[Senate Report 107-80]
[From the U.S. Government Publishing Office]
Calendar No. 190
107th Congress Report
SENATE
1st Session 107-80
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DEPARTMENT OF VETERANS AFFAIRS MEDICAL PROGRAMS ENHANCEMENT ACT OF 2001
_______
October 10, 2001.--Ordered to be printed
_______
Mr. Rockefeller, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany S. 1188]
The Committee on Veterans' Affairs, to which was referred
the bill S. 1188, to amend title 38, United States Code, to
enhance the authority of the Secretary of Veterans Affairs to
recruit and retain qualified nurses for the Veterans Health
Administration, and for other purposes, having considered the
same, reports favorably thereon with an amendment in the nature
of a substitute and an amendment to the title, and recommends
that the bill, as amended, do pass.
Introduction
On June 14, 2001, the Committee held a hearing to develop a
greater understanding of the factors underlying the imminent
shortage of professional nurses and its projected impact on
health care in the Department of Veterans Affairs. Those
testifying at the hearing included: Senator Max Cleland; Thomas
L. Garthwaite, M.D., Under Secretary for Health, Department of
Veterans Affairs (VA); Catherine J. Rick, R.N., M.S.N., Chief
Nurse Consultant, Nursing Strategic Health Care Group, VA;
Sarah Myers, R.N., Ph.D., President of the Nurses Organization
of Veterans Affairs, Atlanta, GA; Sandra McMeans, R.N.,
Representative, American Nurses Association, Martinsburg, WV;
J. David Cox, R.N., First Vice President, National VA Council,
American Federation of Government Employees, Washington, DC;
Sandra K. Janzen, R.N., M.S., Chief Nurse Executive, Tampa
(James A. Haley) VA Medical Center, Tampa, FL; Robert A.
Petzel, M.D., Director, VA Upper Midwest Health Care Network,
Minneapolis, MN; Karen Robinson, Ph.D., R.N., Chairperson, VISN
13 Nurse Managed Care Initiative, Fargo, ND; and Mary Raymer,
R.N., M.A., Associate Chief of Staff for Patient Care Services,
Salem VA Medical Center, Salem, VA.
Building upon this hearing and other oversight work,
Committee Chairman John D. Rockefeller IV introduced S. 1188 on
July 17, 2001, with the cosponsorship of Ranking Republican
Member Arlen Specter and Senator Max Cleland, to improve nurse
recruitment and retention within VA.
Earlier, on July 10, 2001, Chairman Rockefeller introduced
S. 1160, with Senator Larry Craig joining later as a cosponsor.
S. 1160 would provide the Secretary of Veterans Affairs
authority to provide service dogs to certain disabled veterans.
On July 23, 2001, Ranking Republican Member Specter
introduced S. 1221, which would provide an additional basis for
establishing the inability of veterans to defray expenses of
necessary medical care.
On July 19, 2001, the Committee held a hearing, chaired by
Committee Member Paul Wellstone, to receive testimony on S.
739, S. 1160, S. 1188, and a draft bill prepared by Ranking
Republican Member Specter to change the means test used by the
VA in determining whether veterans will be placed in enrollment
priority group 5 or 7. Written testimony was accepted for all
pending veterans health-related legislation, including S. 739,
S. 1160, S. 1188, and the draft bill, although oral testimony
was limited to S. 739 (reported elsewhere).
Committee Meeting
On August 2, 2001, the Committee met in open session to
consider, among other matters, S. 1188 with an amendment in the
nature of a substitute incorporating provisions from S. 1160,
S. 1188, and S. 1221. Present were Senators Rockefeller,
Wellstone, Murray, Miller, Nelson, Specter, Thurmond, and
Hutchison. The Committee voted unanimously to report favorably
S. 1188, as amended, to the Senate.
Summary of S. 1188 as Reported
S. 1188, as reported (herein referred to as the ``Committee
Bill'') consists of two titles, summarized below.
Title 1--The Department of Veterans Affairs Nurse Recruitment and
Retention Enhancement Act of 2001
Subtitle A--Recruitment Authorities
Section 111 permanently authorizes the Employee Incentive
Scholarship Program; reduces the minimum period of employment
for eligibility in the program from 2 years to 1 year; removes
the award limit for education pursued during a particular
school year by a participant so long as the participant does
not exceed the overall limitation for the equivalent of 3 years
of full-time education; and extends authority to increase the
award amounts based on general Federal pay increases.
Section 112 permanently authorizes the Education Debt
Reduction Program (EDRP); expands the list of eligible
individuals to include those providing direct patient care
services or services incident to direct patient care services;
extends the number of years that an employee may participate in
the EDRP to 5 years and increases the overall award limit to
$44,000, with the award payments for the fourth and fifth years
of an employee's participation in the program limited to
$10,000 each; provides limited special authority (until
December 31, 2001) for the Secretary to waive the eligibility
requirement limiting EDRP participation to recently appointed
employees on a case-by-case basis for individuals appointed on
or after January 1, 1999, through September 30, 2000.
Section 113 requires VA to report on the use of authority
to request waivers of the pay reduction for re-employed
annuitants in order to meet the requirements for appointments
to nurse positions.
Subtitle B--Retention Authorities
Section 121 mandates that VA provide Saturday premium pay
to employees specified in Section 7454(b), the so-called
``title 5/title 38 hybrids.'' Such hybrids include licensed
practical nurses, pharmacists, certified or registered
respiratory therapists, physical therapists, and occupational
therapists.
Section 122 gives VA nurses enrolled in the Federal
Employee Retirement System the same ability to use unused sick
leave as part of the retirement year calculation that VA nurses
enrolled in the Civilian Retirement System have.
Section 123 requires VA to carry out an evaluation of
nurse-managed clinics, including primary care and geriatric
clinics. Matters to be evaluated include patient satisfaction,
provider experiences, cost of care, access to care, and
functional status of patients. This evaluation will be reported
to the House and Senate Committees on Veterans' Affairs not
later than 18 months after enactment of this act.
Section 124 requires VA to develop a nationwide policy on
staffing standards to ensure that veterans are provided with
safe and high quality care. Such staffing standards should
consider the numbers and skill mix required of staff in
specific medical settings (such as critical care and long-term
care).
Section 125 requires VA to submit an annual report on
exceptions of experienced nurses from VA's nurse qualification
standards, as set forth by VA directive. The report would
include information on the number of waivers requested and
granted to promote nurses who have not received a bachelor's of
science degree in nursing, as well as information on age, race,
and years of experience of the individuals subject to such
waiver requests and waivers, as the case may be.
Section 126 requires VA to submit a report on the use of
mandatory overtime by licensed nursing staff and nursing
assistants in each facility during 2001, not later than 180
days after passage of this act. The report would include a
description of the amount of mandatory overtime used by
facilities, a description of the mechanisms employed by VA to
monitor overtime, an assessment of the effects of mandatory
overtime on patient care, and recommendations regarding ways to
prevent the use of mandatory overtime in other than emergency
situations.
Subtitle C--Other Matters
Section 131 elevates the office of the VA Nurse Consultant
so that individual would report directly to the VA Under
Secretary for Health.
Section 132 exempts registered nurses, physician
assistants, and expanded-function dental auxiliaries from the
requirement that part-time service performed prior to April 7,
1986, be prorated when calculating retirement annuities.
Section 133 makes modifications to the nurse locality pay
authorities, including allowing VA to use third-party survey
data.
Title 2--Other Matters
Section 201 authorizes VA to provide certain hearing-
impaired veterans, blind veterans, and veterans with spinal
cord injury or dysfunction, or other chronic physical or mental
impairment that substantially limits mobility, hearing, or
activities of daily living, with service dogs to assist them
with everyday activities.
Section 202 modifies the methodology used by the VA in
determining whether veterans will be placed in enrollment
priority group 5 or 7 based on income levels. The current
placement eligibility threshold is set at approximately $24,000
in the preceding calendar year, regardless of where in the
country the veteran is living.
Section 203 requires that the compliance and oversight
activities carried out by field-based units of the Department
of Veterans Affairs Office of Research Compliance and Assurance
shall be charged to the Medical Care appropriation.
Background and Discussion
Title 1--The Department of veterans affairs Nurse Recruitment and
Retention Enhancement Act of 2001
As the average lifespan lengthens in the United States, the
elderly make up a growing proportion of the population.
Researchers project that the proportion of Americans age 65 or
older will expand from approximately 13 percent to 20 percent
between 2010 and 2030, an increase of about 30 million people.
The population age 85 and older is the fastest growing age
group in the United States; and the likelihood that an
individual will require skilled nursing care increases with
age. The demand for skilled nursing care, especially long-term
care services, is projected to increase as the pool of
potential caregivers remains constant or shrinks.
Over the last decade, VA and community health care
providers have embraced managed care principles, which limit
inpatient treatment to the sickest of patients. The demands on
professional nurses have evolved as a growing proportion of
hospitalized patients require highly technical, complex nursing
care. Simultaneously, the explosive growth in community-based
care has increased demand for nursing professionals in
outpatient settings.
Registered nurses (RNs) and licensed practical nurses
(LPNs) represent, respectively, the largest and second-largest
groups of health care providers in the United States. VA
employs over 35,000 RNs, and about 10,000 LPNs; together,
nurses represent about one-third of all VA health care
professionals. The Health Resources and Services
Administration's 2000 National Sample Survey of Registered
Nurses shows that women continue to comprise the vast
majority--more than 95 percent--of professional nurses. As
career opportunities for women have broadened, enrollment in
nursing diploma programs has declined precipitously. In 2000,
the average age of working RNs was 45 years nationally and 48
years within VA. The average age of a newly hired nurse within
VA has climbed to 39 years. Half of VA's nursing workforce will
be eligible for retirement in the next 15 years, with 35
percent of RNs and 29 percent of LPNs eligible to retire by
2005.
Surveys by the American Nurses Association (hereafter ANA),
the Department of Health and Human Services (hereafter HHS),
and academic researchers show that stress, frustration, and low
morale among working nurses have also contributed to the
shrinking workforce. Recent years have seen growing job
dissatisfaction among nurses, including 37 significant nursing
strikes over issues such as the safety of the working
environment, inflexible or excessive work hours, inadequate
wages and benefits, and the lack of a voice in management.
As the number of experienced nurses willing to work in
critical and long-term care declines, understaffing has already
begun to affect medical facilities nationwide. Dr. Thomas L.
Garthwaite, VA Under Secretary for Health, testified at the
Committee's June 14, 2001, hearing that VA can currently ``meet
most of the demands for nursing staff. However, there are
increasing difficulties in filling positions in some locations,
and extreme difficulty filling some specialty assignments.''
This difficulty in filling positions may translate into
adverse working conditions for nurses and diminished services
for veterans. Sandra McMeans, a Martinsburg (WV) VA Medical
Center staff nurse and representative of the ANA, testified at
the Committee's hearing that:
I believe personally that you will see . . . a
decrease in the patient load in the Martinsburg VA,
because I look for the nurses to leave . . . I see a
lot of nurses who are eligible for retirement who are
tired because of the mandatory overtime, because of
having to stay [for] late shifts . . . I see them
leaving and going to the private sector.
