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                                                       Calendar No. 635
104th Congress                                                   Report
                                 SENATE

 2d Session                                                     104-372
_______________________________________________________________________


 
              VETERANS' MEDICAL PROGRAMS AMENDMENTS OF 1996

                               __________

                              R E P O R T

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                              to accompany

                                S. 1359

 


               September 26, 1996.--Ordered to be printed


                     COMMITTEE ON VETERANS' AFFAIRS

ALAN K. SIMPSON, Wyoming, Chairman
JOHN D. ROCKEFELLER IV, West VirginiaSTROM THURMOND, South Carolina
BOB GRAHAM, Florida                  FRANK H. MURKOWSKI, Alaska
DANIEL K. AKAKA, Hawaii              ARLEN SPECTER, Pennsylvania
PAUL WELLSTONE, Minnesota            JAMES M. JEFFORDS, Vermont
PATTY MURRAY, Washington             BEN NIGHTHORSE CAMPBELL, Colorado
                                     LARRY E. CRAIG, Idaho
 Thomas E. Harvey, Chief Counsel/
          Staff Director
   Jim Gottlieb, Minority Chief 
      Counsel/Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Committee Amendments.............................................     1
Introduction.....................................................    14
Committee meeting................................................    16
Summary of S. 1359 as reported...................................    16
Discussion:
    Title I--Veterans Health Administration:
        Subtitle A--Administration:
            Section 101. Revision of authority to share medical 
              facilities, equipment, and information.............    21
            Section 102. Waiting period for administrative 
              reorganizations....................................    22
            Section 103. Repeal of limitations on contracts for 
              conversion of performance of activities of 
              department health-care facilities..................    22
        Subtitle B--Personnel:
            Section 111. Revision of administrative authorities 
              regarding residencies and internships..............    23
            Section 112. Renumerated outside professional 
              activities by Veterans Health Administration 
              personnel..........................................    23
            Section 113. Authority to waive special pay agreement 
              refund requirements for physicians and dentists who 
              enter into residency training programs.............    24
    Title II--Health Care:
        Subtitle A--Readjustment Counseling:
            Section 201. Organization of the Readjustment 
              Counseling Service in the Department of Veterans 
              Affairs............................................    25
            Section 202. Expansion of eligibility for 
              readjustment counseling and certain related 
              counseling services................................    25
            Section 203. Advisory Committee on the Readjustment 
              of Veterans........................................    26
            Section 204. Report on collocation of Vet Centers and 
              Department of Veterans Affairs outpatient clinics..    26
            Section 205. Report on provision of limited health 
              care services at readjustment counseling centers...    26
        Subtitle B--Other Provisions:
            Sec. 211. Payment to States of per diem for veterans 
              receiving adult day health care....................    27
            Sec. 212. Expanded health care sharing agreement 
              authority..........................................    27
            Sec. 213. Evaluation of health status of spouses and 
              children of Persian Gulf War veterans..............    27
            Sec. 214. Transmittal of reports of Special Committee 
              for the Seriously Mentally Ill Veteran.............    28
    Title III--Health Care Research:
             Section 301. Mental illness research, education, and 
              clinical centers...................................    28
            Section 302. Research corporations...................    30
    Title IV--Hospice Care Services:
            Section 402. Programs for furnishing hospice care to 
              veterans...........................................    31
    Title V--Mammography Standards:
            Section 502. Mammography quality standards...........    33
Cost estimate....................................................    35
Regulatory impact statement......................................    38
Tabulation of votes cast in committee............................    38
Agency reports...................................................    38
Changes in existing law made by S. 1359 as reported..............    54


                                                       Calendar No. 635
104th Congress                                                   Report
                                 SENATE

 2d Session                                                     104-372
_______________________________________________________________________



             VETERANS' MEDICAL PROGRAMS AMENDMENTS OF 1996

                                _______
                                

               September 26, 1996.--Ordered to be printed

_______________________________________________________________________


  Mr. Simpson, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 1359]

    The Committee on Veterans' Affairs, to which was referred 
the bill (S. 1359) to revise certain authorities relating to 
management and contracting in the provision of health care 
services and for other purposes, having considered the same, 
reports favorably thereon with an amendment in the form of a 
substitute and an amendment to the title, and recommends that 
the bill as amended do pass.

                          Committee Amendments

    The amendments are as follows:
    Strike out all after the enacting clause and insert in lieu 
thereof the following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Veterans' Medical 
Programs Amendments of 1996''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. References to title 38, United States Code.

TITLE I--VETERANS HEALTH ADMINISTRATION

                       Subtitle A--Administration

Sec. 101. Revision of authority to share medical facilities, equipment, 
and information.
Sec. 102. Waiting period for administrative reorganizations.
Sec. 103. Repeal of limitations on contracts for conversion of 
performance of activities of department health-care facilities.

                         Subtitle B--Personnel

Sec. 111. Revision of administrative authorities regarding residencies 
and internships.
Sec. 112. Renumerated outside professional activities by Veterans 
Health Administration personnel.
Sec. 113. Authority to waive special pay agreement refund requirements 
for physicians and dentists who enter into residency training programs.

TITLE II--HEALTH CARE

                  Subtitle A--Readjustment Counseling

Sec. 201. Organization of the Readjustment Counseling Service in the 
Department of Veterans Affairs.
Sec. 202. Expansion of eligibility for readjustment counseling and 
certain related counseling services.
Sec. 203. Advisory Committee on the Readjustment of Veterans.
Sec. 204. Report on collocation of Vet Centers and Department of 
Veterans Affairs outpatient clinics.
Sec. 205. Report on provision of limited health care services at 
readjustment counseling centers.

                      Subtitle B--Other Provisions

Sec. 211. Payment to States of per diem for veterans receiving adult 
day health care.
Sec. 212. Expanded health care sharing agreement authority.
Sec. 213. Evaluation of health status of spouses and children of 
Persian Gulf War veterans.
Sec. 214. Transmittal of reports of Special Committee for the Seriously 
Mentally Ill Veteran.

TITLE III--HEALTH CARE RESEARCH

Sec. 301. Mental illness research, education, and clinical centers.
Sec. 302. Research corporations.

TITLE IV--HOSPICE CARE SERVICES

Sec. 401. Short title.
Sec. 402. Programs for furnishing hospice care to veterans.

TITLE V--MAMMOGRAPHY STANDARDS

Sec. 501. Short title.
Sec. 502. Mammography quality standards.

SEC. 2. REFERENCES TO TITLE 38, UNITED STATES CODE.

    Except as otherwise expressly provided, whenever in this Act an 
amendment or repeal is expressed in terms of an amendment to or repeal 
of a section or other provision, the reference shall be considered to 
be made to a section or other provision of title 38, United States 
Code.

                TITLE I--VETERANS HEALTH ADMINISTRATION

                       Subtitle A--Administration

SEC. 101. REVISION OF AUTHORITY TO SHARE MEDICAL FACILITIES, EQUIPMENT, 
                    AND INFORMATION.

    (a) Statement of Purpose.--The text of section 8151 is amended to 
read as follows:
    ``It is the purpose of this subchapter to improve the quality of 
health care provided veterans under this title by authorizing the 
Secretary to enter into agreements with health-care providers in order 
to share health-care resources with, and receive health-care resources 
from, such providers while ensuring no diminution of services to 
veterans. Among other things, it is intended by these means to 
strengthen the medical programs at Department facilities located in 
small cities or rural areas which facilities are remote from major 
medical centers.''.
    (b) Definitions.--Section 8152 is amended--
          (1) by striking out paragraphs (1), (2), and (3) and 
        inserting in lieu thereof the following new paragraphs (1) and 
        (2):
          ``(1) The term `health-care resource' includes hospital care 
        (as that term is defined in section 1701(5) of this title), any 
        other health-care service, and any health-care support or 
        administrative resource.
          ``(2) The term `health-care providers' includes health-care 
        plans and insurers and any organizations, institutions, or 
        other entities or individuals that furnish health-care 
        resources.''; and
          (2) by redesignating paragraph (4) as paragraph (3).
    (c) Authority To Secure Health-Care Resources.--(1) Section 8153 is 
amended--
          (A) by striking out paragraph (1) of subsection (a) and 
        inserting in lieu thereof the following new paragraph (1):
    ``(1) The Secretary, when the Secretary determines it to be 
necessary in order to secure health-care resources which might not 
otherwise be feasibly available or to utilize effectively health-care 
resources, may make arrangements, by contract or other form of 
agreement, for the mutual use, or exchange of use, of health-care 
resources between Department health-care facilities and non-Department 
health-care providers. The Secretary may make such arrangements without 
regard to any law or regulation relating to competitive procedures.''; 
and
          (B) by striking out subsection (e).
    (2)(A) The section heading of such section is amended to read as 
follows:

``Sec. 8153. Sharing of health-care resources''.

    (B) The table of sections at the beginning of chapter 81 is amended 
by striking out the item relating to section 8153 and inserting in lieu 
thereof the following new item:

``8153. Sharing of health-care resources.''.

SEC. 102. WAITING PERIOD FOR ADMINISTRATIVE REORGANIZATIONS.

    Section 510(b) is amended by striking out ``90-day period of 
continuous session of Congress following'' and inserting in lieu 
thereof ``45-day period (30 days of which shall be days during which 
Congress shall have been in continuous session) beginning on''.

SEC. 103. REPEAL OF LIMITATIONS ON CONTRACTS FOR CONVERSION OF 
                    PERFORMANCE OF ACTIVITIES OF DEPARTMENT HEALTH-CARE 
                    FACILITIES.

    Section 8110 is amended by striking out subsection (c).

                         Subtitle B--Personnel

SEC. 111. REVISION OF ADMINISTRATIVE AUTHORITIES REGARDING RESIDENCIES 
                    AND INTERNSHIPS.

    (a) Covered Residents and Interns.--Section 7406(c) is amended by 
striking out ``Department hospital'' each place it appears (other than 
paragraphs (2)(B) and (4)(C)) and inserting in lieu thereof 
``Department facility furnishing hospital care or medical services''.
    (b) Conforming Amendments.--Such section is further amended--
          (1) in paragraph (2)(B), by striking out ``Department 
        hospital'' and inserting in lieu thereof ``Department 
        facility'';
          (2) in paragraph (4), by striking out ``participating 
        hospital, including a Department hospital'' and inserting in 
        lieu thereof ``participating facility, including a Department 
        facility''; and
          (3) in paragraph (5), by striking out ``hospital'' both 
        places it appears and inserting in lieu thereof ``facility''.

SEC. 112. RENUMERATED OUTSIDE PROFESSIONAL ACTIVITIES BY VETERANS 
                    HEALTH ADMINISTRATION PERSONNEL.

    (a) Authority.--Subsection (b) of section 7423 is amended--
          (1) by striking out paragraph (1); and
          (2) by redesignating paragraphs (2) through (6) as paragraphs 
        (1) through (5), respectively.
    (b) Conforming Amendment.--Subsection (c) of such section is 
amended in the matter preceding paragraph (1) by striking out 
``subsection (b)(6)'' and inserting in lieu thereof ``subsection 
(b)(5)''.

SEC. 113. AUTHORITY TO WAIVE SPECIAL PAY AGREEMENT REFUND REQUIREMENTS 
                    FOR PHYSICIANS AND DENTISTS WHO ENTER INTO 
                    RESIDENCY TRAINING PROGRAMS.

    Section 7432(b)(2) is amended--
          (1) by inserting ``(A)'' after ``(2)''; and
          (2) by adding at the end the following:
    ``(B) The Secretary may suspend the applicability of an agreement 
under this subchapter in the case of a physician or dentist who enters 
a residency training program for the period of the participation of the 
physician or dentist, as the case may be, in the program. The physician 
or dentist shall not be subject to the refund requirements with respect 
to the agreement under paragraph (1) during the period of the 
suspension.''.

                         TITLE II--HEALTH CARE

                  Subtitle A--Readjustment Counseling

SEC. 201. ORGANIZATION OF THE READJUSTMENT COUNSELING SERVICE IN THE 
                    DEPARTMENT OF VETERANS AFFAIRS.

    (a) Revision of Organizational Structure.--(1) The Secretary of 
Veterans Affairs may not alter or revise the organizational structure 
or the administrative structure of the organization (known as the 
Readjustment Counseling Service) within the Veterans Health 
Administration created to implement the programs established under 
section 1712A of title 38, United States Code, until--
          (A) the Secretary has submitted to the Committees on 
        Veterans' Affairs of the Senate and the House of 
        Representatives a report containing a full and complete 
        statement of the proposed alteration or revision; and
          (B) a period of 60 days has elapsed after the date on which 
        the report is received by the committees.
    (2) In the computation of the 60-day period under paragraph (1)(B), 
there shall be excluded any day on which either House of Congress is 
not in session because of an adjournment of more than 3 calendar days 
to a day certain.
    (b) Budget Information Relating to the Service.--Each budget 
submitted to Congress by the President under section 1105 of title 31, 
United States Code, shall set forth the amount requested in the budget 
for the operation of the organization referred to in subsection (a)(1) 
in the fiscal year covered by the budget and shall set forth separately 
the amount requested for administrative oversight of the activities of 
the organization.

SEC. 202. EXPANSION OF ELIGIBILITY FOR READJUSTMENT COUNSELING AND 
                    CERTAIN RELATED COUNSELING SERVICES.

    (a) Readjustment Counseling.--(1) Subsection (a) of section 1712A 
is amended to read as follows:
    ``(a)(1)(A) Upon the request of any veteran referred to in 
subparagraph (B) of this paragraph, the Secretary shall furnish 
counseling to the veteran to assist the veteran in readjusting to 
civilian life.
    ``(B) Subparagraph (A) applies to the following veterans:
          ``(i) Any veteran who served on active duty in a theater of 
        combat operations (as determined by the Secretary in 
        consultation with the Secretary of Defense) during the Vietnam 
        era.
          ``(ii) Any veteran who served on active duty during the 
        Vietnam era if the veteran seeks such counseling before January 
        1, 2000.
          ``(iii) Any veteran referred to in clause (ii) of this 
        subparagraph if the veteran is furnished counseling under this 
        subsection before the date referred to in that clause.
          ``(iv) Any veteran who served on active military, naval, or 
        air service in a theater of combat operations (as so 
        determined) during a period of war, or in any other area during 
        a period in which hostilities (as defined in subparagraph (D) 
        of this paragraph) occurred in such area.
    ``(C) Upon the request of any veteran other than a veteran covered 
by subparagraph (A) of this paragraph, the Secretary may furnish 
counseling to the veteran to assist the veteran in readjusting to 
civilian life.
    ``(D) For the purposes of subparagraph (B) of this paragraph, the 
term `hostilities' means an armed conflict in which the members of the 
Armed Forces are subjected to danger comparable to the danger to which 
members of the Armed Forces have been subjected in combat with enemy 
armed forces during a period of war, as determined by the Secretary in 
consultation with the Secretary of Defense.
    ``(2) The counseling referred to in paragraph (1) of this 
subsection shall include a general mental and psychological assessment 
of a covered veteran to ascertain whether such veteran has mental or 
psychological problems associated with readjustment to civilian 
life.''.
    (2) Subsection (c) of such section is repealed.
    (b) Other Counseling.--Such section is further amended by inserting 
after subsection (b) the following new subsection (c):
    ``(c)(1) The Secretary shall provide the counseling services 
described in section 1701(6)(B)(ii) of this title to the surviving 
parents, spouse, and children of any member of the Armed Forces who 
dies--
          ``(A) in a theater of combat operations (as determined by the 
        Secretary in consultation with the Secretary of Defense) while 
        on active military, naval, or air service during a period of 
        war;
          ``(B) in an area in which hostilities (as defined in 
        subsection (a)(1)(D) of this section) are occurring while on 
        such service during such hostilities;
          ``(C) as a result of a disease, injury, or condition incurred 
        while on such service in a theater of combat operations (as so 
        determined)
    ``(2) The Secretary may provide the counseling services referred to 
in paragraph (1) of this subsection to the surviving parents, spouse, 
and children of any member of the Armed Forces who dies while serving 
on active duty or from a condition (as determined by the Secretary) 
incurred in or aggravated by such service.''.
    (c) Authority To Contract for Counseling Services.--Subsection (e) 
of such section is amended by striking out ``subsections (a) and (b)'' 
each place it appears and inserting in lieu thereof ``subsections (a), 
(b), and (c)''.

SEC. 203. ADVISORY COMMITTEE ON THE READJUSTMENT OF VETERANS.

    (a) In General.--(1) Subchapter III of chapter 5 is amended by 
inserting after section 544 the following:

``Sec. 545. Advisory Committee on the Readjustment of Veterans

    ``(a)(1) There is in the Department the Advisory Committee on the 
Readjustment of Veterans (hereinafter in this section referred to as 
the `Committee').
    ``(2) The Committee shall consist of not more than 18 members 
appointed by the Secretary from among individuals who--
          ``(A) have demonstrated significant civic or professional 
        achievement; and
          ``(B) have experience with the provision of veterans benefits 
        and services by the Department.
    ``(3) The Secretary shall seek to ensure that members appointed to 
the Committee include individuals from a wide variety of geographic 
areas and ethnic backgrounds, individuals from veterans service 
organizations, individuals with combat experience, and women.
    ``(4) The Secretary shall determine the terms of service and pay 
and allowances of the members of the Committee, except that a term of 
service may not exceed 2 years. The Secretary may reappoint any member 
for additional terms of service.
    ``(b)(1) The Secretary shall, on a regular basis, consult with and 
seek the advice of the Committee with respect to the provision by the 
Department of benefits and services to veterans in order to assist 
veterans in the readjustment to civilian life.
    ``(2)(A) In providing advice to the Secretary under this 
subsection, the Committee shall--
          ``(i) assemble and review information relating to the needs 
        of veterans in readjusting to civilian life;
          ``(ii) provide information relating to the nature and 
        character of psychological problems arising from service in the 
        Armed Forces;
          ``(iii) provide an on-going assessment of the effectiveness 
        of the policies, organizational structures, and services of the 
        Department in assisting veterans in readjusting to civilian 
        life; and
          ``(iv) provide on-going advice on the most appropriate means 
        of responding to the readjustment needs of veterans in the 
        future.
    ``(B) In carrying out its duties under subparagraph (A), the 
Committee shall take into special account the needs of veterans who 
have served in a theater of combat operations.
    ``(c)(1) Not later than March 31 of each year, the Committee shall 
submit to the Secretary a report on the programs and activities of the 
Department that relate to the readjustment of veterans to civilian 
life. Each such report shall include--
          ``(A) an assessment of the needs of veterans with respect to 
        readjustment to civilian life;
          ``(B) a review of the programs and activities of the 
        Department designed to meet such needs; and
          ``(C) such recommendations (including recommendations for 
        administrative and legislative action) as the Committee 
        considers appropriate.
    ``(2) Not later than 90 days after the receipt of a report under 
paragraph (1), the Secretary shall transmit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives a copy of 
the report, together with any comments and recommendations concerning 
the report that the Secretary considers appropriate.
    ``(3) The Committee may also submit to the Secretary such other 
reports and recommendations as the Committee considers appropriate.
    ``(4) The Secretary shall submit with each annual report submitted 
to the Congress pursuant to section 529 of this title a summary of all 
reports and recommendations of the Committee submitted to the Secretary 
since the previous annual report of the Secretary submitted pursuant to 
that section.
    ``(d)(1) Except as provided in paragraph (2), the provisions of the 
Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the 
activities of the Committee under this section.
    ``(2) Section 14 of such Act shall not apply to the Committee.''.
    (2) The table of sections at the beginning of chapter 5 is amended 
by inserting after the item relating to section 544 the following:

``545. Advisory Committee on the Readjustment of Veterans.''.

