives and other targeted training programs, we carefully monitor their clinical practice to ensure they are delivering state-of-the-art care to their patients.
Finally, I would like to mention that VA has established the Military Sexual Trauma (MST) Support Team at the national level to monitor MST screening and treatment, oversee MST-related education and training, and promote best practices for screening and treatment of the mental and physical health consequences of MST. This MST Support Team hosts monthly MST teleconference training calls. Typically, more than 100 phone-lines are used with multiple listeners on each line. Sample topics include: evidence-based psychotherapies, MST in Primary Care settings, health issues associated with men who have experienced MST, and cultural issues affecting patients suffering from MST and/or MST-related treatments. Credits for professional continuing education are available for those who participate in these training calls. The MST Support Team operates an intranet website homepage with links to MST-related resources and materials (including training materials), reports on MST screening and treatment of MST-related health problems, and MST-related discussion forums. The Team also hosts an annual clinical training program for MST Coordinators, which is a five-day training session on both the treatment of MST and program development strategies for VA facilities. Lastly, the MST Support Team is currently revising the Veterans Health Initiative Independent Study course on MST for which Continuing Education credit is available.
In short, the training described above is designed to complement the professional training of VA’s highly qualified mental health staff by providing them with additional training in emerging, cutting-edge therapies and practices. Note that this is in addition to the continuing medical education required by the providers’ state licensing boards and/or professional specialty boards and organizations.
VA estimates the cost of implementing section 202 to be $9.5 in Fiscal Year 2010, $46 million over a five-year period, and $99 million over a 10-year period.
Section 203 would require VA, not later than six months after the date of the bill’s enactment, to carry out a 2-year pilot program at no fewer than three VISNs to furnish child-care services (directly or indirectly) to eligible veterans as a means of improving their access to mental and health care services. Eligible veterans would include veterans who are the primary caretaker of a child and who are receiving regular or intensive mental health care services or any other intensive health care services for which the Secretary determines the provision of child care would improve the veterans’ access to care. Child care would be limited to the time during which the veteran actually receives the covered services and the time required to travel to and from the VA facility for the covered services. VA would be permitted to provide child care services through a variety of means, i.e., stipends offered by licensed child care centers (directly or through a voucher system), the development of partnerships with private agencies, collaboration with other Federal facilities or programs, or the arrangement of after-school care.
We share the Committee's interest in ensuring appropriate access to care. Once we have completed our analysis, we will submit our views and cost estimate for the record.
Section 204 would require the Department’s Advisory Committee on Women Veterans to include recently-separated women veterans. It would also require the Department’s Advisory Committee on Minority Veterans to include recently separated minority-group veterans. These requirements would apply to committee appointments made on or after the date of this bill’s enactment.
We fully support section 204. These amendments would help both Committees to better identify and address the needs of their respective veteran-populations.
Mr. Chairman, this concludes my prepared statement. I would be pleased to answer any questions you or any of the members of the Subcommittee may have.