A recent report by HHS confirmed earlier studies showing
that the quality of care declines and the length of inpatient
stays increases when nursing staff levels dwindle.\1\ Long-term
strategies are needed to avert a national health care crisis
already developing due to the looming nursing shortage. While
this issue is getting attention in Congress, pending
legislation developed by other congressional committees has not
addressed the needs of nurses in Federal health care systems.
In an effort to improve prospects for nursing careers in
general, and to offer VA strategies to recruit and retain
skilled nurses within an increasingly competitive market, the
Committee has developed the legislation described below.
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\1\ Nurse Staffing and Patient Outcomes in Hospitals (2001). Health
Resource and Services Administration. Department of Health and Human
Services, Washington, DC.
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Recruitment Authorities
The increased demand for nurses able to provide either
complex technical care or direct outpatient care has not been
matched by a growing supply. Despite Bureau of Labor Statistics
estimates showing that employment opportunities for registered
nurses will grow more rapidly through 2008 than for all other
occupations in the United States, a smaller percentage of
graduating high school students enter nursing degree programs
each year. Between 1995 and 1998, enrollment in nursing
baccalaureate programs declined 19 percent. Predictably, the
number of new nurses has steadily declined over the last 5
years, resulting in a shrinking labor pool available to VA and
community health care providers. As medical facilities compete
for an ever-diminishing number of qualified professionals,
understaffing has become a constant factor in the health care
environment.
Testimony offered by each of the registered nurses at the
Committee's June 14, 2001, hearing confirmed that inadequate
staffing creates stressful working conditions for nurses and
endangers patient safety. Understaffing endangers not only the
quality of direct patient care, but impedes VA's ability to
conduct clinical research and to provide nursing and medical
students with critical supervision and training. However,
mandating that VA increase staffing levels is simply not an
option without a pool of qualified nurses willing to enter and
remain in the field.
VA faces the same challenges as private sector hospitals in
recruiting and retaining nurses, exacerbated by budget
constraints and a nursing workforce more rapidly approaching
retirement. The passage of the Department of Veterans Affairs
Health Care Personnel Incentive Act of 1998 as Public Law 105-
368 offered VA means to recruit and retain qualified health
care professionals in fields where high demand produces
competition from the private sector. The Employee Incentive
Scholarship Program (hereafter EISP) authorized VA to award up
to $10,000 per year of scholarship money toward full-time
study, for up to 3 years, to eligible VA health care
professionals in return for a period of obligated service.
Currently, enrollment in the scholarship program is limited to
employees with 2 or more years of VA employment and is
scheduled to terminate on December 31, 2001.
This legislation also authorized the Education Debt
Reduction Program (hereafter EDRP), allowing VA to repay
education-related loans incurred by recently hired
professionals in high-demand areas. This program, still in the
final implementation process and also scheduled to terminate on
December 31, 2001, authorized VA to pay $6,000, $8,000, and
$10,000 per year, respectively, over 3 years toward principal
and interest on educational loans for professionals in high-
demand fields.
As of June 14, 2001, VA had awarded 189 scholarships
amounting to over $1.7 million, primarily for nursing and
pharmacist degrees, through the EISP and VA's National Nursing
Education Initiative. As evidenced by many letters from VA
employees submitted for the record of the Committee's hearing,
the EISP provides an excellent incentive for recruiting nurses
and other health care professionals to VA. Section 111 of the
Committee bill would permanently authorize the EISP, reduce the
minimum period of employment for eligibility from 2 years to 1
year, and remove the award limit for a participant's
educational expenses during a single school year as long as
these do not exceed the overall limitation for the equivalent
of 3 years of full-time education. Section 112 of the Committee
bill would permanently authorize the EDRP; would expand the
list of eligible individuals to include those providing either
direct or incidental patient care services; would extend the
window of participation to 5 years and the overall award limit
to $44,000, with the payments for the fourth and fifth years
limited to $10,000 each; and would provide limited authority
(until December 31, 2001) for the Secretary to extend EDRP
participation to recently appointed employees on a case-by-case
basis. These changes, supported by both the American Federation
of Government Employees (hereafter AFGE), and the Nurses
Organization of Veterans Affairs, will allow VA to compete more
aggressively with similar educational recruitment packages that
private sector employers can offer to nurses and other highly
sought health care professionals.
Attracting a new generation of nursing students into the
profession is essential to ensuring that VA and other health
care providers can replace retiring nurses in the next two
decades. Many working nurses were introduced to nursing careers
through now defunct youth service organizations, such as the
American Red Cross ``candystriper'' program. New programs, such
as the recently developed VA Nurse Cadet program at the Salem
(Virginia) VA Medical Center, must now fill the need to
introduce students to nursing and to professional nurse role
models. Mary Raymer, R.N., and founder of the VA Nurse Cadet
program, testified at the Committee hearing that:
With no formal mentoring programs and frequent media
attention to the problems and hazards of the nurses'
work environment, there are few positive messages to
choose nursing. Interventions to correct workplace
issues must be made in concert with developing and
expanding mentoring programs, such as the VA Cadet,
that provide the youth opportunities for positive
experiences in the healthcare setting.
However, until such programs can be expanded successfully,
immediate measures must be taken to increase the pool of
working skilled nurses. Within VA, allowing annuitants to work
without endangering their retirement pay would provide an
immediate reserve of qualified nurses. The testimony of VA
Under Secretary for Health Garthwaite at the Committee's
hearing stated that VA has existing authority to request that
the Office of Personnel Management waive dual compensation
restrictions under special conditions. The frequency with which
these waivers have been applied to rehiring retired nurses is
unclear. Section 111 of the Committee bill would require VA to
report on the use of these waivers to assist in filling
appointments to VA nursing positions.
Retention Authorities
A large survey recently conducted by the University of
Pennsylvania's Center for Health Outcomes and Policy Research
showed that more than 40 percent of American nurses surveyed
reported being dissatisfied with their jobs, and that more than
20 percent planned to leave those jobs in the next year. Job
dissatisfaction related to issues of ``burnout,'' with the
majority of nurses surveyed reporting that too few nurses care
for too many patients, that nurses are not included in
management and scheduling decisions, and that inadequate
support staffing further strains already overextended
professional nurses by forcing RNs to take on non-nursing
tasks.
Although VA enjoys a lower rate of nurse turnover
systemwide than the national average (8.5% as compared to 15%
in 1999), the testimony of all three VA field nurses at the
Committee's hearing indicated that nurses' morale has begun to
decline as staffing shortages worsen in VA. Although
competitive salaries and scholarship bonuses offer VA means to
recruit qualified nurses, new initiatives will be needed to
retain these nurses. The Committee bill includes provisions
intended to help VA become a national model for safe working
conditions and the employer of choice for professional nurses.
Sufficient pay, with wages equivalent to other local health
care providers, is an obvious cornerstone of nurse recruitment
and retention. Premium pay in particular refers to a
differential rate of pay offered for undesirable tours of duty,
such as weekends or holidays. Currently, title 38 guarantees
premium pay (at 25 percent over the basic rate) for VA RNs who
work regular Saturday and Sunday shifts. However, LPNs and
other support personnel who straddle both title 5 and title 38
authorities are eligible only for Sunday premium pay, leaving
Saturday premium pay at the discretion of the medical facility
directors. Under this law, LPNs and other ``title 5/title 38
hybrids'' working side-by-side with RNs may not receive the
same benefits for serving during unpopular tours.
Section 121 of the Committee bill establishes Saturday
premium pay standards for LPNs and other professionals
(pharmacists, certified or registered respiratory therapists,
physical therapists, and occupational therapists) classified as
``title 5/title 38 hybrids.'' Creating equitable premium pay
rates for these professionals should improve VA's ability to
recruit and retain these personnel, whose efforts are essential
both to direct patient care and to supporting RNs.
Currently, VA RNs enrolled in the Civilian Retirement
System can receive credit for days of unused sick leave in
calculating total days of service for annuity benefits.
However, the same benefit is not available to nurses who
enrolled in the Federal Employee Retirement System. Section 122
of the Committee bill would establish parity for nurses
enrolled in these retirement programs in computing total
service.
Although salary levels certainly play a critical role in
drawing nurses to specific providers, working conditions have a
far greater impact on nurse recruitment and retention. In
response to the nursing surveys cited above, RNs consistently
identified opportunities for career development as a key
component of professional satisfaction. Several studies have
also shown that both patient outcomes and nurse recruitment
improve in health care settings in which nurses have direct
control over the patient care environment.
Nurse-managed clinics offer advanced practice nurses
increased authority as independent primary care providers. Four
nurse-managed community-based outpatient clinics established in
VA's Upper Midwest Health Care Network have operated since
1999, providing primary care to an average of 1,000 veterans.
Dr. Robert Petzel, director of this network, testified at the
Committee's hearing that ``nurse practitioners are effective as
providers of safe, high-quality, cost-effective primary care,
which results in high patient satisfaction,'' but acknowledged
that ``we must now demonstrate in terms of outcomes-based
research the services that nurse practitioners provide and
their positive impact on client outcomes.''
Preliminary findings suggest that these nurse-managed
clinics not only improve veterans' access to care, but may
promote improved health outcomes through better patient
education. Nurse-managed clinics might prove especially
valuable as an avenue to provide preventive and chronic care to
the aging veterans population. To test this theory, section 123
of the Committee bill requires VA to evaluate how nurse-managed
clinics affect patient health care outcomes as well as nurse
retention.
Staffing levels also contribute to the nursing work
environment and nurse retention, with nurses increasingly
expressing frustration over growing patient-to-nurse ratios. In
a recent ANA survey, 75 percent of more than 7,000 nurses
surveyed felt that the quality of nursing care in their work
settings had declined in the past two years, with inadequate
staffing cited as a chief cause. Research supports these
perceptions. This February, HHS released the aforementioned
study on patient outcomes and nurse staffing, based on data
from more than 5 million inpatient discharges in 11 states. The
HHS study confirmed earlier research demonstrating a strong
relationship between higher nurse staffing levels and lower
rates of serious adverse events such as urinary tract
infections, pneumonia, shock, and upper gastrointestinal
bleeding. High nurse staffing also correlated with shorter
lengths of inpatient stay, reducing costs to the hospitals as
well as the burdens for patients and their families.
Given the clearly established connections between adequate
nurse staffing levels and improved patient outcomes, a
nationally recognized safe staffing standard would provide an
essential tool for maintaining high quality health care and
improving working conditions for nurses. No such national
standard currently exists, and older systems for determining
staffing levels no longer suit the rapidly evolving health care
environment in the United States. According to the June 14
testimony submitted by David Cox, RN, representing AFGE:
Currently, DVA only maintains staffing standards for
Intensive Care Units and the operating room. These
standards have forced DVA to maintain minimal staffing
ratios on these wards. In other wards, like psychiatric
and medical, staffing standards are determined by the
number of staff on duty, not the needs of the patients.
In other words, staffing standards at the DVA are not
consistent from facility to facility. Nor are the
staffing levels adequately measured or rational.