    (b) Original Members.--(1) Notwithstanding subsection (a)(2) of 
section 545 of title 38, United States Code (as added by subsection 
(a)), the members of the Advisory Committee on the Readjustment of 
Vietnam and Other War Veterans on the date of the enactment of this Act 
shall be the original members of the advisory committee recognized 
under such section.
    (2) The original members shall so serve until the Secretary of 
Veterans Affairs carries out appointments under such subsection (a)(2). 
The Secretary shall carry out such appointments as soon after such date 
as is practicable. The Secretary may make such appointments from among 
such original members.

SEC. 204. REPORT ON COLLOCATION OF VET CENTERS AND DEPARTMENT OF 
                    VETERANS AFFAIRS OUTPATIENT CLINICS.

    (a) Requirement.--(1) The Secretary of Veterans Affairs shall 
submit to the Committees on Veterans' Affairs of the Senate and the 
House of Representatives a report on the feasibility and desirability 
of the collocation of Vet Centers and outpatient clinics (including 
rural mobile clinics) of the Department of Veterans Affairs as current 
leases for such centers and clinics expire.
    (2) The Secretary shall submit the report not later than 6 months 
after the date of the enactment of this Act.
    (b) Covered Matters.--The report under this section shall include 
an assessment of the following:
          (1) The results of any collocation of Vet Centers and 
        outpatient clinics carried out by the Secretary before the date 
        of the enactment of this Act, including the effects of such 
        collocation on the quality of care provided at such centers and 
        clinics.
          (2) The effect of such collocation on the capacity of such 
        centers and clinics to carry out their primary mission.
          (3) The extent to which such collocation will impair the 
        operational independence or administrative integrity of such 
        centers and clinics.
          (4) The feasibility of combining the services provided by 
        such centers and clinics in the course of such collocation.
          (5) The advisability of the collocation of centers and 
        clinics of significantly different size.
          (6) The effect of the locations (including urban and rural 
        locations) of the centers and clinics on the feasibility and 
        desirability of such collocation.
          (7) The amount of any costs savings to be achieved by 
        Department as a result of such collocation.
          (8) Any other matters that the Secretary determines 
        appropriate.

SEC. 205. REPORT ON PROVISION OF LIMITED HEALTH CARE SERVICES AT 
                    READJUSTMENT COUNSELING CENTERS.

    (a) Report.--Not later than 6 months after the date of the 
enactment of this Act, the Secretary of Veterans Affairs shall submit 
to the Committees on Veterans' Affairs of the Senate and the House of 
Representatives a report on the feasibility and desirability of 
providing a limited battery of health care services (including 
ambulatory services and health care screening services) to veterans at 
Department of Veterans Affairs readjustment counseling centers.
    (b) Report Elements.--The report under subsection (a) shall include 
a discussion of the following:
          (1) The effect on the advisability of providing health care 
        services at readjustment counseling centers of the geographic 
        location of such centers, including the urban location and 
        rural location of such centers and the proximity of such 
        centers to Department of Veterans Affairs medical facilities.
          (2) The effect on the advisability of providing such services 
        at such centers of the type and level of services to be 
        provided, and the demographic characteristics (including age, 
        socio-economic status, ethnicity, and sex) of veterans likely 
        to be provided the services.
          (3) The effect of providing such services at such centers on 
        the readjustment counseling center program in general and on 
        the efficiency and autonomy of the clinical and administrative 
        operations of the readjustment counseling centers in 
        particular.
          (4) Any other matters that the Secretary considers 
        appropriate.

                      Subtitle B--Other Provisions

SEC. 211. PAYMENT TO STATES OF PER DIEM FOR VETERANS RECEIVING ADULT 
                    DAY HEALTH CARE.

    (a) Payment of Per Diem for Veterans Receiving Adult Day Care.--
Section 1741 is amended--
          (1) by inserting ``(1)'' after ``(a)'';
          (2) by redesignating paragraphs (1) and (2) as subparagraphs 
        (A) and (B), respectively; and
          (3) by adding at the end the following new paragraph (2):
    ``(2) The Secretary may pay each State per diem at a rate 
determined by the Secretary for each veteran receiving adult day health 
care in a State home, if such veteran is eligible for such care under 
laws administered by the Secretary.''.
    (b) Assistance to States for Construction of Adult Day Care 
Facilities.--(1) Section 8131(3) is amended by inserting ``adult day 
health,'' before ``or hospital care''.
    (2) Section 8132 is amended by inserting ``adult day health,'' 
before ``or hospital care''.
    (3) Section 8135(b) is amended--
          (A) in paragraph (2)(C), by inserting ``or adult day health 
        care facilities'' after ``domiciliary beds''; and
          (B) in paragraph (3)(A), by inserting ``or construction 
        (other than new construction) of adult day health care 
        buildings'' before the semicolon.

SEC. 212. EXPANDED HEALTH CARE SHARING AGREEMENT AUTHORITY.

    Section 204 of the Veterans Health Care Act of 1992 (Public Law 
102-585; 106 Stat. 4950; 38 U.S.C. 8111 note) is amended by striking 
out ``October 1, 1996'' and inserting in lieu thereof ``December 31, 
1998''.

SEC. 213. EVALUATION OF HEALTH STATUS OF SPOUSES AND CHILDREN OF 
                    PERSIAN GULF WAR VETERANS.

    Section 107(b) of the Persian Gulf War Veterans' Benefits Act 
(title I of Public Law 103-446; 108 Stat. 4652; 38 U.S.C. 1117 note) is 
amended by striking out ``September 30, 1996'' and inserting in lieu 
thereof ``December 31, 1998''.

SEC. 214. TRANSMITTAL OF REPORTS OF SPECIAL COMMITTEE FOR THE SERIOUSLY 
                    MENTALLY ILL VETERAN.

    (a) Transmittal.--Not later than 60 days after the submittal to the 
Under Secretary for Health of the Department of Veterans Affairs of a 
report referred to in subsection (b), the Secretary of Veterans Affairs 
shall transmit to the Committees on Veterans' Affairs of the Senate and 
the House of Representatives a copy of the report, together with the 
comments of the Under Secretary for Health on the report.
    (b) Covered Reports.--Subsection (a) applies to any report 
submitted to the Under Secretary for Health by the Special Committee 
for the Seriously Mentally Ill Veteran as in existence on July 1, 1996.

                    TITLE III--HEALTH CARE RESEARCH

SEC. 301. MENTAL ILLNESS RESEARCH, EDUCATION, AND CLINICAL CENTERS.

    (a) In General.--Subchapter II of chapter 73 is amended by adding 
at the end the following:

``Sec. 7319. Mental illness research, education, and clinical centers

    ``(a) The purpose of this section is to improve the provision of 
health-care services and related counseling services to eligible 
veterans suffering from mental illness, especially mental illness 
related to service-related conditions, through research (including 
research on improving mental health service facilities of the 
Department and on improving the delivery of mental health services by 
the Department), education and training of personnel, and the 
development of improved models and systems for the furnishing of mental 
health services by the Department.
    ``(b)(1) In order to carry out the purpose of this section, the 
Secretary, upon the recommendation of the Under Secretary for Health 
and pursuant to the provisions of this subsection, shall--
          ``(A) designate not more than five health-care facilities of 
        the Department as the locations for a center of research on 
        mental health services, on the use by the Department of 
        specific models for furnishing such services, on education and 
        training, and on the development and implementation of 
        innovative clinical activities and systems of care with respect 
        to the delivery of such services by the Department; and
          ``(B) subject to the appropriation of funds for such purpose, 
        establish and operate such centers at such locations in 
        accordance with this section.
    ``(2) The Secretary shall designate at least one facility under 
paragraph (1) not later than January 1, 1997.
    ``(3) The Secretary shall, upon the recommendation of the Under 
Secretary for Health, ensure that the facilities designated for centers 
under paragraph (1) are located in various geographic regions.
    ``(4) The Secretary may not designate any health-care facility as a 
location for a center under paragraph (1) unless--
          ``(A) the peer review panel established under paragraph (5) 
        has determined under that paragraph that the proposal submitted 
        by such facility as a location for a new center under this 
        subsection is among those proposals which have met the highest 
        competitive standards of scientific and clinical merit; and
          ``(B) the Secretary, upon the recommendation of the Under 
        Secretary for Health, determines that the facility has 
        developed (or may reasonably be anticipated to develop)--
                  ``(i) an arrangement with an accredited medical 
                school which provides education and training in 
                psychiatry and with which the facility is affiliated 
                under which arrangement residents receive education and 
                training in psychiatry through regular rotation through 
                the facility so as to provide such residents with 
                training in the diagnosis and treatment of mental 
                illness;
                  ``(ii) an arrangement with an accredited graduate 
                program of psychology under which arrangement students 
                receive education and training in clinical, counseling, 
                or professional psychology through regular rotation 
                through the facility so as to provide such students 
                with training in the diagnosis and treatment of mental 
                illness;
                  ``(iii) an arrangement under which nursing, social 
                work, counseling, or allied health personnel receive 
                training and education in mental health care through 
                regular rotation through the facility;
                  ``(iv) the ability to attract scientists who have 
                demonstrated creativity and achievement in research--
                          ``(I) into the evaluation of innovative 
                        approaches to the design of mental health 
                        services; or
                          ``(II) into the causes, prevention, and 
                        treatment of mental illness;
                  ``(v) a policymaking advisory committee composed of 
                appropriate mental health-care and research personnel 
                of the facility and of the affiliated school or schools 
                to advise the directors of the facility and the center 
                on policy matters pertaining to the activities of the 
                center during the period of the operation of the 
                center; and
                  ``(vi) the capability to evaluate effectively the 
                activities of the center, including the evaluation of 
                specific efforts to improve the quality and 
                effectiveness of mental health services provided by the 
                Department at or through individual facilities.
    ``(5)(A) In order to provide advice to assist the Under Secretary 
for Health and the Secretary to carry out their responsibilities under 
this section, the official within the Central Office of the Veterans 
Health Administration responsible for mental health and behavioral 
sciences matters shall establish a panel to assess the scientific and 
clinical merit of proposals that are submitted to the Secretary for the 
establishment of new centers under this subsection.
    ``(B) The membership of the panel shall consist of experts in the 
fields of mental health research, education and training, and clinical 
care. Members of the panel shall serve as consultants to the Department 
for a period of no longer than six months.
    ``(C) The panel shall review each proposal submitted to the panel 
by the official referred to in subparagraph (A) and shall submit its 
views on the relative scientific and clinical merit of each such 
proposal to that official.
    ``(D) The panel shall not be subject to the provisions of the 
Federal Advisory Committee Act (5 U.S.C. App.).
    ``(c) Clinical and scientific investigation activities at each 
center established under subsection (b)(1) may compete for the award of 
funding from amounts appropriated for the Department of Veterans 
Affairs medical and prosthetics research account and shall receive 
priority in the award of funding from such account insofar as funds are 
awarded to projects and activities relating to mental illness.
    ``(d) The Under Secretary for Health shall ensure that at least 
three centers designated under subsection (b)(1)(A) emphasize research 
into means of improving the quality of care for veterans suffering from 
mental illness through the development of community-based alternatives 
to institutional treatment for such illness.
    ``(e) The Under Secretary for Health shall ensure that useful 
information produced by the research, education and training, and 
clinical activities of the centers established under subsection (b)(1) 
is disseminated throughout the Veterans Health Administration through 
publications and through programs of continuing medical and related 
education provided through regional medical education centers under 
subchapter VI of chapter 74 of this title and through other means.
    ``(f) The official within the Central Office of the Veterans Health 
Administration responsible for mental health and behavioral sciences 
matters shall be responsible for supervising the operation of the 
centers established pursuant to subsection (b)(1).
    ``(g)(1) There are authorized to be appropriated for the Department 
of Veterans Affairs for the basic support of the research and education 
and training activities of the centers established pursuant to 
subsection (b)(1) the following:
          ``(A) $3,125,000 for fiscal year 1997.
          ``(B) $6,250,000 for each of fiscal years 1998 through 2000.
    ``(2) In addition to the funds available under the authorization of 
appropriations in paragraph (1), the Under Secretary for Health shall 
allocate to such centers from other funds appropriated generally for 
the Department of Veterans Affairs medical care account and the 
Department of Veterans Affairs medical and prosthetics research account 
such amounts as the Under Secretary for Health determines appropriate 
in order to carry out the purposes of this section.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
chapter 73 is amended by adding at the end of the matter relating to 
subchapter II the following:

``7319. Mental illness research, education, and clinical centers.''.

    (c) Reports.--Not later than February 1 of each of 1997, 1998, and 
1999, the Secretary of Veterans Affairs shall submit to the Committees 
on Veterans' Affairs of the Senate and the House of Representatives a 
report on the status and activities during the previous fiscal year of 
the mental illness, research, education, and clinical centers 
established pursuant to section 7319 of title 38, United States Code 
(as added by subsection (a)). Each such report shall contain the 
following:
          (1) A description of--
                  (A) the activities carried out at each center and the 
                funding provided for such activities;
                  (B) the advances made at each center in research, 
                education and training, and clinical activities 
                relating to mental illness in veterans; and
                  (C) the actions taken by the Under Secretary for 
                Health pursuant to subsection (d) of such section (as 
                so added) to disseminate useful information derived 
                from such activities throughout the Veterans Health 
                Administration.
          (2) The Secretary's evaluations of the effectiveness of the 
        centers in fulfilling the purposes of the centers.

SEC 302. RESEARCH CORPORATIONS.

    (a) Renewal of Authority.--Section 7368 is amended by striking out 
``December 31, 1992'' and inserting in lieu thereof ``December 31, 
2000''.
    (b) Clarification of Tax-Exempt Status.--(1) Section 7361(b) is 
amended by striking out ``section 501(c)(3) of''.
    (2) Section 7363(c) is amended by striking out ``section 501(c)(3) 
of''.
    (c) Revised Reporting Requirement.--Subsection (d) of section 7366 
is amended to read as follows:
    ``(d) The Secretary shall submit to the Committees on Veterans' 
Affairs of the Senate and the House of Representatives an annual report 
on the corporations established under this subchapter. The report shall 
set forth the following information:
          ``(1) The location of each corporation.
          ``(2) The amount received by each corporation during the 
        previous year, including--
                  ``(A) the total amount received;
                  ``(B) the amount received from governmental entities;
                  ``(C) the amount received from entities the income of 
                which is exempt from taxation under section 501(c)(3) 
                of the Internal Revenue Code of 1986 (26 U.S.C. 
                501(c)(3));
                  ``(D) the amount received from all other sources; and
                  ``(E) if the amount received from a source referred 
                to in subparagraph (D) exceeded $25,000, information 
                that identifies the source.
          ``(3) The amount expended by each corporation during the 
        year, including--
                  ``(A) the amount expended for salary for research 
                staff and for salary for support staff;
                  ``(B) the amount expended for other direct support of 
                research; and
                  ``(C) if the amount expended with respect to any 
                source exceeded $10,000, information that identifies 
                the source.''.

                    TITLE IV--HOSPICE CARE SERVICES

SEC. 401. SHORT TITLE.

    This title may be cited as the ``Veterans' Hospice Care Services 
Act of 1996''.

SEC. 402. PROGRAMS FOR FURNISHING HOSPICE CARE TO VETERANS.

    (a) Establishment of Programs.--Chapter 17 of title 38, United 
States Code, is amended by adding at the end the following:

  ``Subchapter VII--Hospice Care Pilot Program; Hospice Care Services

``Sec. 1761. Definitions

    ``For the purposes of this subchapter--
          ``(1) The term ``terminally ill veteran'' means any veteran--
                  ``(A) who is (i) entitled to receive hospital care in 
                a medical facility of the Department under section 
                1710(a)(1) of this title, (ii) eligible for hospital or 
                nursing home care in such a facility and receiving such 
                care, (iii) receiving care in a State home facility for 
                which care the Secretary is paying per diem under 
                section 1741 of this title, or (iv) transferred to a 
                non-Department nursing home for nursing home care under 
                section 1720 of this title and receiving such care; and
                  ``(B) who has a medical prognosis (as certified by a 
                Department physician) of a life expectancy of six 
                months or less.
          ``(2) The term `hospice care services' means--
                  ``(A) the care, items, and services referred to in 
                subparagraphs (A) through (H) of section 1861(dd)(1) of 
                the Social Security Act (42 U.S.C. 1395x(dd)(1)); and
                  ``(B) personal care services.
          ``(3) The term ``hospice program'' means any program that 
        satisfies the requirements of section 1861(dd)(2) of the Social 
        Security Act (42 U.S.C. 1395x(dd)(2)).
          ``(4) The term ``medical facility of the Department'' means a 
        facility referred to in section 1701(3)(A) of this title.
          ``(5) The term `non-Department facility' means a facility 
        (other than a medical facility of the Department) at which care 
        to terminally ill veterans is furnished, regardless of whether 
        such care is furnished pursuant to a contract, agreement, or 
        other arrangement referred to in section 1762(b)(1)(D) of this 
        title.
          ``(6) The term `personal care services' means any care or 
        service furnished to a person that is necessary to maintain a 
        person's health and safety within the home or nursing home of 
        the person, including care or services related to dressing and 
        personal hygiene, feeding and nutrition, and environmental 
        support.