Moreover, there is no accountability for unsafe
staffing levels.
Recent studies by HHS,\2\, \3\ the Institute of
Medicine,\4\, \5\ and the General Accounting Office
\6\ have all recognized the link between nurse staffing
standards and patient safety. In addition, they also found that
adequate staffing plays a significant role in creating a
favorable work environment for nurses. Rather than prescribing
specific staffing ratios, section 124 of the Committee bill
would require VA to develop a national policy on nurse staffing
standards that considers intensity of care and other issues of
patient acuity, addresses patient safety and health outcomes,
and improves the working environment for professional nurses.
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\2\ Ibid.
\3\ Appropriateness of Minimum Nurse Staffing Ratios in Nursing
Homes (2001). Report to Congress, Health Care Financing Administration,
Department of Health and Human Services, Washington, DC.
\4\ Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?
(1996). Wunderlich, G.S., Sloan, F.A. and Davis, C.K., Editors.
Institute of Medicine, National Academy of Sciences. Washington, DC:
National Academy Press.
\5\ Improving the Quality of Long-Term Care (2001). Gooloo, S.,
Wunderlich, G.S., and Kohler, P.O., Editors. Committee on Improving
Quality in Long-Term Care, Division of Health Care Services, Institute
of Medicine, National Academy of Sciences. Washington, DC: National
Academy Press.
\6\ Nursing Workforce: Recruitment and Retention of Nurses and
Nurse Aides is a Growing Concern (2001). Testimony before the Senate
Committee on Health, Education, Labor, and Pensions. General Accounting
Office, Washington, DC.
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In an effort to encourage nursing education, VA recently
implemented a directive on revised Nursing Qualification
Standards that requires VA's registered nurses to hold a
bachelor's in nursing (BSN) degree to advance beyond entry
level by 2005, effective immediately for new hires. While these
standards promote professional development and a more skilled
nursing staff, they limit promotions and salary increases for
nurses without bachelor's degrees, regardless of experience.
The Nurses Organization of Veterans Affairs estimates that 35
percent of new hires will not advance beyond entry level under
the new standards if they do not take advantage of scholarship
initiatives. This may shrink the pool of nurses willing to work
for VA at a time when VA facilities are already struggling to
meet staffing needs.
Nurse Professional Standards Boards in each network have
the authority to waive degree requirements for experienced
nurses who completed nursing diplomas or associate's degrees,
but nurses have reported encountering varying degrees of
resistance in obtaining these waivers, leading to the loss of
experienced nurses to the private sector. In order to temper
higher educational standards with the need to retain
experienced nurses, section 125 of the Committee bill would
require VA to report annually on the use of education
requirement waivers systemwide to identify the numbers of
waivers requested and granted, and how these relate to the age,
race, and experience of the applicants.
To meet demands for skilled nurses, many health care
organizations rely heavily upon mandatory overtime to fill
staffing gaps. Unplanned and significant increases in working
hours, often in consecutive shifts, lead to dangerous fatigue
and a high turnover rate. A lack of nursing executives leaves
nurses with little administrative support for reporting unsafe
conditions. RNs who refuse overtime can be charged with patient
abandonment, endangering their licenses.
Testimony given at the June 14, 2001, hearing suggested
that some VA medical centers rely on mandatory overtime
regularly, and that its use makes VA a less attractive employer
in areas where community hospitals offer solely voluntary
overtime. The AFGE estimates that VA has nearly doubled its
costs for overtime in the past few years, from $31.5 million in
FY 1997 to $57.6 million in FY 2000, supporting estimates that
VA has increased its dependence on overtime as a tool to meet
staffing needs. According to testimony submitted by the AFGE:
The DVA does not have a nationwide policy on
mandatory overtime, nor does DVA take disciplinary
actions against Medical Directors or nurse managers who
rely upon mandatory overtime excessively in lieu of
adequate staffing. Only the patient and the RN suffer
the consequences when a bleary-eyed RN makes a medical
error at the end of two consecutive tours of duty. AFGE
regards DVA's failure to hold management accountable
for excessive overtime as a disturbing indication of
DVA's lack of commitment to patient safety and in
becoming the employer of choice.
Catherine J. Rick, VA's Chief Nurse Consultant, testified
that VA has experienced a ``slight increase in the use of
overtime over the past three years,'' but acknowledged that VA
Headquarters has no systemwide policy on mandatory overtime and
initiated surveys to determine the extent of mandatory overtime
use in the field only in immediate anticipation of the
Committee's hearing. As the Committee is deeply concerned about
growing dependence on a potentially unsafe working practice,
section 126 of the Committee bill would require VA to report
not later than 180 days after the passage of this act on the
use of mandatory overtime in the VA health care system in 2001,
to assess its effects on patient care, and to identify
strategies for eliminating its use.
Title 1--Other Matters
RNs comprise the largest group of health care workers
within VA, providing the greatest proportion of direct health
care services to veterans. To improve communication to and from
this essential workforce, VA has recently transformed the
Nursing Service office into the Nursing Strategic Healthcare
Group (NSHG), which serves as a resource for the development of
policies and research strategies to support the nursing
workforce. However, despite the realignment of VHA Headquarters
to create executive level offices that reflect key functions
within VA's health care system, the office of the nurse
consultant remains outside of the chief officer structure.
Section 131 of the Committee bill would elevate the office
of the VA Nurse Consultant to report directly to the VA Under
Secretary for Health, which would be analogous to similar
positions within HHS and the Office of the Surgeon General.
Creating this position would provide the VA Under Secretary for
Health with a clearly recognized source of information on the
roles and needs of nurses, and demonstrate an unmistakable
commitment to including nurses within health care decision-
making processes.
Section 132 of the Committee bill addresses an issue of
fairness in retirement annuity benefits promised to part-time
VA nurses prior to 1986. Organizations that provide inpatient
care face the perennial challenge of recruiting highly skilled
health care providers amenable to working night shifts,
weekends, and holidays. In the past, VA offered retirement
incentives for part-time nurses as a mechanism of preventing
nursing shortages and encouraging part-time nurses to work
unpopular tours of duty on nights and weekends. Specifically,
VA recruited title 38 medical staff by offering to credit these
employees with 40 hours of work per week for retirement
purposes, regardless of the actual number of hours worked. In
return, these staff committed to VA as an exclusive employer,
enabling VA to secure coverage for undesirable shifts at the
discretion of medical facility directors.
Prior to 1980, the civil service annuity formula used to
determine pension levels relied upon the highest salary
received in the average year of the highest-paid 3 years (high-
3 pay) of Federal employment, with no distinction between the
pensions of full-time and part-time workers except for salary
level. Public Law 96-330, requested by VA and passed in 1980,
amended section 4109 of title 38 to use the full-time
equivalent of the high-3 pay for part-time VA medical
personnel, prorated to the portion of time actually worked. VA
sought this legislation to eliminate disproportionately large
annuities accruing to staff (particularly physicians) who had
worked a mixture of full- and part-time hours during their
careers. Subsequent ``technical amendments'' passed
sequentially in Public Law 96-385 (section 508) and Public Law
97-72 (section 402) first repealed and then restored the
retrospective changes.
When Congress passed Public Law 99-272, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA), all part-
time employees in the federal workforce including those covered
by titles 5 and 38 became subject to the same retirement
formula, with annuities based on full-time equivalent high-3
pay prorated to the portion of time worked. This law
``grandfathered'' any part-time service completed before its
enactment on April 6, 1986, and repealed section 4109(b) of
title 38, which treated VA medical personnel covered under
title 38 differently than other Federal employees. This
restored full-time work credit to VA nurses who had been
recruited under the part-time work agreement prior to the
enactment date.
In response, VA requested legislation to exclude all title
38 employees from the provision giving full-time retirement
credit for part-time work in Public Law 99-272. VA's request
was based on the assumption that many part-time VA physicians
enjoyed lucrative outside salaries, including private medical
practices. Congress granted the VA's request, incorporating the
change into Public Law 99-509 (section 7003), the 1986 Omnibus
Budget Reconciliation. This provision removed all title 38
employees from Public Law 99-272 and restored all prospective
and retrospective part-time retirement annuity provisions in
Public Law 96-330 (section 114). Thus, current law treats
retirement credit for VA nurses for part-time work performed
prior to April 6, 1986, differently from any other part-time
Federal employees.
Section 132 of the Committee bill would amend section 7426
of title 38 to exempt registered nurses, physician assistants,
and expanded-function dental auxiliaries from the requirement
that part-time service performed prior to April 7, 1986, be
prorated when calculating retirement annuities. This action
would restore the commitment made to VA nurses and support
personnel who forfeited the opportunity to seek other full-time
or supplemental part-time work in return for retirement annuity
benefit. This provision would not restore full-time work
credits toward the annuities for physicians or dentists,
addressing VA's historical concerns about the costs of such
benefits.
Section 133 of the Committee bill would make modifications
to the nurse locality pay authorities, including allowing VA to
use third-party survey data to establish consistency in wages
for nurses at all rates of compensation, rather than only on
beginning rates. Section 7251 of title 38 allows the directors
of VA health care facilities to request adjustments to the
minimum rates of basic pay for nurses based on local variations
in the labor market. This ability to modify nurse salaries to
achieve consistency with the local market conditions allows VA
to recruit nurses competitively in regions with high demand.
Currently, VA health care facilities must rely on industry-wage
surveys provided by the Bureau of Labor Statistics (BLS), or
upon third-party industry wage surveys if no BLS data is
available, to calculate beginning rates of compensation for
corresponding health care professionals.
Title 2--Other Matters
SEC. 201. SERVICE DOGS FOR CERTAIN DISABLED VETERANS
Section 201 of the Committee bill, which would authorize
the Secretary to provide dog-guides to blind veterans and
authorize the provision of service dogs to hearing-impaired
veterans and veterans with spinal cord injuries, is drawn
directly from S. 1160, introduced by Committee Chairman
Rockefeller. Service dogs have traditionally been viewed only
as assisting the visually impaired. However, primarily as a
result of the Americans with Disabilities Act of 1990, there
have been efforts in recent years to find alternative methods
of providing assistance to people with various kinds of
disabilities. While there have been many technological
developments in this field, a need still remains for long-term
assistance that allows for the greatest possible independence
on the part of the disabled individual. The Paralyzed Veterans
Association of America strongly endorses this goal, stating
that:
For over half a century, PVA has fought for the
integration of people with disabilities into the
economic and social life of our Nation. Providing
service dogs to veterans who need them would be a major
step forward in the ultimate realization of this goal.
There are numerous ways in which service dogs can assist
their owners. Tasks such as opening and closing doors, turning
switches on and off, carrying bags, and dragging a person to
safety in the case of an emergency are just a few of the
standard duties for service dogs. Their ability to perform
these types of duties makes them invaluable to those who
require day-to-day aid. Dr. Ronald D. Fletcher, a veteran from
Fayetteville, Pennsylvania, wrote to the Committee Chairman,
stating that he had to pay out of his own pocket to acquire a
service dog. He expressed that: ``Because of my dog-hearing
guide, I live a happier and more independent life.'' Having
this sort of assistance can make a big difference in terms of
offering not only physical support, but companionship as well.
Various types of evidence illustrate the value of companion
pets, not just to the disabled, but to everyone. The Journal of
the American Medical Association published a trial study a few
years ago that examined the impact of service dogs on the lives
of people with disabilities--both in terms of economic and
social impacts. The study concluded that:
Substantial positive changes on most dependent
measures were associated with the presence of a service
dog both between and within groups. Psychologically,
all participants showed substantial improvements in
self-esteem, internal locus of control, and
psychological well-being within 6 months after
receiving their service dogs. Socially, all
participants showed similar improvements in community
integration. Demographically, participants demonstrated
substantial increases in terms of school attendance and
part-time employment. Economically, all participants
showed dramatic decreases in the number of paid
assistance hours.
Overall, the JAMA study concluded that service dogs can
greatly improve the quality of life for the disabled. Given the
various ways in which these dogs can assist their owners and
the relatively low cost of implementing this program, the
Committee has included section 201 in the Committee bill.
SEC. 202. MODIFICATION OF MEANS TEST
Section 202, which is drawn from S. 1221, as introduced by
Senator Specter, modifies the means test used by VA in
determining whether veterans will be placed in enrollment
priority group 5 or 7. In accordance with section 1722(a) of
title 38, United States Code, veterans with incomes below
specified levels currently set at approximately $24,000 for
veterans with no dependents are placed in enrollment priority
group 5 and as such, are eligible to receive medical care at VA
facilities at no charge. Under current law, only one means test
threshold is set for all non-service-connected veterans seeking
access to VA health care, with no variation based upon
locality. Section 202 would establish new geographically based
income thresholds for VA.
The purpose of the change proposed in section 202 is to
eliminate the inequity imposed on those veterans living in
higher cost-of-living areas. The cost of living in large urban
areas is generally much greater than in many rural parts of the
country. This provision restructures the means tests threshold
to make it locality based, by taking the costs of living in
each region into account when determining a veteran's
eligibility for certain VA health care treatment. As the
Paralyzed Veterans of America (PVA), which supports this
change, testified, the VA already has experience using locality
based pricing for its reasonable charges for the recovery of
third-party health care costs and for VERA calculations.
The Department of Housing and Urban Development (HUD) has
an index for determining income levels that is based upon the
cost of living for an identified locality, as well as the
number of dependents within the family. PVA provided testimony
that veterans in high cost-of-living areas would benefit from
the higher income standard found in the HUD formula, with many
being qualified for enrollment priority 5 because of their
increased inability to defray copayments.
This provision changes section 1722 of title 38, United
States Code, to also include the HUD income index in
determining eligibility for treatment as a low-income family
based upon the veteran's permanent residence. This eligibility
determinant is in addition to ability to receive state
assistance under title XIX of the Social Security Act, the
receipt of pension under section 1521 of title 38, United
States Code, or meeting VA's annual means test thresholds. An
important goal in creating this additional eligibility
determinant is to protect those veterans already enrolled in
priority 5 from being reevaluated and placed into priority 7,
thereby triggering various copayment requirements. Thus, the
current national threshold would remain in place as the base
figure even if the HUD formula determines the low-income rate
for a particular area is actually less than that amount.
The effective date of this change is January 1, 2002, and
shall apply to all means tests after December 31, 2001, using
data from the HUD index at the time the means test is given.
SEC. 203. FUNDING OF COMPLIANCE AND OVERSIGHT ACTIVITIES
Section 203 of the Committee bill addresses funding of the
VA office which is responsible for the protection of human
research subjects and research integrity within VA medical
centers, the Office of Research Compliance and Assurance
(hereafter ORCA). The rapid pace of biomedical research in
recent years has led to substantial medical advancements, and
concomitantly, to a dramatic increase in research trials
involving human and animal subjects. VA established ORCA by
directive in 1999, in the wake of an NIH-mandated shutdown of
all human studies at the VA Greater Los Angeles Healthcare
System because of lax procedures for approving and overseeing
trials involving human research subjects.
The staff of ORCA advises the VA Under Secretary for Health
on all matters affecting the integrity of research, the safety
of human research subjects and research personnel, and the
welfare of laboratory animals, and investigates any allegations
of research improprieties or scientific misconduct. ORCA staff
at VA Headquarters work with other appropriate Federal and VA
offices to provide guidance and develop policies and procedures
related to research safety and integrity. Staff from the four
ORCA regional offices conduct both routine periodic and
unannounced inspections of research programs at VA medical
centers within their designated geographical areas to ensure
compliance with policies concerning research integrity and
scientific misconduct. The ORCA regional staff investigate
allegations of non-compliance with research and safety policies
and procedures, develop appropriate educational materials and
administer remedial training if necessary, and assist research
staff in restoring compliance.
The ORCA Chief Officer reports to the office of the Under
Secretary for Health, and funding for the headquarters ORCA
office comes from the Medical Administration and Miscellaneous
Operating Expenses (MAMOE) account. However, VA currently funds
ORCA's regional offices from the Medical and Prosthetic
Research Program account, the account which is intended to
cover the direct costs of research projects.
HHS recently recognized an inherent conflict of interest in
allowing the National Institutes of Health (hereafter NIH) to
manage and fund the oversight of safety and integrity in human
studies research. In June 2000, HHS eliminated the NIH Office
of Protection from Research Risks and transferred all authority
for human subject protection to the Office of Human Research
Protections, which reports directly to the HHS Under Secretary
for Health and receives funding from non-research accounts.
Funding of the ORCA regional offices from VA's Research
account creates a similar conflict of interest, and does not
ensure human research subjects of oversight protection by an
appropriately independent, objective, and unbiased entity.
Other oversight mechanisms within VA, such as Institutional
Review Boards, are not funded from the Research account. VA's
General Counsel has determined that congressional authority is
required to allow VA to fund ORCA's regional offices from
accounts other than the research appropriation. Therefore,
section 203 of the Committee bill would authorize VA to fund
ORCA's regional offices out of the Medical Care appropriation,
as these offices directly protect patient and human subject
welfare.
Cost Estimate
In compliance with paragraph 11(a) of rule XXVI of the
Standing Rules of the Senate, the Committee, based on
information supplied by the Congressional Budget Office (CBO),
estimates that, compared to the CBO baseline, there would be
costs resulting from enactment of the Committee bill.
The cost estimate provided by CBO follows:
U.S. Congress,
Congressional Budget Office,
Washington, DC, September 10, 2001.
Hon. John D. Rockefeller IV,
Chairman, Committee on Veterans' Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 1188, the Department
of Veterans Affairs Medical Programs Enhancement Act of 2001.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sam
Papenfuss.
Sincerely,
Dan L. Crippen, Director.
Enclosure.
S. 1188, Department of Veterans Affairs Medical Programs Enhancement
Act of 2001 (As ordered reported by the Senate Committee on
Veterans' Affairs on August 2, 2001)
S. 1188 would change how the Department of Veterans Affairs
(VA) compensates nurses and other employees and would provide
expanded medical benefits to some veterans. The bill would
increase retirement benefits for VA nurses by changing how
retirement annuities are calculated and would make permanent
the authority to provide scholarships and pay school debts as
an incentive to attract and keep employees in critical
occupations. Under the bill, certain VA employees also would be
eligible for premium pay for working on Saturdays. Finally, S.
1188 would calculate the income thresholds for determining
whether a veteran qualifies for free health care on a regional
basis rather than using a single national level.
CBO estimates that enacting the bill would increase direct
spending by $1 million in 2002, $9 million over the 2002-2006
period, and $26 million over the 2002-2011 period. Because the
bill would affect direct spending, pay-as-you-go procedures
would apply. In addition, S. 1188 would authorize funding or
modify provisions governing discretionary spending for
veterans' programs, which CBO estimates would result in
additional outlays of about $390 million in 2002 and about $3
billion over the 2002-2006 period, assuming appropriation of
the estimated amounts.
S. 1188 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would not affect the budgets of state, local, or tribal
governments.
ESTIMATED COST TO THE FEDERAL GOVERNMENT
The estimated budgetary impact of S. 1188 is shown in Table
1. This estimate assumes the legislation will be enacted near
the start of fiscal year 2002 and that the necessary funds for
implementing the bill will be provided for each year. The costs
of this legislation fall within budget functions 600 (income
security) and 700 (veterans benefits and services).
Table 1.--Estimated Budgetary Impact of S. 1188
[By Fiscal Year, in Millions of Dollars]
------------------------------------------------------------------------
2002 2003 2004 2005 2006
------------------------------------------------------------------------
Changes in Direct Spending
Estimated Budget Authority...... 1 1 2 2 2
Estimated Outlays............... 1 1 2 2 2
Changes in Spending Subject to
Appropriation
Estimated Authorization Level... 428 559 691 714 726
Estimated Outlays............... 388 539 671 704 716
------------------------------------------------------------------------
Direct Spending
Section 132 would change the way part-time service
performed by registered nurses, physicians assistants, and
certain dental technicians at VA prior to April 7, 1986, is
treated in calculating retirement annuities. Under current law,
retirement benefits for these workers are calculated according
to a formula that prorates all part-time service performed in
these positions. For most other federal workers, part-time
service performed prior to April 7, 1986, is treated as full-
time service when calculating retirement annuities. Information
about these employees is limited, but based on information
supplied by VA, CBO estimates there are about 1,600 of these
workers still employed by the federal government. Assuming that
retirement benefits calculated under the new formula would be
between 4 percent and 13 percent higher than under the current
formula, depending on how much part-time service was performed
before April 7, 1986, CBO estimates that enacting this section
would increase direct spending by $1 million in 2002, $8
million over the 2002-2006 period, and $23 million over the
2002-2011 period.
Section 122 would authorize unused sick leave to be counted
toward total years of service when calculating retirement
benefits accrued by registered nurses who are employed by the
Veterans Health Administration and retire under the Federal
Employees' Retirement System (FERS). Under current law, unused
sick leave is counted toward total service under the Civil
Service Retirement System, but not under FERS. According to
information from VA, about 1,000 registered nurses retire from
VA every year, and most employees have between 3 and 6 months
of accrued sick leave upon retirement. CBO estimates that
enacting this provision would increase direct spending by less
than $500,000 every year until 2011 when the increase would
round to $1 million, with the 10-year costs totaling $3
million.
Spending Subject to Appropriation
Table 2 shows the estimated effects of S. 1188 on
discretionary spending for veterans' programs, assuming that
appropriations are provided in the amounts of the estimated
authorizations.