``Sec. 1762. Hospice care: pilot program requirements

    ``(a)(1) During the period beginning on October 1, 1996, and ending 
on December 31, 2001, the Secretary shall conduct a pilot program in 
order--
          ``(A) to assess the desirability of furnishing hospice care 
        services to terminally ill veterans; and
          ``(B) to determine the most effective and efficient means of 
        furnishing such services to such veterans.
    ``(2) The Secretary shall conduct the pilot program in accordance 
with this section.
    ``(b)(1) Under the pilot program, the Secretary shall--
          ``(A) designate not less than 15 nor more than 30 medical 
        facilities of the Department at or through which to conduct 
        hospice care services demonstration projects;
          ``(B) designate the means by which hospice care services 
        shall be provided to terminally ill veterans under each 
        demonstration project pursuant to subsection (c);
          ``(C) allocate such personnel and other resources of the 
        Department as the Secretary considers necessary to ensure that 
        services are provided to terminally ill veterans by the 
        designated means under each demonstration project; and
          ``(D) enter into any contract, agreement, or other 
        arrangement that the Secretary considers necessary to ensure 
        the provision of such services by the designated means under 
        each such project.
    ``(2) In carrying out the responsibilities referred to in paragraph 
(1) the Secretary shall take into account the need to provide for and 
conduct the demonstration projects so as to provide the Secretary with 
such information as is necessary for the Secretary to evaluate and 
assess the furnishing of hospice care services to terminally ill 
veterans by a variety of means and in a variety of circumstances.
    ``(3) In carrying out the requirement described in paragraph (2), 
the Secretary shall, to the maximum extent feasible, ensure that--
          ``(A) the medical facilities of the Department selected to 
        conduct demonstration projects under the pilot program include 
        facilities located in urban areas of the United States and 
        rural areas of the United States;
          ``(B) the full range of affiliations between medical 
        facilities of the Department and medical schools is represented 
        by the facilities selected to conduct demonstration projects 
        under the pilot program, including no affiliation, minimal 
        affiliation, and extensive affiliation;
          ``(C) such facilities vary in the number of beds that they 
        operate and maintain; and
          ``(D) the demonstration projects are located or conducted in 
        accordance with any other criteria or standards that the 
        Secretary considers relevant or necessary to furnish and to 
        evaluate and assess fully the furnishing of hospice care 
        services to terminally ill veterans.
    ``(c)(1) Subject to paragraph (2), hospice care to terminally ill 
veterans shall be furnished under a demonstration project by one or 
more of the following means designated by the Secretary:
          ``(A) By the personnel of a medical facility of the 
        Department providing hospice care services pursuant to a 
        hospice program established by the Secretary at that facility.
          ``(B) By a hospice program providing hospice care services 
        under a contract with that program and pursuant to which 
        contract any necessary inpatient services are provided at a 
        medical facility of the Department.
          ``(C) By a hospice program providing hospice care services 
        under a contract with that program and pursuant to which 
        contract any necessary inpatient services are provided at a 
        non-Department medical facility.
    ``(2)(A) The Secretary shall provide that--
          ``(i) care is furnished by the means described in paragraph 
        (1)(A) at not less than five medical facilities of the 
        Department; and
          ``(ii) care is furnished by the means described in 
        subparagraphs (B) and (C) of paragraph (1) in connection with 
        not less than five such facilities for each such means.
    ``(B) The Secretary shall provide in any contract under 
subparagraph (B) or (C) of paragraph (1) that inpatient care may be 
provided to terminally ill veterans at a medical facility other than 
that designated in the contract if the provision of such care at such 
other facility is necessary under the circumstances.
    ``(d)(1) Except as provided in paragraph (2), the amount paid to a 
hospice program for care furnished pursuant to subparagraph (B) or (C) 
of subsection (c)(1) may not exceed the amount that would be paid to 
that program for such care under section 1814(i) of the Social Security 
Act (42 U.S.C. 1395f(i)) if such care were hospice care for which 
payment would be made under part A of title XVIII of such Act.
    ``(2) The Secretary may pay an amount in excess of the amount 
referred to in paragraph (1) (or furnish services whose value, together 
with any payment by the Secretary, exceeds such amount) to a hospice 
program for furnishing care to a terminally ill veteran pursuant to 
subparagraph (B) or (C) of subsection (c)(1) if the Secretary 
determines, on a case-by-case basis, that--
          ``(A) the furnishing of such care to the veteran is necessary 
        and appropriate; and
          ``(B) the amount that would be paid to that program under 
        section 1814(i) of the Social Security Act would not compensate 
        the program for the cost of furnishing such care.

``Sec. 1763. Care for terminally ill veterans

    ``(a) During the period referred to in section 1762(a)(1) of this 
title, the Secretary shall designate not less than 10 medical 
facilities of the Department at which hospital care is being furnished 
to terminally ill veterans in order to furnish the care referred to in 
subsection (b)(1).
    ``(b)(1) Palliative care to terminally ill veterans shall be 
furnished at the facilities referred to in subsection (a) by one of the 
following means designated by the Secretary:
          ``(A) By personnel of the Department providing one or more 
        hospice care services to such veterans at or through medical 
        facilities of the Department.
          ``(B) By personnel of the Department monitoring the 
        furnishing of one or more of such services to such veterans at 
        or through non-Department facilities.
    ``(2) The Secretary shall furnish care by the means referred to in 
each of subparagraphs (A) and (B) of paragraph (1) at not less than 
five medical facilities designated under subsection (a).

``Sec. 1764. Information relating to hospice care services

    ``The Secretary shall ensure to the extent practicable that 
terminally ill veterans who have been informed of their medical 
prognosis receive information relating to the eligibility, if any, of 
such veterans for hospice care and services under title XVIII of the 
Social Security Act (42 U.S.C. 1395 et seq.).

``Sec. 1765. Evaluation and reports

    ``(a) Not later than September 30, 1997, and on an annual basis 
thereafter until October 1, 2002, the Secretary shall submit a written 
report to the Committees on Veterans' Affairs of the Senate and House 
of Representatives relating to the conduct of the pilot program under 
section 1762 of this title and the furnishing of hospice care services 
under section 1763 of this title. Each report shall include the 
following information:
          ``(1) The location of the sites of the demonstration projects 
        provided for under the pilot program.
          ``(2) The location of the medical facilities of the 
        Department at or through which hospice care services are being 
        furnished under section 1763 of this title.
          ``(3) The means by which care to terminally ill veterans is 
        being furnished under each such project and at or through each 
        such facility.
          ``(4) The number of veterans being furnished such care under 
        each such project and at or through each such facility.
          ``(5) An assessment by the Secretary of any difficulties in 
        furnishing such care and the actions taken to resolve such 
        difficulties.
    ``(b) Not later than August 1, 2000, the Secretary shall submit to 
the committees referred to in subsection (a) a report containing an 
evaluation and assessment by the Under Secretary for Health of the 
hospice care pilot program under section 1762 of this title and the 
furnishing of hospice care services under section 1763 of this title. 
The report shall contain such information (and shall be presented in 
such form) as will enable the committees to evaluate fully the 
desirability of furnishing hospice care services to terminally ill 
veterans.
    ``(c) The report under subsection (b) shall include the following:
          ``(1) A description and summary of the pilot program.
          ``(2) With respect to each demonstration project conducted 
        under the pilot program--
                  ``(A) a description and summary of the project;
                  ``(B) a description of the facility conducting the 
                demonstration project and a discussion of how such 
                facility was selected in accordance with the criteria 
                set out in, or prescribed by the Secretary pursuant to, 
                subparagraphs (A) through (D) of section 1762(b)(3) of 
                this title;
                  ``(C) the means by which hospice care services care 
                are being furnished to terminally ill veterans under 
                the demonstration project;
                  ``(D) the personnel used to furnish such services 
                under the demonstration project;
                  ``(E) a detailed factual analysis with respect to the 
                furnishing of such services, including (i) the number 
                of veterans being furnished such services, (ii) the 
                number, if any, of inpatient admissions for each 
                veteran being furnished such services and the length of 
                stay for each such admission, (iii) the number, if any, 
                of outpatient visits for each such veteran, and (iv) 
                the number, if any, of home-care visits provided to 
                each such veteran;
                  ``(F) the direct costs, if any, incurred by 
                terminally ill veterans, the members of the families of 
                such veterans, and other individuals in close 
                relationships with such veterans in connection with the 
                participation of veterans in the demonstration project;
                  ``(G) the costs incurred by the Department in 
                conducting the demonstration project, including an 
                analysis of the costs, if any, of the demonstration 
                project that are attributable to (i) furnishing such 
                services in facilities of the Department, (ii) 
                furnishing such services in non-Department facilities, 
                and (iii) administering the furnishing of such 
                services; and
                  ``(H) the unreimbursed costs, if any, incurred by any 
                other entity in furnishing services to terminally ill 
                veterans under the project pursuant to section 
                1762(c)(1)(C) of this title.
          ``(3) An analysis of the level of the following persons' 
        satisfaction with the services furnished to terminally ill 
        veterans under each demonstration project:
                  ``(A) Terminally ill veterans who receive such 
                services, members of the families of such veterans, and 
                other individuals in close relationships with such 
                veterans.
                  ``(B) Personnel of the Department responsible for 
                furnishing such services under the project.
                  ``(C) Personnel of non-Department facilities 
                responsible for furnishing such services under the 
                project.
          ``(4) A description and summary of the means of furnishing 
        hospice care services at or through each medical facility of 
        the Department designated under section 1763(a) of this title.
          ``(5) With respect to each such means, the information 
        referred to in paragraphs (2) and (3).
          ``(6) A comparative analysis by the Under Secretary for 
        Health of the services furnished to terminally ill veterans 
        under the various demonstration projects referred to in section 
        1762 of this title and at or through the designated facilities 
        referred to in section 1763 of this title, with an emphasis in 
        such analysis on a comparison relating to--
                  ``(A) the management of pain and health symptoms of 
                terminally ill veterans by such projects and 
                facilities;
                  ``(B) the number of inpatient admissions of such 
                veterans and the length of inpatient stays for such 
                admissions under such projects and facilities;
                  ``'(C) the number and type of medical procedures 
                employed with respect to such veterans by such projects 
                and facilities; and
                  ``(D) the effectiveness of such projects and 
                facilities in providing care to such veterans at the 
                homes of such veterans or in nursing homes.
          ``(7) An assessment by the Under Secretary for Health of the 
        desirability of furnishing hospice care services by various 
        means to terminally ill veterans, including an assessment by 
        the Director of the optimal means of furnishing such services 
        to such veterans.
          ``(8) Any recommendations for additional legislation 
        regarding the furnishing of care to terminally ill veterans 
        that the Secretary considers appropriate.''.
    (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is amended by adding at the end the following:

  ``Subchapter VII--Hospice Care Pilot Program; Hospice Care Services

``1761. Definitions.
``1762. Hospice care: pilot program requirements.
``1763. Care for terminally ill veterans.
``1764. Information relating to hospice care services.
``1765. Evaluation and reports.''.

    (c) Authority To Carry Out Other Hospice Care Programs.--The 
amendments made by subsection (a) may not be construed as terminating 
the authority of the Secretary of Veterans Affairs to provide hospice 
care services to terminally ill veterans under any program in addition 
to the programs required under the provisions added by such amendments.
    (d) Authorization of Appropriations.--Funds are authorized to be 
appropriated for the Department of Veterans Affairs for the purposes of 
carrying out the evaluation of the hospice care pilot programs under 
section 1765 of title 38, United States Code (as added by subsection 
(a)), as follows:

          (1) For fiscal year 1997, $1,200,000.
          (2) For fiscal year 1998, $2,500,000.
          (3) For fiscal year 1999, $2,200,000.
          (4) For fiscal year 2000, $100,000.

                     TITLE V--MAMMOGRAPHY STANDARDS

SEC. 501. SHORT TITLE.

    This title may be cited as the ``Women Veterans' Mammography 
Quality Standards Act''.

SEC. 502. MAMMOGRAPHY QUALITY STANDARDS.

    (a) Performance of Mammograms.--Mammograms may not be performed at 
a Department of Veterans Affairs facility unless that facility is 
accredited for that purpose by a private nonprofit organization 
designated by the Secretary of Veterans Affairs. The organization 
designated by the Secretary under this subsection shall meet the 
standards for accrediting bodies established by the Secretary of Health 
and Human Services under section 354(e) of the Public Health Service 
Act (42 U.S.C. 263b(e)).
    (b) Quality Standards.--(1) Not later than 120 days after the date 
of the enactment of this Act, the Secretary of Veterans Affairs shall 
prescribe quality assurance and quality control standards relating to 
the performance and interpretation of mammograms and use of mammogram 
equipment and facilities by personnel of the Department of Veterans 
Affairs. Such standards shall be no less stringent than the standards 
prescribed by the Secretary of Health and Human Services under section 
354(f) of the Public Health Service Act.
    (2) The Secretary of Veterans Affairs shall prescribe standards 
under this subsection in consultation with the Secretary of Health and 
Human Services.
    (c) Inspection of Department Equipment.--(1) The Secretary of 
Veterans Affairs shall, on an annual basis, inspect the equipment and 
facilities utilized by and in Department of Veterans Affairs health-
care facilities for the performance of mammograms in order to ensure 
the compliance of such equipment and facilities with the standards 
prescribed under subsection (b). Such inspection shall be carried out 
in a manner consistent with the inspection of certified facilities by 
the Secretary of Health and Human Services under section 354(g) of the 
Public Health Service Act.
    (2) The Secretary of Veterans Affairs may not delegate the 
responsibility of such Secretary under paragraph (1) to a State agency.
    (d) Application of Standards to Contract Providers.--The Secretary 
of Veterans Affairs shall ensure that mammograms performed for the 
Department of Veterans Affairs under contract with any non-Department 
facility or provider conform to the quality standards prescribed by the 
Secretary of Health and Human Services under section 354 of the Public 
Health Service Act.
    (e) Report.--(1) The Secretary of Veterans Affairs shall submit to 
the Committees on Veterans' Affairs of the Senate and House of 
Representatives a report on the quality standards prescribed by the 
Secretary under subsection (b)(1).
    (2) The Secretary shall submit the report not later than 180 days 
after the date on which the Secretary prescribes such regulations.
    (f) Definition.--In this section, the term ``mammogram'' shall have 
the meaning given such term in section 354(a)(5) of the Public Health 
Service Act (42 U.S.C. 263b(a)).


    Amend the title to read as follows:

    ``To amend title 38, United States Code, to improve the provision 
of health care services to veterans by the Department of Veterans 
Affairs, and for other purposes.''.

                              Introduction

    On October 24, 1995, the Chairman of the Committee, Senator 
Alan K. Simpson, introduced S. 1359, which would have revised 
certain authorities relating to management and contracting in 
the provision of health care services by the Department of 
Veterans Affairs (VA).
    On January 30, 1995, Senator Kent Conrad introduced S. 293 
with the cosponsorship of Senators Thomas A. Daschle, Byron L. 
Dorgan, and Claiborne Pell, and Committee members Daniel K. 
Akaka, James M. Jeffords, and Bob Graham, which would have 
authorized the payment to States of per diem for veterans 
receiving adult day health care in State facilities.
    On February 14, 1995, Senator Akaka introduced S. 403 with 
the cosponsorship of Senator Daschle, Senator Wellstone, 
Senator Daniel K. Inouye, and Senator Jeffords, which would 
have modified authorities relating to the organization and 
administration of VA's Readjustment Counseling Service, and 
would have modified eligibility for readjustment and related 
counseling services.
    On February 15, 1995, the Ranking Minority Member of the 
Committee, Senator John D. Rockefeller IV, introduced S. 425 
with the cosponsorship of Senator Akaka, Committee member Ben 
Nighthorse Campbell, Senator Dorgan, and Senator Wellstone, 
which would have required the establishment in VA of mental 
illness research, education, and clinical centers.
    On March 14, 1995, Senator Rockefeller introduced S. 548, 
which would have required VA to adopt quality standards with 
respect to the provision of mammography services.
    On March 24, 1995, Senator Rockefeller introduced S. 612 
with the cosponsorship of Senator Daschle and Committee members 
Bob Graham and Frank H. Murkowski, which would have established 
in VA a pilot program to provide hospice care services to 
terminally ill veterans.
    On March 29, 1995, Committee member Campbell introduced S. 
644 with the cosponsorship of Senator Hank Brown and Committee 
member Akaka, which would have reauthorized the establishment 
of research corporations in the VA's Veterans Health 
Administration (VHA).
    On May 13, 1996, Senator Simpson introduced several bills 
at the request of the administration, including S. 1750, which 
would have modified VA's disbursement agreement authority so 
that compensation to medical residents and interns serving in 
any VA health care facility would be included within that 
authority; S. 1752, which would have exempted full-time 
registered nurses, physician assistants, and expanded-function 
dental auxiliaries from restrictions on remunerated outside 
professional activities; and S. 1753, which would have expanded 
the VA's authority to suspend special pay agreements so that 
such agreements might be waived with respect to physicians and 
dentists who enter residency training programs.
    On May 11, 1995, the Committee on Veterans' Affairs held a 
hearing on a proposal to reorganize VHA, and on potential 
modifications to the ``waiting period'' requirement of 38 
U.S.C. Sec. 510 which later became a portion of S. 1359, as 
introduced. The Committee received testimony from the Honorable 
Kenneth W. Kizer, M.D., M.P.H., Under Secretary for Health, 
Department of Veterans Affairs, accompanied by Thomas L. 
Garthwaite, M.D., Deputy Under Secretary for Health; Jule 
Moravec, Ph.D., Associate Chief Medical Director for 
Operations; Kenneth J. Clark, Director, West Los Angeles VA 
Medical Center, and Chair, Board of Directors, Southern 
California and Nevada Directors Association; and Robert E. Coy, 
Deputy General Counsel. Testimony was also submitted for the 
hearing record by the Air Force Sergeants Association, The 
American Legion, Vietnam Veterans of America, Nurses 
Organization of Veterans Affairs, National Association of VA 
Physicians and Dentists, and the American Psychological 
Association.
    On October 25, 1995, the Committee held a hearing on, among 
other things, S. 1359, S. 293, S. 403, S. 425, S. 548, S. 612, 
and S. 644. The Committee received testimony from the Honorable 
Kenneth W. Kizer, M.D., M.P.H., Under Secretary for Health, 
Department of Veterans Affairs, accompanied by the Honorable 
Mary Lou Keener, General Counsel, Department of Veterans 
Affairs. Testimony was also received from The American Legion, 
Veterans of Foreign Wars, Disabled American Veterans, and 
Paralyzed Veterans of America.
    On May 23, 1996, the Committee held a hearing on, among 
other things, S. 1750, S. 1752, and S. 1753. Testimony was 
received from the Honorable Frank Q. Nebeker, Chief Judge, 
Court of Veterans Appeals; the Honorable Charles L. Cragin, 
Chairman, Board of Veterans' Appeals, Department of Veterans 
Affairs, accompanied by Jule D. Moravec, Ph.D., Chief Network 
Officer, Veterans Health Administration; Mr. J. Gary Hickman, 
Director, Compensation and Pension Service, Veterans Benefits 
Administration; Mr. Keith R. Pedigo, Director, Loan Guaranty 
Service, Veterans Benefits Administration; and Mr. Robert E. 
Coy, Deputy General Counsel, Department of Veterans Affairs. 
Testimony was also received from representatives of The 
American Legion, Veterans of Foreign Wars, Disabled American 
Veterans, Paralyzed Veterans of America, Vietnam Veterans of 
America, Nurses Organization of Veterans Affairs, National 
Association of VA Physicians and Dentists, National 
Organization of Veterans' Advocates, and the Advisory 
Committee, Veterans Consortium Pro Bono Program. In addition, 
testimony was submitted for the hearing record by the Honorable 
Preston M. Taylor, Jr., Assistant Secretary of Labor for 
Veterans' Employment and Training, and by the Non Commissioned 
Officers Association of the United States.