Table 2.--Estimated Changes in Spending Subject to Appropriations for S. 1188
[By Fiscal Year, in Millions of Dollars]
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005 2006
----------------------------------------------------------------------------------------------------------------
Spending Under Current Law for Veterans' Medical Care
Estimated Authorization Level a........................... 20,863 21,866 22,110 22,839 23,547 24,285
Estimated Outlays......................................... 20,418 21,501 22,020 22,613 23,298 24,028
Proposed Changes
Compensation:
Estimated Authorization Level........................... 0 8 9 11 14 16
Estimated Outlays....................................... 0 8 9 11 14 16
Income Threshold:
Estimated Authorization Level........................... 0 420 550 680 700 710
Estimated Outlays....................................... 0 380 530 660 690 700
Total Changes:
Estimated Authorization Level........................... 0 428 559 691 714 726
Estimated Outlays....................................... 0 388 539 671 704 716
Spending Under S. 1188
Estimated Authorization Level............................. 20,863 22,294 22,669 23,530 24,261 25,011
Estimated Outlays......................................... 20,418 21,889 22,559 23,284 24,002 24,744
----------------------------------------------------------------------------------------------------------------
a The 2001 level is the estimated net amount appropriated for that year. The current-law amounts for the 2002-
2006 period assume that appropriations remain at the 2001 level, with adjustments for inflation.
Compensation. S. 1188 contains several provisions that
would increase compensation and benefits for health care
workers employed by VA. CBO estimates that these provisions
would increase discretionary spending by $8 million in 2002 and
by $58 million over the 2002-2006 period, assuming
appropriation of the necessary amounts.
Employee Incentive Scholarships. VA currently administers a
program to provide scholarships for employees in the Veterans
Health Administration as an incentive to help meet staffing
needs in critical occupations. The authority to provide those
incentive scholarships expires on December 31, 2001. Section
111 would permanently extend this authority as well as clarify
the rules for awarding full-time and part-time scholarships. VA
expects to spend about $7 million on this program in fiscal
year 2001. CBO estimates that allowing VA to continue to
provide those scholarships would cost $7 million in 2002 and
$58 million over the 2002-2006 period, assuming appropriation
of the estimated amounts. Because VA is currently funding this
program, the costs associated with this provision are assumed
in the baseline levels shown for veterans' medical care.
Education Debt Reduction. VA currently has the authority to
reimburse new employees for employee payments of principal and
interest on debts incurred for education related to the
position the employee presently holds. The authority to enroll
employees into this program expires on December 31, 2001. To
date, VA has not implemented this program nor has it finalized
the regulations under which the program would operate. Section
112 would extend this authority permanently, increase the
maximum amount that could be reimbursed from $24,000 over three
years to $44,000 over five years, and temporarily expand the
definition of a new employee through December 31, 2001. CBO
estimates that about 200 employees would take advantage of this
program on an annual basis, with about two-thirds receiving the
full amount allowed under the bill. CBO estimates that
extending this authority along with the other changes would
cost $4 million in 2002 and $36 million over the 2002-2006
period, assuming both appropriation of the estimated amounts
and that VA actually implements this program by January 1,
2002. Since this program has not yet begun operation, the
current law baseline does not reflect the costs of extending
the program and these costs are included in the
``Compensation'' section of Table 2.
Saturday Pay. Currently, pharmacists, licensed practical
nurses, and many therapists receive premium pay when they work
on Sundays, but premium pay for work performed on Saturdays is
managed at a local level and many do not receive such pay for
Saturday work. Section 121 would require that all these
employees receive premium pay, equal to 25 percent of their
hourly wage, for all hours worked on Saturday. Using data from
VA, CBO estimates that this provision would cost $4 million in
2002 and $22 million over the 2002-2006 period, assuming
appropriation of the estimated amounts.
Income Threshold. Under current law, VA furnishes free
medical care to veterans who meet certain eligibility
requirements--one of which is an income threshold. Any veteran
eligible for Medicaid, or who receives a VA pension, or who has
an income below a statutory level (currently $23,688 for a
veteran without a dependent) can receive free health care.
Under the bill, veterans eligible for low-income housing also
would qualify for free medical care. In general, the Department
of Housing and Urban Development sets eligibility for low-
income housing at 80 percent of each county's median income
with adjustments for cost-of-living.
This provision would affect both veterans who currently
receive medical care from VA and those who do not currently use
VA health care services. CBO estimates that the total cost
associated with expanding eligibility for free VA medical care
would be $380 million in 2002 and about $3 billion over the
2002-2006 period, assuming appropriation of the estimated
amounts.
Current VA Health Care Users. Using data from VA and the
Current Population Survey, CBO estimates that under this
provision about 1.4 million veterans would become eligible for
free health care. CBO estimates that this number includes more
than 250,000 veterans who currently use VA medical facilities
but are not presently eligible for free health care. Under the
bill, these veterans would no longer need to make copayments
when receiving health care benefits. Because individuals use
more health care services when they do not face any out-of-
pocket costs, the cost of providing medical care would increase
for those users who become eligible for free health care. Using
data from VA and from published research, CBO estimates that
those veterans receiving free health care would cost VA about
$700 more per person in 2002. Using that information and
adjusting for inflation, CBO estimates that providing free
health care to veterans currently using VA would cost about
$170 million in 2002 and almost $1 billion over the 2002-2006
period, assuming appropriation of the estimated amounts.
Because the veterans discussed above would be eligible for
free health care, VA also would lose the copayments that these
veterans make when receiving care. CBO estimates that the lost
copayments would total about $40 million over the 2002-2006
period. Under current law, those copayments can be spent by VA,
if authorized by the appropriators. Since CBO's baseline
assumes both the collection and the spending of those
copayments, the budgetary effect would be neutral. Although
there is no net budgetary impact, VA would not be able to
provide the same level of care as they currently do without
additional appropriations to replace the lost copayments.
New VA Health Care Users. CBO also estimates that some
veterans who do not currently use VA medical facilities because
of the requirement to make copayments would do so once they
became eligible for free health care. Currently, only about 20
percent of veterans eligible for free health care based on
income actually use VA medical facilities. CBO expects that an
even lower percentage of those who would become eligible for
free health care would end up using VA medical facilities,
because some of those veterans have access to health care from
other sources. CBO estimates that eventually about 100,000
newly eligible veterans would begin using VA medical care at a
cost of more than $4,000 per person. CBO estimates that
providing free health care to these veterans would cost $210
million in 2002 and about $2 billion over the 2002-2006 period,
assuming appropriation of the estimated amounts.
PAY-AS-YOU-GO CONSIDERATIONS
The Balanced Budget and Emergency Deficit Control Act sets
up pay-as-you-go procedures for legislation affecting direct
spending or receipts. The net changes in outlays that are
subject to pay-as-you-go procedures are shown in Table 3. For
the purposes of enforcing pay-as-you-go procedures, only the
effects in the current year, the budget year, and the
succeeding four years are counted.
Table 3.--Estimated Impact of S. 1188 on Direct Spending and Receipts
[By Fiscal Year, in Millions of Dollars]
----------------------------------------------------------------------------------------------------------------
2001 2002 2003 2004 2005 2006 2007 2008 2009
----------------------------------------------------------------------------------------------------------------
Changes in outlays............................... 0 1 1 2 2 2 3 3 3
Changes in receipts *
----------------------------------------------------------------------------------------------------------------
* Not applicable.
INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT
S. 1188 contains no intergovernmental or private-sector
mandates as defined in UMRA and would not affect the budgets of
state, local, or tribal governments.
Estimate prepared by: Federal Costs: Sam Papenfuss and
Geoffrey Gerhardt. Impact on State, Local, and Tribal
Governments: Elyse Goldman. Impact on the Private Sector:
Allison Percy.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis, Congressional Budget Office.
Regulatory Impact Statement
In compliance with paragraph 11(b) of rule XXVI of the
Standing Rules of the Senate, the Committee on Veterans'
Affairs has made an evaluation of the regulatory impact that
would be incurred in carrying out the Committee bill. The
Committee finds that the Committee bill would not entail any
regulation of individuals or businesses or result in any impact
on the personal privacy of any individuals and that the
paperwork resulting from enactment would be minimal.
Tabulation of Votes Cast in Committee
In compliance with paragraph 7 of rule XXVI of the Standing
Rules of the Senate, the following is a tabulation of votes
cast in person or by proxy by members of the Committee on
Veterans' Affairs at its August 2, 2001, meeting. On that date,
the Committee, by unanimous voice vote, ordered S. 1188, as
amended, reported favorably to the Senate.
Agency Report
On August 31, 2001, the Honorable Anthony J. Principi,
Secretary of the Department of Veterans Affairs, transmitted
the Department's views on S. 1811, a bill to enhance the
authority of the Secretary of Veterans Affairs to recruit and
retain qualified nurses for the Veterans Health Administration,
and for other purposes. Excerpts from Secretary Principi's
correspondence are reprinted below:
* * * * * * *
I am pleased to provide the Department's views on S. 1188,
a bill ``to enhance the authority of the Secretary of Veterans
Affairs to recruit and retain qualified nurses for the Veterans
Health Administration, and for other purposes.'' VA's nurses
are critical front-line components of the VA health-care team.
Our health-care providers are our most important resource in
delivering high-quality, compassionate care to our Nation's
veterans. VA must maintain the ability to recruit and retain
well-qualified nurses in order to continue that care.
Compensation, employment benefits and workplace factors affect
that ability, particularly in highly competitive labor markets
and for hard-to-fill specialty assignments. While VA is able to
offer generally competitive pay in most markets, the Department
must continuously monitor the recruitment and retention of
health-care providers, particularly nurses, and trends in
private sector employment and workforce projections. Although
VA nurse staffing is generally stable overall, VA is
experiencing increasing difficulties in filling positions in
some locations, and filling some specialty assignments is
extremely difficult.
S. 1188 contains several proposals that VA believes would
assist us in meeting the challenge of recruiting and retaining
the nurses required to meet VA's patient care needs. However,
it also contains provisions that VA does not support, as
explained below.
Sections 101 and 102 of S. 1188 would make permanent the
Department's Employee Incentive Scholarship Program (EISP) and
Education Debt Reduction Program (EDRP) and make other
technical changes. Specifically, the bill would make the
authority for each of these programs permanent. It would also
require the Secretary to make periodic adjustments to the
amount of assistance paid under these programs when adjustments
are made to the Federal General Schedule. Such adjustments are
now required in the other Educational Assistance Programs
authorized in chapter 76. The bill would also expand
eligibility so that more employees could participate in these
programs. In addition, it would provide that EISP payments are
to be made on a school year basis instead of a calendar year
basis. It would extend to five years (from the current three)
the length of time that an employee may participate in the EDRP
and increase the overall award limit to $44,000.
VA supports the intent of sections 101 and 102 of the bill.
The EISP and EDRP are valuable recruitment and retention tools
for the Department. Indeed, we consider these programs to be
vital in assuring VA's continued ability to place health-care
professionals in hard-to-fill occupations, in ensuring that
VA's registered nurses have the educational foundation to
perform their enhanced role in health-care management, and in
enabling VA to compete with the private sector for highly
qualified health-care professionals.
Section 103 of S. 1188 would require a report on VA's use
of the authority in sections 8344 and 8468 of title 5 to
request waivers of the pay reduction for reemployed annuitants
for appointments to VHA nurse positions. VA supports this
provision.
Section 201 would mandate Saturday premium pay for hybrid
employees. VA does not support this provision because it
appears to be unnecessary. Under the provisions of 38 U.S.C.