                           Committee Meeting

    After carefully reviewing the testimony from the foregoing 
hearings, the Committee met in open session on July 24, 1996, 
and voted unanimously to report S. 1359 with an amendment in 
the nature of a substitute that includes provisions from S. 
1359, as introduced and amended, S. 293, S. 403, S. 425, S. 
548, S. 612, S. 644, S. 1750, S. 1752, and S. 1753, as well as 
original provisions extending expiring authorities relating to 
VA's authority to provide reimbursed medical care to Department 
of Defense beneficiaries and VA evaluations of the health 
status of Persian Gulf veterans, and requiring that VA transmit 
to the Congress a report concerning mentally ill veterans.

                     Summary of S. 1359 as Reported

    S. 1359 as reported (hereinafter referred to as the 
``Committee bill'') consists of five titles summarized below 
that would affect various changes in the administration and 
personnel practices of VHA; would modify existing authorities 
relating to the Readjustment Counseling Service and make other 
modifications and extensions relating to the provision of 
health care by VA; would establish mental illness research, 
education, and clinical centers and reopen VA authority to 
establish research corporations; would establish a pilot 
program for the provision of hospice care services; and would 
establish standards for the provision of mammography services 
by VA.

                TITLE I--VETERANS HEALTH ADMINISTRATION

    Title I contains amendments to title 38, United States 
Code, that would:
    1. Expand the authority of the Department of Veterans 
Affairs (VA) to enter into agreements with other health care 
providers to share VA health care resources with such 
providers, and to procure health care resources from such 
providers (section 101).
    2. Modify the time period during which VA is barred from 
implementing certain administrative reorganizations (section 
102).
    3. Repeal limitations now in force with respect to 
contracts for the performance of VA employee-performed 
activities (section 103).
    4. Amend terminology referring to VA ``hospitals'' so as to 
expand the sites where medical residents and interns can 
provide services to VA under disbursement agreements with 
medical schools and community hospitals (section 111).
    5. Repeal the bar to remunerated outside professional 
activities by VA health care professionals (section 112).
    6. Authorize the temporary waiving of special pay refund 
obligations when VA physicians or dentists enter into residency 
training programs (section 113).

                         TITLE II--HEALTH CARE

    Title II contains freestanding provisions and amendments to 
title 38, United States Code, that would:
    1. Require the filing of a report before an organizational 
or administrative restructuring of the VA's Readjustment 
Counseling Service (RCS) could be undertaken (section 201(a)).
    2. Require that VA annual budget submissions contain a 
separate ``line item'' delineating funds requested for RCS 
operations and administration (section 201(b)).
    3. Require that VA provide readjustment counseling services 
to: (a) any veteran who served on active duty in a theater of 
combat operations during the Vietnam era; (b) any veteran who 
served on active duty during the Vietnam era if the veteran 
seeks, or has sought, such counseling before January 1, 2000; 
(c) any veteran who served on active duty in a theater of 
combat operations during any period of war; and (d) any veteran 
who served on active duty in an area other than a theater of 
combat operations if that area is determined by VA to have been 
an area in which hostilities occurred (section 202(a)).
    4. Authorize VA to provide readjustment counseling services 
to other veterans, upon their request, to assist the veteran in 
readjusting to civilian life (section 202(a)).
    5. Require that VA provide counseling services to the 
surviving parents, spouse, and children of any member of the 
Armed Forces who dies in a theater of combat operations or area 
of hostilities, or as a result of a disease, injury, or 
condition incurred while in service in a theater of combat 
operations (section 202(b)).
    6. Authorize VA to provide counseling services to the 
surviving parents, spouse, and children of any member of the 
Armed Forces who dies while serving on active duty or from a 
condition incurred in or aggravated by such service (section 
202(b)).
    7. Establish an Advisory Committee on the Readjustment of 
Veterans to advise the VA on the readjustment needs of 
veterans, the nature and character of psychological problems 
arising from service, and the effectiveness of VA policies, 
organizational structures, and services, in providing for the 
readjustment needs of veterans (section 203).
    8. Require VA to report on the feasibility and desirability 
of collocating Readjustment Counseling Service Vet Centers and 
VA outpatient clinics (section 204).
    9. Require VA to report on the feasibility and desirability 
of providing limited health care services at VA readjustment 
counseling centers (section 205).
    10. Authorize VA to make per diem payments to States which 
provide adult day health care services to veterans in State 
homes if the veteran beneficiaries of such services are 
eligible for such services at VA (section 211(a)).
    11. Authorize VA to furnish assistance to States in the 
construction or acquisition of facilities to provide adult day 
health care services (section 211(b)).
    12. Extend until December 31, 1998, authority under which 
VA and the Department of Defense (DOD) enter into ``sharing 
agreements'' under which VA provides health care services, for 
reimbursement, to persons eligible for such services at DOD, or 
DOD-contractor, facilities (section 212).
    13. Extend until December 31, 1998, the requirement that VA 
conduct a study to evaluate the health status of spouses and 
children of Persian Gulf War veterans (section 213).
    14. Require VA to submit to the Congress any report 
submitted to the VA's Under Secretary of Health by VA's Special 
Committee for the Seriously Mentally Ill Veteran (section 214).

                    TITLE III--HEALTH CARE RESEARCH

    Title III contains amendments to title 38, United States 
Code, that would:
    1. Require the VA Secretary to designate not more than five 
VA health care facilities as locations for mental illness 
research, education, and clinical centers (MIRECCs), with at 
least one to be designated by January 1, 1997 (section 301(a)).
    2. Provide that, to qualify for designation, a facility 
must demonstrate that it can: (1) maintain arrangements with an 
accredited medical school which provides training in 
psychiatry, and with a graduate program of psychology, under 
which residents and students receive training and education 
through regular rotation at the VA facility; (2) maintain an 
arrangement under which nursing, social work, or other allied 
health personnel receive training and education in mental 
health at the VA facility; (3) attract the participation of 
scientists who have demonstrated creativity and achievement in 
mental illness research and treatment; (4) maintain a 
policymaking advisory committee composed of VA mental health 
staff and research representatives from the affiliated schools; 
and (5) effectively conduct evaluations of the activities of 
the center (section 301(a)).
    3. Provide that a peer review panel be used to determine 
the location of such centers so as to ensure that any such 
center meets the highest competitive standards of scientific 
and clinical merit prior to selection by the Secretary (section 
301(a)).
    4. Require the Secretary to ensure that the sites selected 
are located in various geographic areas (section 301(a)).
    5. Require that at least three of the five centers 
emphasize the development of community-based alternatives to 
institutional treatment (section 301(a)).
    6. Authorize the appropriation of $3.125 million for fiscal 
year 1997, and $6.25 million for each of fiscal years 1998, 
1999, and 2000 for MIRECCs (section 301(a)).
    7. Require VA to submit reports to Congress during 1997, 
1998, and 1999 concerning the activities of MIRECCs (section 
301(c)).
    8. Reauthorize, through December 31, 2000, the 
establishment of nonprofit corporations at VA medical centers 
to provide for a flexible funding mechanism for the conduct of 
approved research at the medical center (section 302(a)).
    9. Revise the contents of reports which VA is required to 
submit to the Congress annually with respect to such nonprofit 
corporations (section 302(c)).

                    TITLE IV--HOSPICE CARE SERVICES

    Title IV contains freestanding provisions and amendments to 
title 38, United States Code, that would:
    1. Require VA, during the period October 1, 1996-December 
31, 2001, to conduct a pilot program to assess the feasibility 
and desirability of furnishing hospice care services to 
terminally ill veterans, and determine the most efficient and 
effective means of furnishing such services (section 402(a)).
    2. Require VA to furnish hospice care services under the 
pilot program to any veteran who has a life expectancy of 6 
months or less (as certified by a VA physician), and who is (a) 
entitled to VA hospital care, (b) eligible for and receiving VA 
hospital or nursing home care, (c) eligible for and receiving 
care in a community nursing home under a VA contract, or (d) 
eligible for and receiving care in a State veterans home for 
which VA is making per diem payments to offset the costs of 
that care (section 402(a)).
    3. Specify that the hospice care services that VA must 
provide to veterans under the pilot program are: (a) the 
services to which Medicare beneficiaries are entitled; and (b) 
personal care services, including care or services relating to 
dressing, personal hygiene, feeding, and housekeeping (section 
402(a)).
    4. Require VA to establish hospice care demonstration 
projects that would provide these services at not fewer than 
15, but not more than, 30 VA medical centers by one of three 
means: (a) a hospice operated by the VA medical center; (b) a 
non-VA hospice under contract with a VA medical center, which 
VA medical center furnishes necessary inpatient services; or 
(c) a non-VA hospice under contract with a VA medical center, 
which non-VA facility furnishes necessary inpatient services 
(section 402(a)).
    5. Require that each of the three means for furnishing 
hospice care services be used at not fewer than five VA medical 
centers (section 402(a)).
    6. Require that VA ensure, to the maximum extent feasible, 
that VA medical centers selected to conduct demonstration 
projects under the pilot program include facilities that: (a) 
are located in urban areas and rural areas; (b) encompass the 
full range of affiliations between VA medical centers and 
medical schools; (c) operate and maintain various numbers of 
beds; and (d) meet any additional criteria or standards that 
the Secretary may deem relevant or necessary (section 402(a)).
    7. Provide that the amount paid by VA to a non-VA hospice 
under a hospice care services contract generally not exceed the 
amount that would be paid to that hospice under the Medicare 
hospice benefit, and authorize VA to pay an amount in excess of 
the Medicare reimbursement rate if VA determines, on a case by 
case basis, that the Medicare rate would not adequately 
compensate the hospice for the costs associated with furnishing 
necessary care to a terminally ill veteran (section 402(a)).
    8. Require VA to designate not fewer than 10 VA medical 
centers that furnish less comprehensive hospice services than 
those which would be provided by the pilot program VA medical 
centers to serve as a ``control group'' (section 402(a)).
    9. Require VA to ensure, to the maximum extent practicable, 
that terminally ill veterans receive information regarding 
their eligibility (if any) for Medicare's hospice care benefit 
(section 402(a)).
    10. Require VA, not later than September 30, 1997, and on 
an annual basis thereafter until October 1, 2002, to submit 
periodic written reports to Congress on the pilot hospice care 
program (section 402(a)).
    11. Require the Director of VA's Health Services Research 
and Development Service, not later than August 1, 2000, to 
submit to Congress a detailed report on the pilot program, 
including an assessment of the feasibility and desirability of 
furnishing hospice care services to terminally ill veterans, an 
assessment of the optimal means of furnishing such services, 
and recommendations, if any, for additional legislation 
regarding such care (section 402(a)).
    12. Clarify that the pilot program would not preclude VA 
from furnishing hospice care services at VA medical centers not 
participating in the pilot program or the control group 
(section 402(c)).
    13. Authorize the appropriation of funds to cover costs 
associated with the evaluation of the pilot program in the 
following amounts: (a) $1.2 million for FY 1997; (b) $2.5 
million for FY 1998; (c) $2.2 million for FY 1999; and (d) 
$100,000 for FY 2000 (section 402(d)).

                     TITLE V--MAMMOGRAPHY STANDARDS

    Title V contains freestanding provisions that would:
    1. Require that all VA facilities that perform mammography 
be accredited by a private nonprofit organization designated by 
VA, and require that the designated organization be one that 
meets standards for accrediting bodies that are no less 
stringent than those established by the Department of Health 
and Human Services (HHS) pursuant to the Mammography Quality 
Standards Act of 1992 (section 502(a)).
    2. Require VA, in consultation with HHS, to issue quality 
assurance and quality control standards for mammography 
services furnished in VA facilities that would be no less 
stringent than the HHS regulations to which other mammography 
providers are subject under the Mammography Quality Standards 
Act of 1992 (section 502(b)).
    3. Require VA to issue such regulations not later than 120 
days after HHS issues regulations to implement the Mammography 
Quality Standards Act of 1992 (section 502(b)).
    4. Require VA to inspect mammography equipment operated by 
VA facilities on an annual basis in a manner consistent with 
requirements contained in the Mammography Quality Standards Act 
of 1992, except that VA would not have the authority to 
delegate inspection responsibilities to a State agency (section 
502(c)).
    5. Require VA health care facilities that provide 
mammography through contracts with non-VA facilities contract 
only with facilities that comply with HHS mammography quality 
assurance and quality control regulations (section 502(d)).
    6. Require VA, not later than 180 days after it prescribes 
mammography quality assurance and quality control regulations, 
to submit a report to Congress on the implementation of those 
regulations (section 502(e)).

                               Discussion

                TITLE I--VETERANS HEALTH ADMINISTRATION

    Title I of the Committee bill, which is derived from S. 
1359 as introduced, and from S. 1750, S. 1752, and S. 1753, 
would modify certain administrative requirements and personnel 
policies under which VA now operates.

                       Subtitle A--Administration

Sec. 101. Revision of authority to share Medical facilities, equipment, 
        and information

    Under section 8153 of title 38, United States Code, VA is 
authorized to enter into sharing agreements, contracts, or 
other arrangements under which VA purchases or otherwise 
procures medical resources from community providers and shares 
VA medical resources with such providers. Such agreements allow 
both VA medical centers and community providers to provide 
medical care to their respective patient populations more 
efficiently by avoiding wasteful duplication of equipment and 
services within a local community.
    VA sharing authority is significantly restricted in scope. 
For example, under section 8153, VA may only share ``medical 
resources,'' and not, for example, risk assessment, accounting, 
or other nonmedical services it might need or be able to share 
with other providers. In addition, the ``medical resources'' 
that VA may procure or share must be ``specialized'' medical 
resources, a limitation which gives rise to questions 
concerning what resources are themselves sufficiently 
``specialized'' to fall within section 8153's scope and whether 
certain resources within a particular community or setting 
might be ``specialized'' in that setting and not in others. 
Finally, VA may only enter into sharing agreements with 
``health-care facilities (including organ banks, blood banks, 
or similar institutions), research centers, or medical 
schools.'' Other potential sharing partners--for example, 
health maintenance organizations, insurance carriers, 
individual physicians, or other individual care providers--are 
not included within section 8153's definition, thereby 
precluding VA medical centers from entering into sharing 
agreements with such organizations or individuals.
    Section 101 of the Committee bill would ease these various 
restrictions by authorizing VA to enter into agreements with 
any non-VA health care provider for the mutual use or exchange 
of use of any health care resources. The Committee's intention 
is to strengthen VA's capabilities, especially in VA medical 
facilities in smaller cities and rural areas, to provide care 
to veterans.

Sec. 102. Waiting period for administrative reorganizations

    VA has broad authority to organize its personnel and 
operations as it deems advisable for the efficient and timely 
delivery of services to veterans. However, that authority is 
not unlimited. Before VA may proceed to implement an 
``administrative reorganization'' as defined in section 510 of 
title 38, United States Code, it must first give notice to 
Congress and then wait until 90 days of continuous session have 
passed. (Continuity of session is broken by adjournment sine 
die. In computing the number of days of session, any day in 
which either House of Congress is not in session for an 
adjournment of more than 3 days is not counted.) An 
``administrative reorganization'' which is subject to this 
``notice and wait'' requirement is one in which there would be, 
in a particular fiscal year, full-time staff reductions at a 
covered field office or facility of 15 percent or more, or by a 
percent which, when added to the percent reductions (if any) 
made in the preceding fiscal year, is 25 percent or more.
    The Committee has concluded that a 90-day waiting period, 
as defined by section 510(b), is longer than necessary to 
ensure that Congress receives adequate notice of, and has time 
to respond to, reorganizations that would significantly alter 
employment patterns in VA field facilities. Section 102 of the 
Committee bill would, therefore, reduce the waiting period to 
45 days, 30 days of which are days within which Congress shall 
have been in continuous session as defined in current law.