7454(b) and (c), the Secretary may authorize premium pay under
Title 38, including Saturday premium pay, for hybrid employees
at any location. This authority has been delegated to facility
directors. VHA believes that the flexibility to authorize
premium pay according to local practices and to maintain VA's
competitive stance is the most equitable and cost-effective
method of adjusting premium pay. The cost estimate for this
provision is under development.
Section 202 would amend section 8415 of title 5, United
States Code, by adding a new subsection (I) to allow the use of
unused sick leave in the annuity computations of registered
nurses with the Veterans Health Administration (VHA). This
would provide an incentive for VA nurses to accumulate and save
their sick leave because the unused sick leave would count as
additional service credit upon retirement and would increase
the employees' annuities. VA opposes this provision. It is
inappropriate to extend this incentive to such a narrow class
of Federal employees. Further, this provision would likely have
PAYGO costs for the civil service retirement and disability
fund, although no estimate has been developed yet.
Section 203 of S. 1188 would require an evaluation of VA
nurse-managed care clinics, including primary care and
geriatric clinics located in three different Veterans
Integrated Service Networks (VISNs). If VHA does not have three
such clinics, VHA would be required to establish three. The
evaluation is to address: patient satisfaction; provider
experiences; access to care, including waiting time; functional
status of clinic patients; other matters determined by the
Secretary. VA would be required to provide a report on the
evaluation. VA supports this provision. VA intends to use
current nurse-managed care clinics or convert existing clinics
to nurse-managed care clinics as evaluation sites.
Section 204 of the bill would require that we establish a
nationwide policy for assuring adequate staffing to maintain
VHA capacity mandated by section 8110, taking into account
staffing levels and skill mix required for the range of patient
care and services provided in VA facilities. It also would
require that we have staffing necessary to maintain mandated
VHA capacity, consistent with our overtime policies, and
consistent with the new nationwide staffing policy.
VA opposes section 204. There are currently no universally
accepted staffing guidelines or staffing ratios in the public
or private sector. While a mandated standard would seemingly
make determination of quality a matter of a simple equation,
staffing is too multi-factorial to be so easily structured. All
facilities must comply with Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) staffing standards. JCAHO
does not look for rigid staffing standards or staff-to-patient
ratios since these measures have proven to be ineffective
predictors of quality. JCAHO is currently piloting a staffing
standard that takes into account clinical/service indicators
(quality outcomes) in combination with human resource
indicators (both direct and indirect caregivers). The approach
calls for multiple indicators to be considered in combination.
This has been the recommended VHA approach for staffing
methodology over the past several years. Professional judgment
is the essence and final guarantor of quality care; VA's system
is designed to foster such professionalism. Some of the complex
factors that influence staffing decisions are:
Patient acuity and mix on a given unit
Availability of varying personnel types, i.e.,
physician specialties, RNs, LPNs, and nursing assistants
Experience, education and quality of staff
Availability of other professional partners (i.e.
social workers, pharmacists)
Availability of support services, supplies and
equipment
Physical layout of the patient care and treatment
areas
Technological and administrative support
availability
Academic affiliation, etc.
Staffing decisions are dependent upon these factors applied
on a 24-hour and seven-day per week basis. VA believes that
staffing decisions must be made near the site of care. There is
no known national methodology that is workable. Additional
costs can be anticipated to result from an inflexible national
staffing standard.
Section 205 of the bill would require an annual report,
beginning in 2002, concerning VA's use of authorities to
enhance retention of experienced nurses. Included are
educational assistance programs, waivers of educational
requirements (by age, race, and years of experience) in the VA
nurse qualification standard and other available retention
authorities. VA supports this provision.
Section 206 would require a report on the use of mandatory
overtime by licensed nursing staff and nursing assistants in
each facility. The report would include a description of
mechanisms to monitor mandatory overtime, an assessment of the
effects of mandatory overtime, including its contribution to
medical errors, recommendations concerning mechanisms for
preventing mandatory overtime other than for emergency
situations, and other matters VA considers appropriate. VA
supports this provision.
Section 301 of S. 1188 would elevate the position of the
Chief Consultant for Nursing Programs (Director, Nursing
Service) so that it would report directly to the Under
Secretary for Health. Currently, this position reports to the
Under Secretary through the Chief Patient Care Services Officer
(Associate Deputy Under Secretary for Health). The effect of
this provision is to recognize the importance of this position
as the chief advisor to the Under Secretary for Health on
nursing issues, as well as its role as the operational head for
VA nursing programs. VA supports this provision.
Section 302 would change the treatment, for purposes of
retirement credit, of part-time service performed by certain
title 38 employees prior to April 7,1986. Currently, part-time
service performed by title 5 employees prior to April 7,1986,
is treated as full-time service; title 38 employees' part-time
service prior to April 7, 1986, is credited as part-time
service on a pro rata basis, thus resulting in lower annuities.
Part-time service after April 6,1986, is prorated for both
title 5 and title 38 employees. VA believes there should be
parity in the treatment of part-time service for title 38 and
title 5 employees for retirement purposes. There are some
potential unintended effects associated with this provision.
Therefore, the Administration is seeking to resolve, in a
comprehensive manner, technical problems associated with
computations of part-time service. This provision would likely
have PAYGO costs for the civil service retirement and
disability fund, although no estimate has been developed yet.
Section 303 of S. 1188 would make clarifying amendments to
VA's nurse locality pay statute, 38 U.S.C. Sec. 7451,
consistent with recent changes made by Public Law 106-419.
Those changes were intended to improve the survey process used
to adjust nurse locality pay rates. This provision would amend
subparagraphs (A) and (B) of section 7451(d)(3) by deleting the
phrase ``beginning rates of'' throughout. This is consistent
with the requirement under the recent amendments that third-
party surveys conducted under this authority must now include
broader compensation data. It also would delete the phrase ``or
at any other time that an adjustment in rates of pay is
scheduled to take place'' in section 7451(d)(4). This provision
provided VA medical center directors with discretion to not
pass on General Schedule adjustments to nurse salaries. The
recent amendments provide for an automatic adjustment to nurse
salaries at the same time and in the same amount as the General
Schedule increase; facility directors no longer have discretion
to limit such increases.
Further, section 303 of S. 1188 would eliminate the
requirement that facility directors notify the Under Secretary
for Health within 10 days of a decision not to adjust salary
rates based on survey data as unnecessary. Public Law 106-419
reinstated an annual reporting requirement, which includes
information concerning facility directors' decisions not to
adjust salary rates based on survey data. Finally, this
proposal would delete references to ``grades'' of positions in
the report required under section 7451(e)(4) so as to achieve
consistency with the way VA collects information for the
report. These amendments would improve administration of the
complicated nurse locality pay system, consistent with the
intent of the amendments in Public Law 106-419.
Section 304 of S. 1188 would make technical amendments to
section 38 U.S.C. Sec. 7631.
Because S. 1188 would affect direct spending, it is subject
to the pay-as-you-go (PAYGO) requirement of the Omnibus Budget
Reconciliation Act of 1990. VA's cost estimate of S. 1188 is
under development and will be provided to you when complete.
The Office of Management and Budget has advised that there
is no objection to the submission of this report from the
standpoint of the Administration's program.
* * * * * * *
On July 19, 2001, the Honorable Thomas L. Garthwaite, MD,
Under Secretary for Health, Department of Veterans Affairs,
appeared before the Committee and submitted testimony on, among
other things, S. 1188, S. 1160, and a draft bill to change the
means test used by the VA in determining whether veterans will
be placed in enrollment priority group 5 or 7. Excerpts from
this statement are reprinted below:
STATEMENT OF THOMAS L. GARTHWAITE, MD, UNDER SECRETARY FOR
HEALTH, DEPARTMENT OF VETERANS AFFAIRS
Mr. Chairman and Members of the Committee, I am pleased to
be here to present the Department's views on six different
bills being considered by the Committee. They cover a wide
range of subjects related to personnel matters and VA's
provision of health care services to veterans. We support many
provisions in the bills before the Committee, however there are
some on which we recommend modifications, and others which we
cannot support at this time. thank you for the opportunity to
testify today on several legislative items of great interest to
veterans.
* * * * * * *
S. 1188
Mr. Chairman I will next present our views on S. 1188, a
bill designed to improve the recruitment and retention of VA
nurses. Our nurses are critical front-line components of the VA
health care team. Our health care providers are our most
important resource in delivering high-quality, compassionate
care to our Nation's veterans. We must maintain the ability to
recruit and retain well-qualified nurses in order to continue
that care. Compensation, employment benefits and workplace
factors affect that ability, particularly in highly competitive
labor markets and for hard-to-fill specialty assignments.
Thanks to the efforts of this Committee and the House Veterans'
Affairs Committee, we have been able to offer generally
competitive pay in most markets. We continuously monitor the
recruitment and retention of health care providers,
particularly nurses, and trends in private sector employment
and workforce projections. As we noted in testimony before this
committee last month, VA nurse staffing is generally stable
overall, but there are increasing difficulties in filling
positions in some locations, and filling some specialty
assignments is extremely difficult. However, I am not prepared
to give the Administration's views on this bill without further
study. We will provide our views on this measure as soon as
possible.
* * * * * * *
S. 1160
Mr. Chairman I now turn to S. 1160, a bill that would
authorize us to furnish a service dog to any veteran with a
compensable service-connected disability who is hearing
impaired or who has a spinal cord injury or dysfunction.
Service dogs can assist a disabled person in his or her daily
life and can assist that person during medical emergencies.
They can be trained in many tasks, including, but not limited
to, pulling a wheelchair, carrying a back-pack, opening and
closing doors, helping with dressing and undressing, picking up
things one drops, picking up the phone, and hitting a distress
button on the phone. Such dogs can also notice when the
disabled individual is in distress and can find help. Dogs can
also assist the hearing impaired by alerting them to doorbells,
ringing phones, smoke detectors, crying babies, and emergency
sirens on vehicles. We support this bill, and any new costs
will be handled under existing resources within the FY 2002
President's Budget. Having said that, however if it were to
become law, we would promulgate prescription criteria and
guidelines for provision of such dogs to insure that we provide
animals only to those veterans who can most benefit from them.
* * * * * * *
Draft Legislation on the Means Test Threshold
Mr. Chairman, also on the agenda is a draft bill that would
establish new geographically based income thresholds for VA to
use in determining a nonservice-connected veteran's priority
for receiving VA care and whether the veteran must agree to pay
copayments in order to receive that care. As you know, Mr.
Chairman, the law now requires that most veterans enroll in our
health care system in order to receive care. Enrollees are
placed in an enrollment priority group that is based, in many
instances, on their level of income and net worth. Although we
currently provide care to veterans in all enrollment priority
groups, if there were funding shortages in the future, it might
be necessary to determine that those with relatively higher
incomes must be disenrolled, meaning they could no longer
receive VA care. Current law establishes, on a National basis,
the specific income thresholds that we must use to determine
the priority group of any given enrollee with no service-
connected disability or other special status. We place higher
income veterans in priority group 7 and lower income veterans
in priority group 5. This draft bill would establish new
geographically based income thresholds that VA could use for
placing veterans in those priority groups. The draft bill would
use a specific statutorily based poverty index used by the
Department of Housing and Urban Development that is established
for Metropolitan Statistical Areas (MSA's), Primary
Metropolitan Statistical Areas (PMSA's) and counties. The index
defines a family as low income if family income does not exceed
80% of the median family income for the area in which the
family resides. If we determined that a veteran's income was
below the threshold for the specific area where the veteran
lived, and his net worth was below our threshold, we would
place that veteran in enrollment priority category 5. In many
instances, particularly in urban areas, this new income
threshold is greater then the current statutory income
threshold that we use for determining whether a veteran should
be placed in priority group 5. The draft bill would provide
that if the new geographically based income threshold is lower
then the current threshold, VA would use the old threshold as
that would benefit the veteran.
We in VA are very interested in examining the use of
geographically based income thresholds for placing nonservice-
connected veterans in different enrollment priority groups. We
recognize that the cost of living in large urban areas is much
greater then in many more rural parts of the country. What
might be considered a reasonably high income in some locations
may be totally inadequate in other higher cost locations.
However, at this time we cannot support the methodology
proposed in the draft bill. There are many poverty indexes that
are established in various ways. However, there are serious
issues about what these indexes really measure. We believe
further study is needed to determine the most appropriate
method for tackling this problem. I will next present our views
on S. 1188, a bill designed to improve the recruitment and
retention of VA nurses. Our nurses are critical front-line
components of the VA health care team. Our health care
providers are our most important resource in delivering high-
quality, compassionate care to our Nation's veterans. We must
maintain the ability to recruit and retain well-qualified
nurses in order to continue that care. Compensation, employment
benefits and workplace factors affect that ability,
particularly in highly competitive labor markets and for hard-
to-fill specialty assignments. Thanks to the efforts of this
Committee and the House Veterans' Affairs Committee, we have
been able to offer generally competitive pay in most markets.
We continuously monitor the recruitment and retention of health
care providers, particularly nurses, and trends in private
sector employment and workforce projections. As we noted in
testimony before this committee last month, VA nurse staffing
is generally stable overall, but there are increasing
difficulties in filling positions in some locations, and
filling some specialty assignments is extremely difficult.
However, I am not prepared to give the Administration's views
on this bill without further study. We will provide our views
on this measure as soon as possible.
Changes in Existing Law Made by the Committee Bill, As Reported
In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (existing law proposed to be omitted is enclosed in
black brackets, new matter is printed in italic, existing law
in which no change is proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
subchapter i--general
Sec.
1701. * * *
* * * * * * *
subchapter ii--hospital, nursing home or domiciliary care and medical
treatment
* * * * * * *
[1714. FITTING AND TRAINING IN USE OF PROSTHETIC APPLIANCES; SEEING-EYE
DOGS.]
1714. FITTING AND TRAINING IN USE OF PROSTHETIC APPLIANCES; DOG-GUIDES
AND SERVICE DOGS.
* * * * * * *
[Sec. 1714. Fitting and training in use of prosthetic appliances;
seeing-eye dogs]
Sec. 1714. Fitting and training in use of prosthetic appliances; dog-
guides and service dogs
* * * * * * *
[(b) The Secretary may provide seeing-eye or guide dogs
trained for the aid of the blind to veterans who are entitled
to disability compensation, and may pay travel and incidental
expenses (under the terms and conditions set forth in section
111 of this title) to and from their homes and incurred in
becoming adjusted to such seeing-eye or guide dogs. The
Secretary may also provide such veterans with mechanical or
electronic equipment for aiding them in overcoming the handicap
of blindness.]
(b)(1) The Secretary may provide any blind veteran who is
entitled to disability compensation with--
(A) a dog-guide trained for the aid of the blind; and
(B) mechanical or electronic equipment for aid in
overcoming the disability of blindness.
(2) The Secretary may provide a service dog to the following:
(A) Any hearing-impaired veteran who is entitled to
disability compensation.
(B) Any veteran with a spinal cord injury or
dysfunction who is entitled to disability compensation.
(C) Any veteran entitled to disability compensation
who has any other chronic physical or mental impairment
that substantially limits mobility, hearing, or
activities of daily living in order to assist such
veteran in overcoming such physical or mental
impairment.
(3) In providing a dog-guide or service dog to a veteran
under this subsection, the Secretary may pay travel and
incidental expenses (under the terms and conditions set forth
in section 111 of this title) of the veteran to and from the
veteran's home and incurred in becoming adjusted to the dog-
guide or service dog, as the case may be.
* * * * * * *
Sec. 1722. Determination of inability to defray necessary expenses;
income thresholds
(a) For the purposes of section 1710(a)(2)(G) of this title,
a veteran shall be considered to be unable to defray the
expenses of necessary care if--
(1) the veteran is eligible to receive medical
assistance under a State plan approved under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.);
(2) the veteran is in receipt of pension under
section 1521 of this title; [or]
(3) the veteran's attributable income is not greater
than the amount set forth in subsection (b)[.]; or
(4) the veteran (including any applicable part of the
veteran's family) is eligible for treatment as a low-
income family under section 3 of the United States
Housing Act of 1937 (42 U.S.C. 1437a) for the area in
which the veteran resides.
* * * * * * *
CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS
subchapter i--organization
Sec.
7301. * * *
* * * * * * *
7324. ANNUAL REPORT ON USE OF AUTHORITIES TO ENHANCE RETENTION OF
EXPERIENCED NURSES.
Sec. 7306. Office of the Under Secretary for Health
(a) The Office of the Under Secretary for Health shall
consist of the following:
* * * * * * *
(5) A Director of Nursing Service, who shall be a
qualified registered nurse and who shall be responsible
to, and report directly to, the Under Secretary for
Health for the operation of the Nursing Service.
* * * * * * *
Sec. 7324. Annual report on use of authorities to enhance retention of
experienced nurses
(a) Annual Report.--Not later than January 31 each year, the
Secretary, acting through the Under Secretary for Health, shall
submit to Congress a report on the use during the preceding
year of authorities for purposes of retaining experienced
nurses in the Veterans Health Administration, as follows:
(1) The authorities under chapter 76 of this title.
(2) The authority under VA Directive 5102.1, relating
to the Department of Veterans Affairs nurse
qualification standard, dated November 10, 1999, or any
successor directive.
(3) Any other authorities available to the Secretary
for those purposes.
(b) Report Elements.--Each report under subsection (a) shall
specify for the period covered by such report, for each
Department medical facility and for each Veterans Integrated
Service Network, the following:
(1) The number of waivers requested under the
authority referred to in subsection (a)(2), and the
number of waivers granted under that authority, to
promote to the Nurse II grade or Nurse III grade under
the Nurse Schedule under section 7404(b)(1) of this
title any nurse who has not completed a bachelors of
science in nursing in a recognized school of nursing,
set forth by age, race, and years of experience of the
individuals subject to such waiver requests and
waivers, as the case may be.
(2) The programs carried out to facilitate the use of
nursing education programs by experienced nurses,
including programs for flexible scheduling,
scholarships, salary replacement pay, and on-site
classes.
* * * * * * *
Sec. 7426. Retirement rights
* * * * * * *
(c) The provisions of subsection (b) shall not apply to the
part-time service before April 7, 1986, of a registered nurse,
physician assistant, or expanded-function dental auxiliary. In
computing the annuity under the applicable provision of law
specified in that subsection of an individual covered by the
preceding sentence, the service described in that sentence
shall be credited as full-time service.
* * * * * * *
Sec. 7451. Nurses and other health-care personnel: competitive pay
* * * * * * *
(d)(1) * * *
* * * * * * *
(3)(A) In the case of a Department health-care facility
located in an area for which there is current information,
based upon an industry-wage survey by the Bureau of Labor
Statistics for that labor market, on [beginning rates of]
compensation for corresponding health-care professionals for
the BLS labor-market area of that facility, the director of the
facility concerned shall use that information as the basis for
making adjustments in rates of pay under this subsection.
Whenever the Bureau of Labor Statistics releases the results of
a new industry-wage survey for that labor market that includes
information on [beginning rates of] compensation for
corresponding health-care professional, the director of that
facility shall determine, not later than 30 days after the
results of the survey are released whether an adjustment in
rates of pay for employees at that facility for any covered
position is necessary in order to meet the purposes of this
section. If the director determines that such an adjustment is
necessary, the adjustment, based upon the information
determined in the survey, shall take effect on the first day of
the first pay period beginning after that determination.
(B) In the case of a Department health-care facility located
in an area for which the Bureau of Labor Statistic does not
have current information on [beginning rates of] compensation
for corresponding health-care professional for the labor-market
area of that facility for any covered position, the director of
that facility shall conduct a survey in accordance with this
subparagraph and shall adjust the amount of the minimum rate of
basic pay for grades in that covered position at that facility
based upon that survey. To the extent practicable, the director
shall use third-party industry wage surveys to meet the
requirements of the preceding sentence. Any such survey shall
be conducted in accordance with regulations prescribed by the
Secretary. Those regulations shall be developed in consultation
with the Secretary of Labor in order to ensure that the
director of a facility collects information that is valid and
reliable and is consistent with standards of the Bureau. The
survey should be conducted using methodology comparable to that
used by the Bureau in making industry-wage surveys except to
the extent determined infeasible by the Secretary. To the
extent practicable, all surveys conducted pursuant to this
subparagraph or subparagraph (A) shall include the collection
of salary midpoints, actual salaries, lowest and highest
salaries, average salaries, bonuses, incentive pays,
differential pays, actual beginning rates of pay, and such
other information needed to meet the purpose of this section.
Upon conducting a survey under this subparagraph the director
concerned shall determine, not later than 30 days after the
date on which the collection of information through the survey
is completed or published, whether an adjustment in rates of
pay for employees at that facility for any covered position is
necessary in order to meet the purposes of this section. If the
director determines that such an adjustment is necessary, the
adjustment, based upon the information determined in the
survey, shall take effect on the first day of the first pay
period beginning after that determination.
(C)(i) A director of a Department health-care facility may
use data on the [beginning rates of] compensation paid to
certified registered nurse anesthetists who are employed on a
salary basis by entities that provide anesthesia services
through certified registered nurse anesthetists in the labor-
market area only if the director--
(I) has conducted a survey of [beginning rates of]
compensation for certified registered nurse
anesthetists in the local labor-market area of the
facility under subparagraph (B);
* * * * * * *
(4) If the director of a Department health-care facility, or
the Under Secretary for Health with respect to Regional and
Central Office employees, determines, after any survey under
paragraph (3)(B) [or at any other time that an adjustment in
rates of pay is scheduled to take place under this subsection],
that it is not necessary to adjust the rates of basic pay for
employees in a grade of a covered position at that facility in
order to carry out the purpose of this section, such an
adjustment for employees at that facility in that grade shall
not be made. [Whenever a director makes such a determination,
the director shall within 10 days notify the Under Secretary
for Health of the decision and the reasons for the decision.]