Sec. 103. Repeal of limitations on contracts for conversion of 
        performance of activities of Department health-care facilities

    As discussed above, VA currently has authority to enter 
into ``sharing agreements'' which allow it to procure ``medical 
resources'' from other health care providers in the community. 
That authority, which currently allows a VA medical center to 
purchase a wide range of services, for example, anesthesiology 
services, from community providers, and this authority would be 
expanded under section 101 of the Committee bill. Nonetheless, 
section 8110(c) of title 38, United States Code, bars VA 
medical centers from converting any VA ``direct patient care 
activity'' or any ``activity incident to direct patient care'' 
to an activity carried out by a non-VA entity; and it allows 
other activities at a VA medical center to be ``contracted 
out,'' but only in accordance with procedures and limitations 
specified in section 8110(c).
    Section 1103 of Public Law 103-446 suspended the operation 
of section 8110(c) for fiscal years 1995 through 1999. This 
action was taken in conjunction with the enactment of a 
limitation on the effect of government-wide personnel 
reductions on VA's staff. In so doing, Congress recognized that 
VA medical centers needed the ability to convert some functions 
as part of the overall reductions in government staffing. As is 
recognized by the policy underlying the amendments to VA's 
sharing authority, VA facilities must have the ability to 
procure services from other community sources when such sources 
can provide them more efficiently than VA can on an ``in-
house'' basis. By such arrangements, efficiencies of scale can 
be achieved by the seller, thereby yielding lower costs to the 
buyer and the stretching of limited VA resources.
    These considerations have not changed since enactment of 
the suspension of section 8110(c) by Public Law 103-446. Nor 
are they likely to change for the foreseeable future. Section 
103 of the Committee bill, therefore, would repeal section 
8110(c).

                         Subtitle B--Personnel

Sec. 111. Revision of administrative authorities regarding residencies 
        and internships

    Physicians in training (residents and interns) at medical 
schools with which VA medical centers are affiliated typically 
receive part of their training at VA medical centers and part 
of their training at the medical school or other community 
facilities or both. To ease the logistics of VA paying its 
share of the stipend owed to such residents and interns, 
section 7406 of title 38, United States Code, authorizes VA to 
enter into ``disbursement agreements'' with medical schools and 
community hospitals. Those agreements provide that one of the 
non-VA facilities will pay the physician in training, and VA 
will reimburse VA's share to the paying hospital.
    As section 7406 currently reads, VA is authorized to enter 
into such agreements to provide for the payment of residents 
and interns who treat patients ``in a Department [of Veterans 
Affairs] hospital.'' Physician training, however, does not take 
place in VA hospitals only. Residents and interns also train in 
VA outpatient clinics, nursing homes, domiciliaries, and other 
VA health care facilities.
    Section 111 would amend section 7406 to authorize payments 
to residents and interns who provide services ``in any [VA] 
facility furnishing hospital care or medical services'', rather 
than in VA hospitals alone. The Committee intends that these 
common sense arrangements be available to simplify VA personnel 
management irrespective of the character of the medical 
facility in which a resident or intern is receiving VA 
training.

Sec. 112. Remunerated outside professional activities by Veterans 
        Health Administration personnel

    Section 7423(b)(1) of title 38, United States Code, bars 
full-time VA health care personnel who are employed under the 
title 38 personnel system--physicians, dentists, podiatrists, 
optometrists, registered nurses, physician assistants, and 
expanded-function dental auxiliaries--from ``assum[ing] 
responsibility for the medical care of any patient other than a 
[VA] patient. * * *'' Thus, these full-time VA health care 
professionals may not ``moonlight,'' except where necessary to 
meet unmet community health care needs on a short-term basis. 
Part-time VA employees are free to practice their professions 
elsewhere.
    In urging that the Congress eliminate the ``moonlighting'' 
ban with respect to three professions--registered nurses, 
physician assistants, and expanded-function dental 
auxiliaries--VA testified as follows at the Committee's May 23, 
1996, hearing:

          VA requested this legislation because the current 
        restrictions on moonlighting for these employees is 
        [sic] outdated. Removal of these restrictions on an 
        employee's use of personal time will allow VA to become 
        more competitive with employers who impose no such 
        restriction. The original purpose of the outside-
        professional-activities restriction was to ensure the 
        availability of health care professionals who are 
        responsible for around-the-clock care of VA patients. 
        VA has considerable flexibility to ensure coverage of 
        these three professions and no longer uses this 
        authority to provide coverage.

    In addition, VA posited two additional reasons for 
eliminating the moonlighting ban with respect to registered 
nurses, physician assistants, and expanded-function dental 
auxiliaries: negative effect on employee morale, and skill-
enhancement advantages to be gained from outside professional 
employment opportunities. The Committee concludes that these 
considerations apply equally with respect to all of the 
professions which are now subjected to the moonlighting ban. 
The Committee bill, therefore, would repeal the ban.

Sec. 113. Authority to waive special pay agreement refund requirements 
        for physicians and dentists who enter into residency training 
        programs

    Under current law, VA is authorized to pay ``special pay'' 
to full- and part-time VA physicians (ranging from $4,000 to 
$45,000 per year depending on level of experience, 
qualifications, and duties) in order to attract them to VA 
employment. Physicians and dentists are required, however, to 
refund ``special pay'' to VA (on a sliding scale) in the event 
that they leave VA employment before 4 years expire. VA may 
waive the refund provision, but only if the physician or 
dentist leaves VA employment ``as a result of circumstances 
beyond the control of the physician or dentist.''
    VA physicians and dentists are often presented with 
opportunities to enhance their skills by participating in 
residency training programs which require that they leave VA 
employment. It is consistent with VA's interests that its 
employees be allowed, and encouraged, to gain advanced 
training--so long as the physician or dentist returns to VA 
employment at the completion of such training. The Committee 
bill, therefore, would allow VA to suspend the refund provision 
during training. Upon departure from training, the refund 
provision would be reinstated, and if the physician or dentist 
did not return to VA employment it would again be operative.

                         TITLE II--HEALTH CARE

    Title II of the Committee bill, which is derived from S. 
293 and S. 403, and which also contains original provisions, 
would modify VA Readjustment Counseling Service programs, 
authorize VA to make per diem payments to States which provide 
adult day health care services to veterans, and extend and 
modify other provisions of law.

                  Subtitle A--Readjustment Counseling

Background

    Within the Department of Veterans Affairs, the Readjustment 
Counseling Service (RCS) of the Veterans Health Administration 
(VHA) provides readjustment counseling and mental health 
services, as currently specified in section 1712A of title 38, 
United States Code, to two eligible veteran populations: all 
veterans who served on active duty during the Vietnam era; and 
all veterans who served on active duty after May 7, 1975 (the 
end of the Vietnam era), in an area at a time during which 
hostilities occurred in such area. In the case of Vietnam- era 
veterans, as distinguished from post-Vietnam-era veterans, 
there is no requirement of service in Vietnam (or in any other 
area of hostilities) for eligibility for readjustment 
counseling services. There is no provision in section 1712A for 
the provision of such services, on a ``mandatory'' or space-
available basis, to other veterans.
    Readjustment counseling services are furnished through 201 
Vet Centers located throughout the United States and in Puerto 
Rico and the Virgin Islands, and through contracts with non-VA 
entities. The RCS program is managed by a director, located in 
the central office of VHA, through a regional management 
structure.
    VA is also authorized to provide consultation, professional 
counseling, training, and mental health services to members of 
a veteran's immediate family (and to the veteran's legal 
guardian or household caregiver) if such services are necessary 
in connection with the treatment of the veteran's service-
connected disability or, at VA's discretion and under certain 
circumstances, the veteran's non-service- connected disability. 
Persons who were actually receiving such services at the time 
of the veteran's unexpected death, or the veteran's death while 
participating in a VA-conducted hospice (or similar) program, 
may also receive limited-term bereavement counseling services 
from VA.

Committee bill

            Sec. 201. Organization of the readjustment counseling 
                    service in the Department of Veterans Affairs
    The Committee bill specifies that VA may not alter the 
organizational or administrative structure of VA's RCS without 
first submitting a report to the Senate and House Committees on 
Veterans' Affairs detailing the proposed alteration or revision 
and waiting for the lapsing of a 60-day period (excluding days 
on which either House of Congress is not in session due to an 
adjournment of more than 3 calendar days). It also requires a 
separate accounting of VA's proposed RCS budget in each annual 
budget request submitted by VA to the Congress.
            Sec. 202. Expansion of eligibility for readjustment 
                    counseling and certain related services
    The Committee bill would modify the universe of veterans to 
whom VA would provide readjustment counseling (and related) 
services on mandatory and ``as requested'' bases. Mandatory 
services would continue to be provided to all Vietnam-era 
veterans (irrespective of actual service in Vietnam) if the 
veteran seeks, or has received, such services before January 1, 
2000. At that time, such services would be limited to Vietnam-
era veterans who served on active duty in a theater of combat 
operations (unless services had previously been sought). With 
respect to non-Vietnam-era veterans--those who served before or 
after that era--VA would be required to provide such services, 
at the veteran's request, to those who served in a theater of 
combat operations during a period of war or in any other area 
during a period in which hostilities occurred in such area. 
Other veterans could be provided such services by VA, but after 
January 1, 2000 (unless the veteran was already receiving such 
services), VA would be required to provide readjustment 
counseling services only to veterans who served in a combat 
theater during a period of war, or who served in an area where 
hostilities occurred.
    The Committee bill would require VA to provide bereavement 
counseling services to the surviving parents, spouse, and 
children of a deceased service member who had died in a combat 
theater during a period of war (or who died as a result of a 
disease, injury, or condition incurred while in such service), 
or who had died in an area in which hostilities were occurring 
while in service there during such hostilities. The parent, 
spouse, and children of other deceased veterans who have died 
while serving, or who have died from a condition incurred or 
aggravated in service, could be provided such services by VA, 
but VA would not be required to provide such services.
            Sec. 203. Advisory Committee on the readjustment of 
                    veterans
    The Committee bill would create an 18-member Advisory 
Committee on the Readjustment of Veterans to advise VA on, 
among other things, the readjustment needs of veterans and the 
effectiveness of VA programs and structures in providing for 
the readjustment needs of veterans. The original members of 
this committee will be the members on the date of enactment of 
this legislation of the administratively established Advisory 
Committee on the Readjustment of Vietnam and Other War 
Veterans. The Advisory Committee would be required to report 
annually to the Secretary of Veterans Affairs.
            Sec. 204. Report on collocation of vet centers and 
                    Department of Veterans Affairs outpatient clinics
    The Committee is aware of proposals to collocate RCS Vet 
Centers and VA outpatient clinics. So that the Committee can 
properly assess such proposals, the Committee bill requires 
that VA submit a report to the Congress, within 6 months of 
enactment of the Committee bill, thoroughly analyzing the 
feasibility and desirability of the collocation concept.
            Sec. 205. Report on provision of limited health care 
                    services at readjustment counseling centers
    The Committee is also aware of proposals to provide limited 
health care services at Vet Centers. So that the Committee can 
properly assess such proposals, the Committee bill also 
requires that VA submit a report to the Congress, within 6 
months of enactment of the Committee bill, on the feasibility 
and desirability of providing a limited battery of health care 
services (including ambulatory services and health care 
screening services) at Vet Centers.

                      Subtitle B--Other Provisions

            Sec. 211. Payment to States of per diem for veterans 
                    receiving adult day health care
    VA currently supports State efforts to provide services to 
veterans by (1) making grants to States to assist them in 
building and initially supplying State-owned veterans 
domiciliaries or nursing home facilities (``State homes'') and 
(2) by making per diem payments to States (not to exceed one 
half of the cost of the State-provided care) at specified rates 
for each veteran receiving domiciliary, nursing home, or 
hospital care in a State home who is eligible for the same 
services at a VA facility.
    Section 211 of the Committee bill would add an additional 
form of assistance to the States: support of State home-
provided adult day health care services. VA would provide such 
assistance via the two mechanisms which currently assist State 
homes. VA would be authorized to make grants to assist the 
States in expanding, remodeling, or altering existing State 
home facilities (but not building new facilities) for the 
provision of such services, and it would be authorized to make 
per diem payments (in a rate deemed appropriate by VA) to 
States providing such services to veterans who are eligible for 
adult day health care at VA.
            Sec. 212. Expanded health care sharing agreement authority
    VA and the Department of Defense (DOD) are required to 
promote the sharing of health care resources between the two 
Departments by establishing guidelines for entering into 
agreements for the mutual use or exchange of use medical 
facilities and other resources. In 1992, that authority was 
expanded by Public Law 102-585 so as to authorize the head of a 
VA health care facility to: (a) enter into sharing agreements 
with (1) the head of a DOD facility, (2) any other DOD official 
responsible for the furnishing of health care services to 
Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS) beneficiaries, or (3) a contractor responsible for 
the furnishing of health care services to CHAMPUS 
beneficiaries; and (b) to enter into sharing agreements that 
would provide for the furnishing of care to Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA) 
and CHAMPUS beneficiaries. Those agreements may provide for the 
waiver, in whole or in part, of copayments and deductibles for 
care provided under such agreements. That expanded authority 
will expire on October 1, 1996.
    The Committee has concluded that the temporary expansion of 
sharing authority enacted in 1992 has operated to the mutual 
advantage of VA and DOD, and to the advantage of VA and DOD 
beneficiaries. The Committee bill, therefore, contains an 
original provision that would extend that authority through 
December 31, 1998.
            Sec. 213. Evaluation of health status of spouses and 
                    children of Persian Gulf war veterans
    Section 107 of Public Law 103-446 directs VA to conduct a 
study to evaluate the health status of spouses and children of 
Persian Gulf War veterans who display symptoms that might be 
associated with a veteran's service in the Gulf to determine 
the nature and extent of the association, if any, between those 
illnesses and those of the veteran. This study is to be carried 
out between November 1, 1994, and September 30, 1996.
    The mandated study has not yet been concluded, and it 
remains unclear at this time whether there is an association 
between Persian Gulf service and maladies suffered by veterans' 
spouses and children. The Committee bill, therefore, would 
extend the period within which this study would be conducted 
until December 31, 1998.
            Sec. 214. Transmittal of reports of Special Committee for 
                    the seriously mentally ill veteran
    The Committee bill contains an original provision directing 
that VA submit all such reports to the Committees on Veterans' 
Affairs of the Senate and the House together with the comments 
of the Under Secretary for Health on those reports.

                    TITLE III--HEALTH CARE RESEARCH

    Title III of the Committee bill, relating to health care 
research, includes two provisions: Section 301, which is 
derived from S. 425 (which was, in turn, derived from S. 1512 
of the 103rd Congress which the Committee reported on March 17, 
1994, and the Senate passed on March 24, 1994), would establish 
Mental Illness Research, Education, and Clinical Centers; and 
section 302, which is derived from S. 644, would facilitate VA 
research by reauthorizing the establishment of research 
corporations at VA medical centers.

Sec. 301. Mental illness research, education, and clinical centers

            Background
    The October 20, 1985, Report of the Special Purpose 
Committee to Evaluate the Mental Health and Behavioral Sciences 
Research Program of the VA, which was chaired by Dr. Seymour 
Kety (``Kety Committee''), concluded that research on mental 
illness and training for mental health specialists at VA 
facilities were inadequate. The report noted that approximately 
40 percent of all VA beds were occupied by veterans who suffer 
from mental disorders, whereas less than 10 percent of VA's 
research resources were directed toward mental illness. These 
percentages have remained at similar levels in subsequent 
years.
    In order to improve and expand the capability of VA health 
care facilities to respond to the needs of veterans with mental 
illnesses, the Kety Committee recommended that VA centers of 
excellence be established to develop first-rate psychiatric 
research programs within VA. Such centers would provide state-
of-the-art treatment, increase innovative basic and clinical 
research opportunities, and enhance and encourage continuing 
education and training in the treatment of mental illness.
    Based on the recommendations of the Kety Committee, the 
Senate Committee on Veterans' Affairs began efforts 8 years ago 
to encourage more research into mental illnesses and to 
establish centers of excellence. First, legislation enacted on 
May 20, 1988, Public Law 100-322, included a provision to add a 
specific reference to mental illness research in the statutory 
description of VA's medical research mission, now set forth in 
section 7303(a)(2) of title 38, United States Code. This 
reference in the law is intended to express the importance of 
research to mental health care and thereby to help counteract 
historical patterns of relatively underfunded mental illness 
research.
    Second, the Committee report accompanying that legislation 
(S. Rept. 100-215, p. 138) urged VA to establish three centers 
of excellence, or Mental Illness Research, Education, and 
Clinical Centers (``MIRECCs''), as proposed by the Kety 
Committee. The VA has yet to take action to do so.
    The Committee notes that the January 1991 final report of 
the VA Advisory Committee for Health Research Policy 
recommended that VA establish MIRECCs as a means of increasing 
opportunities in psychiatric research and encouraging the 
formulation of new research initiatives in mental health care, 
as well as maintaining the intellectual environment so 
important to quality health care. The report stated that 
``[these] centers could provide a way to deal with the emerging 
priorities in the VA and the Nation at large.''
            Committee bill
    The Committee bill would require VA to establish MIRECCs at 
not more than five VA facilities which are geographically 
dispersed and which meet certain specified criteria. The 
purpose of the MIRECCs would be: (1) to facilitate the 
improvement of health care services for eligible veterans 
suffering from mental illness, especially from conditions which 
are service connected, through research, the education and 
training of health personnel, and the development of improved 
models of clinical services; and (2) to develop improved models 
for the furnishing of clinical services.
    The proposed MIRECCs would be modeled after the successful 
Geriatric Research, Education, and Clinical Centers (GRECCs) 
which were authorized in 1980 in section 302 of Public Law 96-
330. The MIRECCs would be designed to: (1) attract clinicians 
and investigators with a clear and focused clinical research 
mission, such as PTSD, schizophrenia, or drug and alcohol 
abuse; (2) provide training and educational opportunities for 
students and residents in psychiatry, psychology, nursing, 
social work, and other professions which treat individuals with 
mental illness; and (3) develop new models of effective care 
and treatment for veterans with mental illnesses, especially 
those which are service connected.
    The Committee believes that the establishment of MIRECCs 
would also encourage research into outcomes of various types of 
treatment for mental illnesses, an aspect of mental illness 
research which, to date, has not been fully pursued either by 
VA or other researchers in the field.
    In order to designate a facility as the site for a MIRECC, 
the Secretary, upon the recommendation of the Under Secretary 
for Health, would have to determine that the facility has 
developed (or might reasonably be expected to develop): (1) 
arrangements with an affiliated medical school and an 
affiliated graduate program of psychology for the regular 
rotation of their residents and students through the center; 
(2) an arrangement under which nursing or other allied health 
personnel receive education and training in mental health care 
through regular rotation through the facility; (3) the ability 
to attract superior mental illness researchers; (4) a 
policymaking advisory committee composed of health care and 
research representatives of the VA facility and the schools 
involved; and (5) the capability to evaluate effectively the 
activities of a MIRECC.
    The Committee bill would require that a peer review panel 
be used to determine the location of such centers so as to 
ensure that, in addition to being geographically diverse, any 
such center meets the highest competitive standards of 
scientific and clinical merit prior to selection by the 
Secretary. Also, at least three of the five centers would be 
required to emphasize the development of community-based 
alternatives to institutional treatment.
    The Committee bill would promote research at the MIRECCs by 
requiring that, in the awarding of research funds for mental 
illness projects, MIRECC applications be given a priority. 
Centers would include an emphasis on the psychosocial dimension 
of mental illness and on developing models for furnishing care 
and treatment of mental illness. Further, the Committee bill 
would promote the dissemination of information regarding all 
aspects of MIRECC activities throughout the Veterans Health 
Administration (VHA) by requiring the Under Secretary for 
Health to develop continuing education programs.
    Finally, beginning February 1, 1997, the Secretary would be 
required to submit three annual reports to the House and Senate 
Committees on Veterans' Affairs on the research, educational, 
and clinical care activities at each MIRECC and on efforts to 
disseminate the information throughout the VA health care 
system. The administration of the program would be assigned to 
the VA Central Office official responsible for mental health 
and behavioral sciences, which is currently the Director of 
Mental Health and Behavioral Sciences.
    The Committee also urges VA--as it has in the past--to 
create a Mental Illness Research Service, similar to research 
services that exist for each of the other categories of 
research expressly mentioned in the statutory provision, 
section 7303(a)(2), which establishes VA's research mission. 
Section 135 of Public Law 100-322, which originated in this 
Committee, added specific mention of mental illness to the 
description of VA's research mission in this section in order 
to emphasize the importance of such research and the 
establishment of such a service. The Committee remains 
convinced that the creation of a separate service with its own 
budgetary allocation would help VA to pursue more creatively 
cost-effective and innovative treatment for veterans suffering 
from mental illness.

Sec. 302. Research corporations

    During the period May 20, 1988, through December 31, 1992, 
VA was authorized to establish nonprofit corporations at its 
medical centers to provide for flexible funding mechanisms for 
the conduct of approved research at the medical centers. Such 
corporations were authorized to receive and administer funds 
other than appropriated funds--for example, gifts or research 
grants--received to support VA research efforts at the medical 
center.
    Authority to establish such research corporations expired 
on December 31, 1992. The Committee has learned that some VA 
medical centers did not establish research corporations when 
the opportunity was presented. The Committee would reopen the 
authority to do so, effective through December 31, 2000. The 
Committee bill would also revise the reporting requirements 
currently imposed on such corporations so as to expand the 
amount of information the Congress receives on both 
contributions to, and expenditures by, these research 
corporations. Such additional information will facilitate 
greater oversight of these entities by the Committee.

                    TITLE IV--HOSPICE CARE SERVICES

    Title IV of the Committee bill, which is derived from S. 
612 (which was, in turn, derived from section 203 of S. 1030 of 
the 103rd Congress which the Committee reported on September 8, 
1993, and the Senate passed on May 25, 1994), would establish a 
hospice care pilot program in VA.

Sec. 402. Programs for furnishing hospice care to veterans

            Background
    As the Committee noted in its report (S. Rept. 103-136) 
accompanying S. 1030 in the 103rd Congress, it is important 
that VA develop cost-effective methods of providing treatment 
to veterans, particularly older veterans, who are most likely 
to seek VA services in the coming years. Among the services 
that can best meet the needs of older veterans are community-
based, noninstitutional services, including hospice care, which 
provides a compassionate alternative to customary curative care 
for terminally ill persons.
    While the record before the Committee on hospice care, 
including hearings in 1991, 1993, and 1995, indicates that VA 
has focused on hospice care, the Committee remains concerned 
that VA has moved too cautiously in establishing programs which 
achieve the goals of hospice care. On April 30, 1992, VA issued 
a directive that required all VA medical centers to implement 
hospice programs. However, that directive provided only vague 
guidelines regarding the manner in which VA medical centers 
should provide hospice care. As a result, significant 
variations now exist in the manner in which hospice care is 
provided.
    It is reported that, at present, all VA medical centers 
have hospice consultation teams (consisting of at least a 
physician, a nurse, a social worker, and a chaplain). In 
addition, 56 of 171 VA medical centers have inpatient hospice 
units, freestanding buildings, or separate units where a home-
like atmosphere is created. While this is an increase in the 
total number of inpatient units since 1993, it is not clear 
that it demonstrates a significant change in the overall effort 
in support of hospice care. VA has submitted material to the 
Committee stating that ``most VA inpatient hospice units are 
small with an average size of 7 beds.'' Other VA medical 
centers provide pain management and other services to 
terminally ill veterans in units in which hospice rooms are 
adjacent to rooms in which other patients are administered 
curative care. Still other VA medical centers provide some 
hospice services such as caregiver counseling and pain 
management.
    Unfortunately, many VAMCs' hospice efforts offer only an 
assessment of a terminally ill veteran's needs and a referral 
to a non-VA hospice. While such referrals may benefit some 
veterans, they are of little value to those veterans who are 
not entitled to Medicare or Medicaid or who lack health 
insurance coverage for hospice care. Because VA has no 
authority under current law to contract with non-VA hospices, 
veterans of limited means can be left with the difficult option 
of foregoing hospice care due to inability to pay for such 
care.
    The Committee is convinced that VA should provide hospice 
care. It is uncertain, however, as to the best way for the 
Department to provide such care. Some assert that the only bona 
fide form of hospice care is a program offering both home and 
inpatient palliative care (noncurative care focusing on 
alleviating pain and other symptoms) and support services to 
meet the psychological, social, and spiritual needs of patients 
and their families. Others believe that equally effective care 
can be furnished by integrating hospice concepts into customary 
care. Similarly, there is considerable disagreement as to 
whether veterans who wish to receive hospice care are best 
served by VA hospice programs or through contracts with non-VA 
providers.
    To this point, VA has not undertaken sufficient research to 
answer with any degree of certainty the most appropriate way in 
which it might furnish hospice care. Therefore, the Committee 
believes that a study of the ways in which hospice care can 
successfully be furnished to veterans is warranted.
    Given the growing numbers of elderly or terminal VA 
patients who could benefit from hospice care, demand for VA 
hospice care is likely to increase. Research related to the 
provision of such care is critical.
            Committee bill
    The Committee bill would require VA to conduct a 5-year 
pilot program to evaluate the best way to provide hospice care. 
The Committee's main goals are to make hospice care services 
more readily available to greater numbers of veterans and to 
develop information about how VA might best offer these 
services.
    The Committee bill would require VA to set up demonstration 
projects at 15 to 30 VA sites to provide hospice care by one of 
three means: (1) a hospice operated by a VA medical center; (2) 
a non-VA hospice under contract under an arrangement providing 
for the furnishing of needed inpatient care at VA facilities; 
or (3) a non-VA hospice under contract under an arrangement 
providing for the furnishing of needed inpatient care at non-VA 
facilities.
    The Committee bill generally would require VA to follow 
Medicare's policy in setting reimbursement rates. Contract 
hospice rates would generally be capped at the Medicare rates. 
However, exceptions could be made in cases in which the 
Secretary determines that the Medicare rate would not 
compensate a non-VA hospice for providing a veteran with 
necessary care. In such cases, the Secretary could either pay a 
rate higher than the Medicare rate or provide in-kind services 
to the contract organization. The Committee bill includes this 
provision to ensure that veterans for whom care is 
extraordinarily expensive due to the nature of their condition, 
such as veterans with AIDS, would not excluded from the 
program.
    Under the Committee bill, the VA pilot program would have 
to include at least 10 VA medical centers that offer a less 
comprehensive range of services to terminally ill veterans as 
part of the evaluation. In including a comparison group in the 
evaluation, the Committee seeks to determine whether furnishing 
a less comprehensive range of services is useful at medical 
centers in which the numbers of veterans desiring such services 
may not be sufficient to justify a full-scale hospice program.
    The Committee bill would require that the Director of VA's 
Health Services Research and Development Service (HSR&D;) 
conduct an evaluation of the various models for furnishing 
hospice care. Lest there be a diversion of scarce funds from 
other meritorious health services research projects, the 
Committee bill would authorize the appropriation of additional 
funds to HSR&D; to cover costs associated with the mandated 
evaluation.
    Finally, to ensure that VA patient care is not compromised 
or diminished in any way by the pilot program, the Committee 
bill would provide that VA is not precluded from furnishing 
hospice care services at VA medical centers not participating 
in the pilot program or the control group. Indeed, the 
Committee encourages that VA not only maintain such services, 
but that it expand them.

                     TITLE V--MAMMOGRAPHY STANDARDS

    Title V of the Committee bill, which is derived from S. 548 
(which in turn was derived from section 106 of S. 1030 of the 
103rd Congress which the Committee reported on September 8, 
1993, and the Senate passed on May 25, 1994) would require VA 
to establish standards for the provision of mammography 
services by VA.

Sec. 502. Mammography quality standards

            Background
    The Mammography Quality Standards Act of 1992, Public Law 
102-539, requires that health care facilities which are subject 
to that law be certified by the Department of Health and Human 
Services (HHS) as meeting specified standards for equipment, 
personnel, and quality assurance. That law, however, does not 
apply to VA facilities.
    The Committee believes that women veterans who receive care 
from VA facilities should have services that are equal or 
superior to those provided elsewhere. VA agrees. In a letter 
dated July 12, 1993, to the then-Chairman of the Committee, 
Senator Rockefeller, VA Secretary Jesse Brown wrote, ``It is my 
intent that VA will comply with standards equal to those set 
forth in the Mammography Quality Standards Act of 1992 for all 
mammography done within VA facilities and require that all 
contracts and sharing agreements for mammography include a 
provision for compliance.'' At the Committee's October 25, 
1995, hearing, Dr. Kenneth Kizer, VA's Under Secretary for 
Health, reiterated Secretary Brown's commitment, stating as 
follows:

          I am sure you all will be pleased to know that VA 
        policy now requires compliance with the requirements of 
        the 1992 Mammography Quality Standards Act. Moreover, 
        all VA facilities furnishing mammography services are 
        currently using the FDA's guidelines.

            Committee bill
    The Committee bill would ensure that the goal of giving 
women veterans safe and accurate mammograms continues to be met 
by requiring that the Secretary promulgate quality assurance 
and quality control standards for VA facilities that furnish 
mammography services. Those standards would be no less 
stringent than the HHS standards for other mammography 
providers as promulgated under the Mammography Quality 
Standards Act of 1992. VA facilities that contract with non-VA 
facilities would be required to contract only with facilities 
that comply with that act.
    VA would be required to issue these standards no later than 
120 days after the Secretary of HHS issues regulations to 
implement that act. In addition, VA would be required, not 
later than 180 days after prescribing its own mammography 
standards, to submit a report to the House and Senate 
Committees on Veterans' Affairs on the implementation of those 
regulations.
    The Committee bill would also require that VA facilities 
that furnish mammography services be accredited by a private 
nonprofit organization designated by VA. VA would be permitted 
to designate only an accrediting body that meets the standards 
for accrediting bodies issued by HHS for purposes of 
accrediting mammography facilities subject to Public Law 102-
539. The American College of Radiology (ACR) currently 
administers a voluntary accreditation program for mammography 
providers and, at the present time, is the only accrediting 
body that meets those requirements. Thus, the Committee 
anticipates that, under current circumstances, ACR would serve 
as VA's accrediting body under the Committee bill.
    Finally, the Committee bill would require VA to ensure that 
mammography equipment operated by VA facilities is inspected on 
an annual basis in a manner consistent with requirements 
contained in the Mammography Quality Standards Act of 1992 
concerning annual inspections of mammography equipment by HHS, 
except that VA would not have the authority to delegate 
inspection responsibilities to a State agency. The Committee 
expects VA to correct any deficiencies uncovered as a result of 
these inspections.

                             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 the costs resulting from the enactment of the 
Committee bill (as compared to costs under current law), as 
scored against the current CBO baseline during the remainder of 
FY 1996 and for the first 5 years following enactment, would 
have no effect on direct spending during fiscal years 1996 
through 1998, and would have no effect on Federal direct 
spending during each year in fiscal years 1999 through 2002. 
The bill would not affect the budgets of State and local 
governments. The cost estimate provided by CBO, setting forth a 
detailed breakdown of costs follows:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, August 2, 1996.
Hon. Alan K. Simpson,
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. 1359, the Veterans' 
Medical Programs Amendments of 1996, as ordered reported by the 
Senate Committee on Veterans' Affairs on July 24, 1996.
    The bill would affect direct spending and thus would be 
subject to pay-as-you-go procedures under section 252 of the 
Balanced Budget and Emergency Deficit Control Act of 1985.
    If you wish further details on this estimate, we will be 
pleased to provide them.
            Sincerely,
                                         June E. O'Neill, Director.
    Attachment.

               congressional budget office cost estimate

    1. Bill number: S. 1359.
    2. Bill title: The Veterans' Medical Programs Amendments of 
1996.
    3. Bill status: As ordered reported by the Senate Committee 
on Veterans' Affairs on July 24, 1996.
    4. Bill purpose: The bill would address programs for 
veterans medical care including mental illness centers, a pilot 
program for hospice care, payments to state homes providing 
adult day health care, health assessments of spouses and 
children of veterans of the Persian Gulf War, and readjustment 
counseling services.
    5. Estimated cost to the Federal Government: The following 
table summarizes the budgetary impact of S. 1359, which would 
depend on subsequent appropriations action.

                                    [By fiscal year, in millions of dollars]                                    
----------------------------------------------------------------------------------------------------------------
                                                     1996     1997     1998     1999     2000     2001     2002 
----------------------------------------------------------------------------------------------------------------
                                    SPENDING SUBJECT TO APPROPRIATIONS ACTION                                   
                                                                                                                
Spending Under Current Law:                         16,559   17,171   17,773   18,397   19,040   19,701   20,384
    Estimated authorization level1...............   16,880   17,762   17,746   18,328   18,969   19,629   20,310
    Estimated outlays............................                                                               
Proposed Changes:                                                                                               
    Estimated authorization level................        0       18       23       22       20       15       15
    Estimated outlays............................        0       17       22       23       21       15       15
Spending Under S. 1359:                                                                                         
    Estimated authorization level................   16,559   17,189   17,796   18,419   19,060   19,716   20,399
    Estimated outlays............................   16,880   17,779   17,768   18,351   18,990   19,644  20,325 
----------------------------------------------------------------------------------------------------------------
\1\ The 1996 figure is the amount already appropriated. The amounts shown for 1997-2002 adjust the 1996         
  appropriation for projected inflation. If appropriations are held to the 1996 level, then beginning in 1997   
  the authorization level and outlays would both equal about $16,559 million each year.                         

    6. Basis of estimate: The estimate assumes enactment of the 
bill by October l, 1996, and appropriation of the authorized 
amounts for each fiscal year. CBO used historical spending 
rates for estimating outlays.

Direct spending

    Section 101 would grant VA broad authority to share 
resources with other entities and individuals. These sharing 
agreements would allow VA to collect and spend receipts derived 
from these agreements. This spending would not be subject to 
appropriations action. This section would have no net budgetary 
impact in the long run.

Authorization of appropriations

    This bill contains several provisions that would be subject 
to appropriations action. These provisions would expand 
eligibility for readjustment counseling services to all combat 
veterans, authorize per diem payments to state veterans' homes 
for providing adult day health care, continue a program to 
monitor the health of Persian Gulf veterans' families, 
authorize operation of mental health centers in VA facilities, 
and create a pilot program to provide hospice care for 
terminally ill veterans.

Expansion of eligibility for readjustment counseling services

    Section 202 would expand eligibility for readjustment 
counseling to any veteran who served in a theater of combat 
operations while on active duty. Counseling would also be 
provided to a parent, spouse, or child of a veteran who dies 
while on active duty. Current law provides for counseling to 
veterans who served during the Vietnam era or in a theater of 
combat operations after May 1975. This section would cost about 
$11 million a year.
    The bill would apply primarily to the 3 million veterans 
who served in a combat theater during the Korean conflict or 
World War II. CBO estimates that the World War II and Korean 
War veterans covered by the bill would generate about 132,000 
visits a year based on the estimated number of visits to 
counseling centers from comparable Vietnam veterans and the 
assumption that elapsed time would make the new beneficiaries 
only one-fourth as likely to seek counseling. Based on a 
current average cost of about $82 per visit, the cost of 
providing expanded counseling services under the bill would be 
about $10 million a year.
    The cost of bereavement counseling for relatives of those 
who die while on active duty would be about $1 million a year. 
Based on data from the Department of Defense (DoD), the number 
of active-duty deaths is expected to be about 1,400 per year 
during the estimating period. CBO estimates that on average, 
one family member per casualty would seek this counseling.

Per diems for adult home day care

    Section 211 would authorize VA to pay per diems to state 
veterans' homes for providing adult day health care (ADHC). 
Based on a recent survey of state homes conducted by the 
National Association of State and Veterans Homes, CBO estimates 
that several state homes would be interested in offering ADHC 
under the bill. Because no state homes now offer ADHC and 
legislation at the state level may still be necessary, per diem 
payments would not have a significant cost until 1999. As more 
states offer ADHC, per diem payments would increase to $2 
million by 2002.
    The estimate assumes that the number of veterans 
participating in the program would increase from 60 in 1998 to 
about 300 by 2002. Although the bill would not authorize a 
specific per diem rate, this estimate assumes that the rate 
would be the same as the rate VA pays state homes that provide 
nursing home care--about $17 per veteran per day.
    This section would also authorize VA to make grants to 
states to finance the renovation or expansion of state 
veterans' homes in order to provide ADHC. The estimate assumes 
that one major or two to three minor projects every year would 
result in an annual cost of about $2 million.

Health status of spouses and children of Persian Gulf veterans

    In 1994, VA established a program to evaluate any illnesses 
that may have resulted from having a spouse or parent who 
served in the Persian Gulf War. Section 213 would extend the 
program for two years and would continue to limit total 
expenditures to no more than $2 million. To date, VA has spent 
around $360,000 on the program.