* * * * * * *
(e)(1) * * *
* * * * * * *
(4) Each director of a Department health-care facility shall
provide to the Secretary, not later than July 31 each year, a
report on staffing for covered positions at that facility. The
report shall include the following:
(A) Information on turnover rates and vacancy rates
for each [grade in a] covered position, including a
comparison of those rates with the rates for the
preceding three years.
(B) The director's findings concerning the review and
evaluation of the facility's staffing situation,
including whether there is, or is likely to be, in
accordance with criteria established by the Secretary,
a significant pay-related staffing problem at that
facility for any [grade of a] covered position and, if
so, whether a wage survey was conducted, or will be
conducted with respect to that grade.
* * * * * * *
(D) In any case in which the director, after finding
that there is, or is likely to be, in accordance with
criteria established by the Secretary, a significant
pay-related staffing problem at that facility for any
[grade of a] covered position, determines not to
conduct a wage survey with respect to that position, a
statement of the reasons why the director did not
conduct such a survey.
* * * * * * *
Sec. 7454. Physician assistants and other health care professionals:
additional pay
* * * * * * *
(b)(1) When the Secretary determines it to be necessary in
order to obtain or retain the services of certified or
registered respiratory therapists, licensed physical
therapists, licensed practical or vocational nurses,
pharmacists, or occupational therapists, the Secretary may, on
a nationwide, local, or other geographic basis, pay persons
employed in such positions additional pay on the same basis as
provided for nurses in section 7453 of this title.
(2) Health care professionals employed in positions referred
to in paragraph (1) shall be entitled to additional pay on the
same basis as provided for nurses in section 7453(c) of this
title.
* * * * * * *
Sec. 7631. Periodic adjustments in amount of assistance
(a)(1) Whenever there is a general Federal pay increase, the
Secretary shall increase the maximum monthly stipend amount,
the maximum tuition reimbursement amount, [and the maximum
Selected Reserve member stipend amount] the maximum Selected
Reserve member stipend amount, the maximum employee incentive
scholarship amount. Any such increase shall take effect with
respect to any school year that ends in the fiscal year in
which the pay increase takes effect, and the maximum education
debt reduction payments amount.
(2) The amount of any increase under paragraph (1) of this
subsection is the previous maximum amount under that paragraph
multiplied by the overall percentage of the adjustment in the
rates of pay under the General Schedule made under the general
Federal pay increase. Such amount shall be rounded to the next
lower multiple of $1.
(b) For purposes of this section:
* * * * * * *
(4) The term ``maximum employee incentive scholarship
amount'' means the maximum amount of the scholarship
payable to a participant in the Department of Veterans
Affairs Employee Incentive Scholarship Program under
subchapter VI of this chapter, as specified in section
7673(b)(1) of this title and as previously adjusted (if
at all) in accordance with this section.
(5) The term ``maximum education debt reduction
payments amount'' means the maximum amount of education
debt reduction payments payable to a participant in the
Department of Veterans Affairs Education Debt Reduction
Program under subchapter VII of this chapter, as
specified in section 7683(d)(1) of this title and as
previously adjusted (if at all) in accordance with this
section.
[(4)] (6) The term ``general Federal pay increase''
means an adjustment (if an increase) in the rates of
pay under the General Schedule under subchapter III of
chapter 53 of title 5.
* * * * * * *
Sec. 7631. Periodic adjustments in amount of assistance
* * * * * * *
(b) For purposes of this section:
(1) The term ``maximum monthly stipend amount'' means
the maximum monthly stipend that may be paid to a
participant in the Scholarship Program specified in
section 7613(b) of this title and as previously
adjusted (if at all) in accordance with this
[subsection] section.
(2) The term ``maximum tuition reimbursement amount''
means the maximum amount of tuition reimbursement
provided to a participant in the Tuition Reimbursement
Program specified in section 7622(e) of this title and
as previously adjusted (if at all) in accordance with
this [subsection] section.
(3) The term ``maximum Selected Reserve member
stipend amount'' means the maximum amount of assistance
provided to a person receiving assistance under
subchapter V of this chapter, as specified in section
7653 of this title and as previously adjusted (if at
all) in accordance with this [subsection] section.
* * * * * * *
Sec. 7672. Eligibility; agreement
* * * * * * *
(b) Eligible Department Employees.--For purposes of
subsection (a), an eligible Department employee is any employee
of the Department who, as of the date on which the employee
submits an application for participation in the Program, has
been continuously employed by the Department for not less than
[2 years] one year.
* * * * * * *
Sec. 7673. Scholarship
* * * * * * *
(b) Amounts.--The total amount of the scholarship payable
under subsection (a)--
(1) in the case of a participant in the Program who
is a full-time student, may not exceed $10,000 [for any
1 year]; and
[(2) in the case of a participant in the Program who
is a part-time student, shall be the amount specified
in paragraph (1) reduced in accordance with the
proportion that the number of credit hours carried by
the participant in that school year bears to the number
of credit hours required to be carried by a full-time
student in the course of education or training being
pursued by the participant.
[(c) Limitation on Years of Payment.--(1) Subject to
paragraph (2), a participant in the Program may not receive a
scholarship under subsection (a) for more than three school
years.
[(2) The Secretary may extend the number of school years for
which a scholarship may be awarded to a participant in the
Program who is a part-time student to a maximum of six school
years if the Secretary determines that the extension would be
in the best interest of the United States.]
(2) in the case of a participant in the Program who
is a part-time student, shall bear the same ratio to
the amount that would be paid under paragraph (1) if
the participant were a full-time student in the course
of education or training being pursued by the
participant as the coursework carried by the student
bears to full-time coursework in that course of
education or training.
(c) Limitations on Period of Payment.--(1) The maximum number
of school years for which a scholarship may be paid under
subsection (a) to a participant in the Program shall be six
school years.
(2) A participant in the Program may not receive a
scholarship under subsection (a) for more than the equivalent
of three years of full-time coursework.
* * * * * * *
(e) Full-Time Coursework.--For purposes of this section,
full-time coursework shall consist of the following:
(1) In the case of undergraduate coursework, 30
semester hours per undergraduate school year.
(2) In the case of graduate coursework, 18 semester
hours per graduate school year.
* * * * * * *
[Section 7676 is repealed.]
* * * * * * *
Sec. 7682. Eligibility
* * * * * * *
(a) Eligibility.--An individual is eligible to participate in
the Education Debt Reduction Program if the individual--
(1) is a recently appointed employee in the Veterans
Health Administration serving [under an appointment
under section 7402(b) of this title in a position] in a
position (as determined by the Secretary) providing
direct-patient care services or services incident to
direct-patient care services for which recruitment or
retention of qualified health-care personnel [(as
determined by the Secretary)] (as so determined) is
difficult; and
* * * * * * *
Sec. 7683. Education debt reduction
* * * * * * *
(d) Maximum Annual Amount.--(1) Subject to paragraph (2), the
amount of education debt reduction payments made to a
participant [for a year] under the Education Debt Reduction
Program may not [exceed--
[(A) $6,000 for the first year of the participant's
participation in the Program;
[(B) $8,000 for the second year of the participant's
participation in the Program; and
[(C) $10,000 for the third year of the participant's
participation in the Program.
[(2) The total amount payable to a participant in such
Program for any year may not exceed the amount of the principal
and interest on loans referred to in subsection (a) that is
paid by the individual during such year.] exceed $44,000 over a
total of five years of participation in the Program, of which
not more than $10,000 of such payments may be made in each of
the fourth and fifth years of participation in the Program.
* * * * * * *
[Section 7684 is repealed.]
* * * * * * *
Sec. 8110. Operation of medical facilities
(a)(1) The Secretary shall establish the total number of
hospital beds and nursing home beds in medical facilities over
which the Secretary has direct jurisdiction for the care and
treatment of eligible veterans at not more than 125,000 and not
less than 100,000. The Secretary shall establish the total
number of such beds so as to maintain a contingency capacity to
assist the Department of Defense in time of war or national
emergency to care for the casualties of such war or national
emergency. Of the number of beds authorized pursuant to the
preceding sentence, the Secretary shall operate and maintain a
total of not less than 90,000 hospital beds and nursing home
beds and shall maintain the availability of such additional
beds and facilities in addition to the operating bed level as
the Secretary considers necessary for such contingency
purposes. The President shall include in the Budget transmitted
to the Congress for each fiscal year pursuant to section 1105
of title 31, an amount for medical care and amounts for
construction sufficient to enable the Department to operate and
maintain a total of not less than 90,000 hospital and nursing
home beds in accordance with this paragraph and to maintain the
availability of the contingency capacity referred to in the
second sentence of this paragraph. The Secretary shall staff
and maintain, in such a manner as to ensure the immediate
acceptance and timely and complete care of patients, and in a
manner consistent with the policies of the Secretary on
overtime, sufficient beds and other treatment capacities to
accommodate, and provide such care to, eligible veterans
applying for admission and found to be in need of hospital care
or medical services.
(2) The Secretary shall maintain the bed and treatment
capacities of all Department medical facilities, including the
staffing required to maintain such capacities, so as to ensure
the accessibility and availability of such beds and treatment
capacities to eligible veterans in all States [and to minimize]
to minimize delays in admissions and in the provision of
hospital, nursing home, and domiciliary care, and of medical
services furnished pursuant to section 1710(a) of this title,
and to ensure that eligible veterans are provided such care and
services in an appropriate manner.
(3)(A) The Under Secretary for Health shall at the end of
each fiscal year (i) analyze agencywide admission policies and
the records of those eligible veterans who apply for hospital
care, medical services, and nursing home care, but are rejected
or not immediately admitted or provided such care or services,
and (ii) review and make recommendations regarding the adequacy
of staff levels for compliance with the policy established
under subparagraph (C), the adequacy of the established
operating bed levels, the geographic distribution of operating
beds, the demographic characteristics of the veteran population
and the associated need for medical care and nursing home
facilities and services in each State, and the proportion of
the total number of operating beds that are hospital beds and
that are nursing home beds.
* * * * * * *
(C) The Secretary shall, in consultation with the Under
Secretary for Health, establish a nationwide policy on the
staffing of Department medical facilities in order to ensure
that such facilities have adequate staff for the provision to
veterans of appropriate, high-quality care and services. The
policy shall take into account the staffing levels and mixture
of staff skills required for the range of care and services
provided veterans in Department facilities.
* * * * * * *
TITLE 5, UNITED STATES CODE
* * * * * * *
Sec. 8415. Computation of basic annuity
* * * * * * *
(i) In computing an annuity under this subchapter, the total
service of an employee who retires from the position of a
registered nurse with the Veterans Health Administration on an
immediate annuity, or dies while employed in that position
leaving any survivor entitled to an annuity, includes the days
of unused sick leave to the credit of that employee under a
formal leave system, except that such days shall not be counted
in determining average pay or annuity eligibility under this
subchapter.
* * * * * * *
Sec. 8422. Deductions from pay; contributions for military service
* * * * * * *
(d)(1) Under such regulations as the Office may prescribe,
amounts deducted under subsection (a) shall be entered on
individual retirement records.
(2) Deposit may not be required for days of unused sick leave
credited under section 8415(i).