Mental illness research, education and clinical centers

    Section 301 would authorize research, education, and 
clinical centers to assist veterans suffering from mental 
illnesses, especially illnesses related to military service. 
The bill would authorize appropriations of $3 million in 1997 
and $6 million a year for 1998-2000 in addition to authorizing 
VA to use funds appropriated for VA's medical care and 
prosthetic research accounts for the mental health centers.

Hospice Care Pilot Program

    The bill would create a pilot program to provide hospice 
care for terminally ill veterans. Section 492 would authorize 
appropriations of $1.2 million in 1997, $2.5 million in 1998, 
$2.2 million in 1999 and $100,000 in 2000.

Sharing agreements

    Section 101 would allow VA to agree to share equipment and 
other resources with a broad range of individuals and entities. 
These agreements would allow the resources to be used more 
efficiently and lead to budgetary savings or costs depending on 
the extent that VA would otherwise purchase or forgo the 
resource. CBO cannot estimate the budgetary impact of this 
provision.
    Section 212 would extend through December 31, 1998, an 
expansion of sharing agreements between VA and the Department 
of Defense (DoD) that enable the two agencies to treat patients 
eligible for each other's programs. Because current agreements 
cover a relatively small number of beneficiaries, this 
provision would probably involve relatively low costs.
    7. Pay-as-you-go considerations: The Balanced Budget and 
Emergency Deficit Control Act of 1985 sets up pay-as-you-go 
procedures for legislation affecting direct spending or 
receipts through 1998. The bill would have the following pay-
as-you-go impact:

                [By fiscal years, in millions of dollars]               
------------------------------------------------------------------------
                                            1996       1997       1998  
------------------------------------------------------------------------
Change in outlays......................          0          0          0
Change in receipts.....................  .........        (1)        (1)
------------------------------------------------------------------------
1 Not Applicable.                                                       

    8. Estimated cost to State, local, and tribal governments: 
S. 1359 contains no intergovernmental mandates as defined in 
the Unfunded Mandates Reform Act of 1995 (Public Law 104-4). 
The bill would provide federal assistance to states that opt to 
construct and operate adult day health facilities for veterans.
    9. Estimated impact on the private sector: This bill would 
impose no new federal private-sector mandates as defined in 
Public Law 104-4.
    10. Previous CBO estimate: None.
    11. Estimate prepared by: Federal cost estimate: Mary Helen 
Petrus and Victoria Fraider; impact on State, local, and tribal 
Governments: Marc Nicole; impact on the private sector: Ellen 
Breslin Davidson.
    12. Estimate approved by: Paul N. Van de Water, Assistant 
Director for Budget Analysis.

                      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 which 
would be incurred in carrying out the Committee bill. The 
Committee finds that the Committee bill would not entail any 
significant regulation of individuals or businesses or result 
in any significant 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 July 24, 1996, meeting. On that date, 
the Committee, by unanimous voice vote, ordered S. 1359 
reported favorably to the Senate.

                             Agency Reports


   statement of kenneth w. kizer, m.d., m.p.h., under secretary for 
         health, department of veterans affairs (may 11, 1995)


    Mr. Chairman and Members of the Committee, I am pleased to 
have this opportunity to discuss with you my plan to 
restructure the Veterans Health Administration (VHA) as well as 
the proposal to amend Section 510 of Title 38.
    As you know, copies of the plan, ``Vision for Change,'' 
were sent to the Committee on March 17, 1995, in accordance 
with the current requirements of Section 510 of Title 38. In 
brief, the reorganization plan described in ``Vision for 
Change'' is designed to improve the delivery of health care to 
veterans, improve the quality of this care, increase the 
efficiency with which we provide it, and establish 
accountability for outcomes and bottom-line results. I would 
add that the reorganization plan is also designed to retain or 
continue those things in the system that are functioning well, 
as well as to complement our several statutory missions.
    Perhaps the first issue I would comment on this morning is 
``why change VHA?'' There are a number of reasons.
    As a result of technological advances, economic factors, 
the restaff managed health care systems, and a variety of other 
forces, there have been profound changes in recent years in how 
health care is delivered in this country. There has been a 
marked shift away from inpatient care and a dramatic rise in 
ambulatory or outpatient care. For example, the majority of 
surgery is now performed on an outpatient basis. Likewise, 
chemotherapy for cancer is now routinely administered on an 
outpatient basis. Many complex medical conditions previously 
requiring hospitalization for intravenous antibiotics or other 
treatment are now routinely treated at home or in outpatient 
settings. And even more dramatic changes will occur in the 
years ahead. Indeed, it will not be that many years before the 
traditional general acute care hospital becomes a large ICU 
taking care of only the sickest and most complicated of 
patients. All other medical care will be provided in ambulatory 
care settings, at home, in hospices, or at various types of 
extended care facilities.
    The VA must adapt to these changing conditions in the 
larger health care environment.
    In addition, several reports on VA health care in recent 
years have concluded that structural changes are needed in the 
system. In the aggregate, these reports have consistently found 
that the VA needs to become more flexible, more customer-
focused, more decentralized, and more cost-effective. Our plan 
to restructure the veterans health care system should 
accomplish all of these objectives.
    Finally, for a variety of reasons, there has been a 
fundamental re-analysis of how government functions in recent 
years. The National Performance Review and other activities are 
being undertaken to reinvent government to minimize 
bureaucracy, to reward efficiency and innovation, and to 
empower employees to make government work better for citizens. 
While not undertaken as part of NPR, our plan for restructuring 
the VHA is consistent with its goals.
    The foundation for accomplishing these changes in the 
veterans health care system involves the dissolution of the 
current hierarchical central office and regional office 
structure. In its place we will create a federation of Veterans 
Integrated Service Networks (VISN) that is supported by a 
national headquarters and other infrastructures. At this time, 
the plan calls for 22 VISNs, each including from five to eleven 
medical centers and various other VA assets. VISN boundaries 
have been established in accordance with existing patient 
referral patterns; aggregations of patients and facilities 
needed to support primary, secondary, and tertiary care; and, 
to a lesser extent, political jurisdictional boundaries such as 
state lines.
    It is envisioned that the VISN will become the basic 
budgetary and planning unit for delivering veterans health 
care. The individual and historically independent VA medical 
centers will remain important but less central components of 
larger, more community-based, interlocking networks of care.
    As an integrated system of care, the new VISN structure 
will emphasize the pooling of resources, outpatient and primary 
care, partnerships and customer service. A premium will be 
placed on improved patient services, rigorous cost management, 
process improvement and outcomes. Emphasis will be placed on 
the integration of ambulatory care and acute and extended 
inpatient services to provide a coordinated continuum of care. 
Redundant administrative structures and processes will be 
eliminated. Each layer or process in the new organization will 
be expected to add value to the delivery of services.
    Each VISN director will be assisted by a small staff of 
professional, technical, and support personnel, the number 
varying with the size and complexity of the individual network. 
While the specific numbers and types of employees will be left 
to the discretion of the director, each VISN management will be 
expected to include expertise in medical management, finance 
and budgeting, and planning. Medical management and operations 
management will be expected to work hand-in-hand to provide 
``best value'' care.
    Other areas of expertise may be needed in a VISN from time 
to time that would not warrant a full-time staff member or 
collateral assignment. It is expected that the VISN director 
will draw such expertise on an ad hoc basis from individual 
facilities within the network, from headquarters, or from the 
Support Service Centers.
    Two other important components of the field reorganization 
also warrant comment. The first is the Support Service Centers 
(SSCs). During the transition from where we are now to the new 
organization, the SSCs will preserve the expertise available in 
the existing four regional offices in areas such as 
construction management, finance, planning, and quality 
assurance. They will ensure continuity of operations while the 
regions dissolve and the VISNs become operational.
    Once the VISNs are fully operational and their support 
needs more clearly delineated, and recognizing the concomitant 
decentralization that will take place, the SSCs will provide 
support services as required. We expect they will serve 
primarily as roll-up, data collection, and technical support 
centers providing needed information for both the networks and 
VHA headquarters.
    The second structure I would mention is the Management 
Assistance Councils (MACs), which are conceived to be formal 
structures to ensure input from VHA's internal and external 
stakeholders. The MACs will be composed of facility directors, 
chiefs of staff, nurse executives, union representatives and 
others from within each VISN. Likewise, MACs will contain 
external representatives from veterans service organizations, 
state and local government, academic affiliates, and private 
sector health care entities, all of whom will serve as 
consultants to the council. Each council, working in close 
concert with its external consultants, would formulate plans 
and recommendations to the VISN director. It is intended that 
these MACs will ensure that the needs of the patients, the 
community, and others are incorporated into the decision-making 
process.
    Let me conclude my comments on the field reorganization 
with some comments on how we will achieve accountability in the 
more decentralized VHA system that this reorganization will 
create.
    Concern about accountability led us to devote an entire 
chapter of our plan to performance measurement and systems 
monitoring. The cornerstone of the accountability system will 
be a performance contract between each VISN director and the 
Under Secretary's office. Each contract will cover three 
general areas: (1) system wide needs and tasks that all VISNs 
will be expected to complete; (2) VISN-specific service 
delivery and efficiency objectives directed by headquarters; 
and (3) VISN-specific objectives as developed by VISN 
management.
    The key areas of focus for VHA performance measures will be 
patient satisfaction, ease of access, quality of care, and 
efficiency. Performance measures will focus on outcomes, than 
on processes. In order to compare our performance to that of 
the communities we reside in, we will emphasize performance 
measures that allow for comparison to national and local 
private sector measures, as well as comparison with current 
performance evaluation trends supported by the Joint Commission 
on Accreditation of Health Care Organizations (JCAHO).
    Performance contracts will also address the support of 
education and research, as these missions and our academic 
partnerships have been a major factor in VA's achieving 
excellence in patient care. The fourth mission, emergency 
preparedness, also will be included in the performance contract 
with each VISN director.
    In summary, field units and senior managers will be held 
accountable for measurable improvements to the veterans health 
care system. The resulting efficiencies should allow VHA to 
invest in new ways of providing high quality, efficient 
ambulatory and inpatient care to better meet our veterans' 
needs and expectations.
    Mr. Chairman, in an effort to move as expeditiously as 
possible we have begun to make preliminary plans for 
implementing the field reorganization, subject, of course, to 
compliance with the requirements of Section 510. We have 
established a coordinating committee to oversee the many 
activities that will be involved, and we have created six 
technically oriented work groups that will handle detailed 
actions for restructuring headquarters, activating the VISNs, 
developing performance measurements and executive performance 
contracts, planning employee education and training, improving 
resource allocation, and evaluating our information management 
needs and capabilities. The work group chairs had their first 
meeting here in Washington on April 27th and 28th. Work group 
members have been appointed, and several of the groups are 
having their first meetings this week. We understand that the 
90 days in session provided to the Congress for review of our 
plan under Section 510 (unless earlier legislative approval is 
provided) will be completed in late July or early August of 
this year, depending upon the recess schedule of the Senate. We 
will have completed our planning and preparations for the 
reorganization before then, and should be ready to begin 
implementing the new organization by August 3.
    In order for the field reorganization to be successful, and 
for the VISNs to be empowered to make appropriate operational 
decisions, headquarters must change its focus from micro-
managing operations to the critical role of governing and 
leading the overall system. In recognition of the changes in 
patient care delivery patterns in the field, headquarters must 
be restructured to better support the new delivery paradigm.
    The new headquarters will provide support for specific 
groups of patients or functions rather than advocacy for 
specific medical or technical disciplines. Offices will be 
organized by function or ``product line,'' whenever possible, 
rather than by discipline. Headquarters must focus much greater 
attention on achieving system wide quality improvement and the 
consistency of quality. Likewise, headquarters must focus more 
on cost management and strategic planning.
    To accomplish our headquarters restructuring, I anticipate 
a three-step process. First, the headquarters staff will be 
reorganized as outlined in Chapter 3 and Appendix 5 of our 
report. Next, the staff will identify those operational 
activities that can be decentralized to the field, and they 
will make the necessary changes to policy manuals and 
directives. Third, the new core values and behaviors associated 
with our ``Patients First'' philosophy will begin to become 
institutionalized so that the new VHA headquarters can provide 
the kind of leadership and direction the field will need in the 
future.
    Importantly, a significant part of this process will be to 
identify new functions the headquarters should perform that 
have not been done in the past due to an historically misplaced 
emphasis on operational business. As I mentioned earlier, among 
these will be a heightened emphasis on strategic planning, 
development of ``clinical benchmarks'' (``best practices''), 
quality improvement, and system wide information management.
    This concludes my general overview of our plan to 
restructure the veterans health care system. I would now like 
to present agency views regarding whether the Congressional 
report-and-wait restrictions found in 38 U.S.C. Sec. 510, 
affecting certain VA administrative reorganizations, should be 
repealed.
    As you know, section 510(b) prohibits any VA action to 
implement a covered field administrative reorganization until 
we have submitted a detailed plan and justification to our 
authorizing committees, and then waited for a ``90-day period 
of continuous session of Congress.'' The waiting period 
normally is longer than 90 days and can extend from four to six 
months or longer, depending upon Congressional recesses or when 
during a session the report is submitted. Consequently, there 
is uncertainty as to when the period will expire, or even 
whether the planned VA reorganization will be permitted. VA 
nevertheless must prepare and plan to efficiently implement the 
changes on the assumption that the reorganization will be 
permitted. Personnel transfers, resource real locations and 
mission changes must be identified by this point. This 
activity, coupled with the considerable delay caused by section 
510 causes a great deal of counterproductive uncertainty and 
anxiety among VA managers and staff. (Section 510(d) places 
similar report-and-wait restrictions, although with a shorter 
30-day waiting period, on covered reorganizations within VA 
Central Office; we believe this provision should be repealed as 
well.)
    These restrictions impose burdens on VA operations and 
detract from efforts to improve health care services for 
veterans. The burdens are felt by VA managers in terms of 
inefficiency, uncertainty, prolonged delays and employee 
anxiety--burdens which good managers seek to prevent or 
minimize. Therefore, as a VA manager, and on behalf of the 
Secretary, I ask for your help in removing these unnecessary 
burdens from all VA operations. I ask that you repeal those 
restrictions on the authority of the Secretary to reorganize 
which are contained in subsections (b) through (f) of 38 U.S.C. 
Sec. 510. The basic authority of the Secretary to organize and 
reorganize the Department, contained in subsection (a), should 
of course be retained.
    We recognize that our authorizing committees have a 
legitimate need to be kept fully informed of significant VA 
reorganizations or other changes affecting VA programs. We 
intend to keep you fully informed. As in the past, we will 
continue to work closely with the Congress to provide 
information about any significant change affecting VA programs, 
including VA reorganizations, and answer any questions.
    As I discussed earlier, one of the crucial features of our 
planned reorganization of VHA into VISNs or health care 
networks is to empower local management with as much authority 
as possible and to hold them responsible for measurable 
results, rather than to attempt to micromanage operations. This 
is consistent with the Administration's initiatives to 
``reinvent government'' by giving managers more flexibility and 
fewer restrictions. The delays encountered by the report-and-
wait provisions of section 510 are inconsistent with, and 
frustrate, the ability of local managers to meet their 
responsibilities in a timely manner.
    Under the proposed reorganization, the focus of providing 
services to veteran beneficiaries is predicated upon the 
utilization of a multiple facility network, which permits the 
VISN Director to shift resources and personnel within that 
network. The Section 510(b) restrictions are incompatible with 
this concept, because they focus on the functions and FTEE of 
individual facilities.
    Moreover, retention of section 510(b) requirements could 
result in inconsistent reporting from network to network. For 
example, VISNs with identical reorganization goals could be 
required to act differently because of section 510(b) 
requirements. A VISN with a large FTEE base may be able to 
effect change without a 15 percent triggering FTEE loss to an 
individual facility, while a VISN with a more modest FTEE base 
may, while attempting the identical reallocation of resources, 
trigger the 15 percent FTEE reduction which requires the 
report-and-wait period under Section 510.
    In summary, we believe the requirements of section 510 (b) 
through (f) unduly burden efforts to provide health care 
services more efficiently and effectively, and we therefore 
request that they be repealed.
                                ------                                



   statement of kenneth w. kizer, m.d., m.p.h., under secretary for 
       health, department of veterans affairs (october 25, 1995)


    Good morning Mr. Chairman and Members of the Committee.
    I am pleased to be here this morning to present the 
Administration's views on seven pieces of legislation 
concerning the veterans health care system. The bills cover a 
range of subjects related to VA's provision of health care 
services. As you know, six of the seven bills were considered, 
in one form or another, during the last Congress. As such, they 
were developed to address a different VA operational 
environment than exists today.
    As a preface to my further comments I should note at the 
outset that any cost estimates provided in this testimony 
represent the best estimates available to us at this time and 
are provided to assist the committee in its deliberations. They 
do not, however, represent official Administration estimates.
    Now turning to the proposed legislation.
    The one new measure before the Committee is, of course, 
your bill Mr. Chairman, which would provide VA with greater 
authority to share health care resources with community health 
care providers. I will address that bill first.
Draft bill--health-care resources sharing
    In a word, Mr. Chairman, we strongly support your draft 
bill, which we understand will be known as the Veterans Health 
Care Management and Contracting Act of 1995.
    Earlier this fall, we sent to Congress a legislative 
proposal that contained provisions similar to those contained 
in this bill. At that time, we stated that today's health care 
environment demands that all types of providers cooperate and 
work together. The VA health care system is an integral part of 
the larger health care community, and the VA must be able to 
work with partners in both the private and public sectors. 
Unfortunately, current law limits our ability to obtain needed 
health care resources for veterans, and share our resources 
with others in the community. Your draft bill would remedy this 
problem.
    Currently VA may obtain only ``specialized medical 
resources'' under sharing authority. The term ``specialized 
medical resource'' is limited to medical resources which 
because of cost, limited availability, or unusual nature, are 
either unique in the medical community or are subject to 
optimal utilization only through mutual use. VA may enter into 
sharing agreements with only ``health care facilities (generic 
for hospital), research centers, or medical schools,'' as well 
as certain state veteran homes.
    Your bill would amend existing law to permit the Department 
to share all types of health care resources with all types of 
health care providers. It would define ``health care resource'' 
to include conventional health care services such as hospital 
care, nursing home care, outpatient care, rehabilitative care, 
and preventive care. Additionally, it would include other 
health care support or administrative services essential to the 
operation of a health care system.
    The draft bill would also more broadly define the term 
``health care provider'' to include insurers, health care 
plans, group practices, health care management organizations, 
and individuals such as physicians or other solo providers. 
This would benefit the VA in many ways and probably especially 
so in rural areas.
    A second provision in your bill would permanently eliminate 
certain provisions in title 38 which limit our ability to 
contract for health and health-related services. Last year, in 
Public Law 103-446, Congress suspended for five fiscal years 
the application of those limitations, which are found at 38 
U.S.C. Sec. 8110(c). Permanently eliminating the restrictions 
is consistent with the expanded sharing authority which your 
bill provides.
    As a final matter, your bill would ease title 38, section 
510, restrictions on the Department's ability to reorganize 
itself. Current statute requires the Department to provide 
Congress with advance notice of any administrative 
reorganization realigning functions and affecting more than 10 
percent of employees. After reporting a proposed 
reorganization, we can take no action to implement it until a 
``90-day continuous session of Congress'' waiting period 
expires. Your bill would amend the law to permit us to begin 
implementation 45 calendar days after we submit our report to 
Congress. We support this proposed change.
    The present waiting period is an onerous and unnecessary 
requirement. It is too long. The law provides that House or 
Senate recesses for four days or longer don't count. As a 
result, the waiting period typically will last for five to six 
months. The exact length of the waiting period is difficult to 
predict, and is subject to change up to the last minute because 
of changes in House or Senate recesses. This waiting period 
does not enable us to respond quickly to changes in the health 
care environment or to prepare to implement reorganizations on 
a precise timetable.
    The recent history of our VISN reorganization is a good 
example. We provided Congress with the required report for that 
reorganization on March 17, 1995, but the ``90 day'' waiting 
period did not end until September 5, 1995. Indeed, the House 
went into recess on the 89th day of the 90 day waiting period, 
requiring that we delay implementation for an additional six 
weeks until the House came back into session. Your 45 calendar 
day proposal would provide a sufficient time for Congressional 
review without unduly delaying managerial improvements.
S. 293--Adult day health care in State homes
    S. 293, introduced by Senator Conrad, would enhance the 
ability of States to offer adult day health care programs in 
State veteran homes. The bill would authorize us to pay states 
per diem (at a rate to be determined by the Secretary) for 
veterans who receive such care in a State Home. It would also 
authorize construction grants to states for use in developing 
facilities to furnish such care. As now configured, State 
Veterans Homes provide hospital, nursing home, and domiciliary 
care in facilities owned and operated by the states. VA 
contributes toward the cost of constructing and renovating the 
facilities through a grant program, and also helps pay 
operational costs by paying states a per diem for veterans 
living in the facility.
    Adult day health care generally refers to the provision of 
health care services in a congregate setting during day time 
hours. Adult day health care meets the needs of a very specific 
population. It is not a substitute for all types of nursing 
home care.
    In FY 1991, VA completed and transmitted a study to 
Congress of the adult day health care service in VA and 
community settings. The study concluded that these services are 
popular with patients and their families, but can be more 
expensive than other outpatient alternatives such as Hospital 
Based Home Care. Despite this, potential cost concern, we 
believe adult day health care should be an option for carefully 
selected veterans.
    We estimate that there would be no cost for this provision 
of the bill in the first year while it is being implemented. It 
is conceivable that the five year cost might be as much as $4.4 
million; however, if properly managed, we believe that use of 
this treatment option would be budget neutral.
S. 425--Mental illness research, education, and clinical care centers
    S. 425, introduced by Mr. Rockefeller, calls for the 
Department to establish and operate up to five VA health care 
facilities as centers for mental illness research, education, 
and clinical care. These centers are often referred to as 
MIRECC's, and they are patterned after VA's Geriatric Research, 
Education and Clinical Centers, which are known as GRECC's.
    As I believe representatives of the Department have stated 
in the past, it is the Department's view that we could 
establish MIRECC's without enactment of this legislation. 
Indeed, the Mental Health and Behavioral Sciences Service is 
currently drafting an RFP to establish up to five MIRECC's, 
depending on resource availability within the current 
appropriation.
    In addition to this, I would also note that we are 
currently reviewing the entire research program to better focus 
on the needs of veterans and to ensure optimal use of taxpayer 
dollars. Insofar as the MIRECC concept was proposed several 
years ago as a means of enhancing research on mental illness, 
this approach may not be the most effective means of achieving 
these goals today. We believe decisions on research strategy 
should be left to research managers who consider funding 
availability and competing priorities when determining the best 
approach to meet the mental health research needs of veterans.
    We estimate the costs of this measure would be the amounts 
authorized in the bill, which are $3.125 million for fiscal 
year 1996, and $6.25 million over each of fiscal years 1997 
through 1999.
S. 612--Hospice care program
    S. 625, introduced by Senator Rockefeller, would direct the 
Secretary to undertake two different projects to furnish 
hospice care to terminally ill veterans. The first project 
would be a five-year pilot program to determine the feasibility 
and desirability of furnishing such services. It would require 
that we furnish complete hospice care services at between 15 
and 30 medical centers using three different mechanisms, 
including direct VA care and contract care. The second project 
would require that VA furnish much more limited palliative care 
to veterans, both directly and through contracting. We would 
have to evaluate both projects continuously and report annually 
to the Congress regarding the evaluations.
    Over two years ago, my predecessor provided testimony 
before this committee on a bill substantially the same as that 
being considered today. He stated that the Department strongly 
supports providing hospice care for terminally ill veterans as 
an effective and humane way to care for those who choose it. He 
further indicated that VHA has in recent years established 
excellent programs for the terminally ill, negating the need 
for additional legislation. Today, I echo my predecessor in 
saying that care for the terminally ill is a critical component 
of providing complete health care service. We continue to 
believe that the proposed legislation is unnecessary and that 
resources to carry out an evaluative study of the various means 
of providing hospice services would be better used to enhance 
those programs we now operate.
    Having said this, I should briefly describe VA's hospice 
programs. Hospice actually refers to how one delivers care to 
the terminally ill patient, instead of a type of facility. 
Every medical center in our system has in place a hospice 
consultation team, which is the essence of the program. The 
consultation team exists to make certain that the patient 
receives ``hospice care.'' The team includes, at a minimum, a 
physician, a nurse, a social worker, and a chaplain. Each team 
consults with the patient's primary care team on pain 
management and other care issues. Additionally, the team is 
responsible for advising hospital management on policies and 
procedures related to provision of hospice and palliative care. 
Each team develops and maintains expertise in the clinical care 
of the terminally ill patient, and in the ethical issues 
involved in the care of the dying patient. Finally, the team 
keeps abreast of developments in Medicare and Medicaid hospice 
programs, as well as local community hospice programs.
    Some VA medical centers operate specially designated 
inpatient wards devoted exclusively to caring for the 
terminally ill. The decision whether to operate such an 
inpatient unit is left to individual medical center management 
and is somewhat dependent on bed availability.
    Hospice care is also provided to some veterans through 
community-based home hospice care providers. In cases where 
veterans are eligible for contract care, VA purchases the care 
for them. Additionally, veterans over the age of sixty-five are 
ordinarily eligible for Medicare benefits. When home hospice 
care is available through Medicare approved programs, our 
medical centers refer patients to those programs.
S. 548--Mammography standards
    Three years ago, Congress enacted the Mammography Quality 
Standards Act of 1992, which requires providers to comply with 
accreditation and other standards issued by the Department of 
Health and Human Services for mammography equipment, personnel, 
and quality assurance. VA facilities were expressly excluded 
from coverage under the statute. S. 548, also introduced by 
Senator Rockefeller, would compel VA to establish mammography 
standards that, at a minimum, meet HHS (FDA) standards. We 
compliment Senator Rockefeller for his advocacy on this issue.
    Likewise, I am sure you all will be pleased to know that VA 
policy now requires compliance with the requirements of the 
1992 Mammography Quality Standards Act. Moreover, all VA 
facilities furnishing mammography services are currently using 
the FDA's guidelines. Twenty-eight (28) of VA's 43 mammography 
programs are now fully accredited by the American College of 
Radiology. The remaining 15 have obtained provisional 
accreditation, and within four to six months will receive full 
ACR accreditation. As for contract providers, VA obtains 
mammography services only from FDA certified mammography 
facilities. Indeed, VA issued formal policy to this effect on 
July 11, 1995, thus formalizing existing practice in the 
Veterans Health Administration.
    In sum, thus, VA already has a mammography program in place 
that accomplishes what this bill seeks to do, and the proposed 
legislation is not needed.
S. 644--Research Corporations
    S. 644, introduced by Senator Campbell, would reestablish 
authority for VA to establish nonprofit research corporations 
at VA medical centers.
    Congress first authorized VA to establish nonprofit 
research corporations in 1988, but directed that all 
corporations be established by September 30, 1991. That date 
was subsequently extended to December 31, 1992. Corporations 
were established in 79 locations--i.e., at almost half of all 
VA medical centers. They were established at essentially all 
large, highly affiliated VA centers having sophisticated 
research programs. The corporations are able to obtain gifts, 
grants or contracts from non-VA public and private entities to 
support VA-approved research at VA medical facilities. In most 
cases, the corporations provide a benefit to VA's research 
program without representing any additional costs to VA.
    Despite the value of the existing research corporations, 
there is no compelling need, at this time, to establish 
research corporations at the remaining, mostly smaller, rural 
VA medical centers.
    As I noted earlier, we are not only engaged in a major 
reorganization of the veterans' medical system, but we are also 
reviewing the entire research program as well. After this 
review is done we would be in a better position to determine 
whether more of these entities are needed.
    In addition, we have just published national policy for the 
operation of VA nonprofit research corporations which includes 
guidance for administering, budgeting, and oversight of these 
corporations. We would like to see the efficiencies resulting 
from these guidelines before creating new organizations.
S. 403--Readjustment counseling
    S. 403, introduced by Senator Akaka, contains a number of 
different provisions affecting the Readjustment Counseling 
Service, and the Vet Centers through which we provide 
readjustment counseling services.
    Section 2 of the bill would preserve the existing 
organizational and administrative structure of the Readjustment 
Counseling Service by statutorily mandating that structure. It 
would permit alteration of the structure only after providing 
the Veterans' Affairs Committees with 60 days advance notice of 
the proposed changes. Finally, the section would require that 
each year, the President's Budget must specifically state the 
amount requested for readjustment counseling, including the 
amount requested to fund the Advisory Committee on the 
Readjustment of Veterans.
    As you know, VHA is now implementing a major 
reorganization, and we have determined that the organization 
and structure of the Readjustment Counseling Service should not 
be changed, since it appears to be working well at this time. 
Since any change to this structure already requires 
Congressional review and approval, we can see no advantage to 
statutorily locking in that structure. If at some point in time 
we determine that the organization does need change, we will, 
of course, work with the Congress, Veterans Service 
Organizations, and other interested parties to make certain 
those plans are in the best interests of the program. I would 
also point out that each year in the President's Budget, we 
identify the amount requested for the Readjustment Counseling 
Service, so it is unnecessary to add another law requiring what 
is already done.
    Section 3 of the bill would elevate the position of the 
Director of the Readjustment Counseling Service to that of an 
Assistant Under Secretary for Health. We do not support this 
provision. Earlier this year we sent a bill to Congress which 
would delete statutory requirements that we have discipline 
specific services and positions. We are seeking those changes 
so we may have the flexibility to determine which office and 
position in the organization can best provide management 
direction for particular functions. We intend to retain the 
position of Director of the Readjustment Counseling Service. 
However, to statutorily require that position, as proposed in 
this bill, would be inconsistent with our effort to remove 
these unnecessary requirements.
    Section 4 of the bill would revise eligibility for 
readjustment counseling services. It would provide that VA 
``shall'' furnish services to those now eligible, and to all 
other veterans who served in a combat theater during a period 
of war or other hostilities. It would provide that VA ``may'' 
furnish readjustment counseling to all other veterans. The law 
currently authorizes us to provide those services only to 
Vietnam era veterans, and veterans who served in the Persian 
Gulf, Lebanon, Panama, and Grenada.
    The Administration supports extending these services to 
wartime veterans who served in areas of conflict, particularly 
those who served in World War II and Korea. We anticipate being 
able to provide these services within existing appropriations. 
However, we do not believe we can afford to expand the program 
to all veterans at this time.
    Since their inception in 1979, the Vet Centers have 
primarily addressed the needs of veterans who served in war 
zones, and although all Vietnam Era veterans are eligible for 
services, most demand has been from those who actually served 
in Vietnam. Over the years, eligibility has been extended to 
others who served in the Persian Gulf, Panama, Grenada, and 
Lebanon. The focus of the program on war zone veterans 
recognizes the special readjustment needs those individuals 
have, including treatment of post-traumatic stress disorder 
resulting from combat. That focus has also served to 
distinguish Vet Centers, and make them unique from other mental 
health clinics which seek to meet the needs of a wider 
population.
    To provide all veterans with discretionary eligibility for 
readjustment counseling services might raise the expectations 
of those veterans that they might be able to receive services 
which VA is unlikely to be funded for. Moreover, providing 
services to all veterans could fundamentally change the nature 
of the Vet Centers and their counseling program. In the 
Department's view, veterans who served in combat are deserving 
of the special attention that the Readjustment Counseling 
Service now provides, and we should not compromise that program 
by trying to meet the broader counseling needs of the entire 
veteran population. Section 4 would also authorize Vet Centers 
to provide bereavement counseling. The bill would require that 
VA furnish such counseling to the families of all veterans who 
died in combat. It would permit counseling for families of 
those who are on active duty, or who die as a result of a 
service connected disability.
    The Administration supports a limited bereavement 
counseling role for the families of those who died in combat. 
This would be affordable, and it would be in keeping with the 
nature of Vet Centers as entities serving the specific needs of 
those who served in war. Again, we believe we can provide these 
services within existing appropriations.
    Section 5 of the bill would statutorily establish an 
Advisory Committee on Readjustment Counseling. In essence, it 
would provide a statutory mandate for the Department's current 
Advisory Committee on the Readjustment of Vietnam and Other War 
Veterans. The section would provide that members of the current 
committee would become members of the new committee. The bill 
contains many detailed provisions pertaining to the membership 
on the committee, its operation, and its functions. This 
provision is unnecessary.
    Section 6 would require that we prepare and submit to this 
committee, and its counterpart in the House, a plan for 
converting all Vet Centers into Vietnam Veteran Resource 
Centers. The plan must contain a timetable for this effort.
    Several years ago, at the direction of Congress, VA 
undertook a pilot program in several Vet Centers to provide 
additional services to those eligible for readjustment 
counseling. These resource centers provide benefits counseling; 
employment counseling, training and placement; intake and 
referral services for veterans needing substance abuse 
treatment; and general coordination of benefits. Whether to 
expand the resource center concept throughout the system is a 
matter that should be left to our planning processes. We see no 
need at this time to direct limited resources to the 
development of a plan to expand resource centers.
    Section 7 would require VA to submit a report to Congress 
on the feasibility and desirability of collocation of Vet 
Centers and outpatient clinics.
    Section 8 would direct that we carry out a two-year pilot 
program to provide veterans with outpatient medical services at 
Vet Centers. The bill directs that 10 Vet Centers in diverse 
locations serve as sites for furnishing veterans with basic 
ambulatory services and health care screening. The bill also 
calls for a report to Congress at the conclusion of the pilot 
program.
    Providing basic health care services in Vet Centers would 
fundamentally change the unique nature of these facilities. 
Much of the success these entities have experienced over the 
years is attributed to their not being outpatient clinics 
providing routine medical services. The centers are places 
where veterans who have suffered the psychological ravages of 
war can find assistance from counselors who often have had 
similar experiences. Experts in the field advise that 
introducing basic medical care services into the mix of 
services now provided by Vet Centers would compromise the 
continued success of these facilities.
    Notwithstanding the above, we already have the authority 
which would permit us to furnish outpatient medical services 
through Vet Centers. In some locations Vet Centers are, in 
fact, located side-by-side with clinics providing outpatient 
care. However, those are unique situations, and the facilities 
are carefully tailored to make certain that the Vet Center 
maintains its nature as a counseling center, not a medical 
clinic. But the point is that local VA managers currently have 
all the authority needed to co-locate these activities when it 
is desirable based on local circumstances.
    We have not had time to estimate the costs of this 
legislation, but we believe costs would exceed the estimate we 
made two years ago of $236 million over five fiscal years.
    Mr. Chairman, this concludes my formal testimony. I would 
be pleased to answer any questions.
                                ------                                



 statement of charles l. cragin, chairman, board of veterans' appeals, 
                     department of veterans affairs


    Mr. Chairman and Members of the Committee:
    I am pleased to be here today to present the views of the 
Department of Veterans Affairs (VA) on several bills. Those 
bills are:
          * * * * * * *
          S. 1750, a bill to modify disbursement agreement 
        authority to include residents and interns serving in 
        any VA facility providing hospital care or medical 
        services;
          * * * * * * *
          S. 1752, a bill to exempt full-time registered 
        nurses, physician assistants, and expanded-function 
        dental auxiliaries from restriction on remunerated 
        outside professional activities; and
          S. 1753, a bill to suspend a special pay agreement 
        for physicians and dentists who enter residency 
        training programs.
          * * * * * * *
S. 1750
    This bill would expand VA's authority to enter into 
disbursement agreements with participating medical institutions 
for the central administration of pay and other employee 
benefits for residents and interns who train at VA facilities. 
Currently, the law authorizes the use of such agreements only 
for residents and interns serving in VA hospitals but not those 
serving in outpatient clinics, nursing homes, or other VA 
medical facilities. VA requested this legislation to allow VA 
health care facilities which are not hospitals but are 
nonetheless increasingly important components of the VA health-
care delivery system to participate in the cost saving and 
other benefits provided by disbursement agreements.
          * * * * * * *
S. 1752
    This bill would exempt VHA full-time registered nurses 
(RNs), physician assistants (PAs), and expanded-function dental 
auxiliaries (EFDAs) from the restriction on moonlighting 
applicable to all title 38 employees. VA requested this 
legislation because the current restrictions on moonlighting 
for these employees is outdated. Removal of these restrictions 
on an employee's use of personal time will allow VA to be more 
competitive with employers who impose no such restriction. The 
original purpose of the outside-professional-activities 
restrictions was to ensure the availability of health care 
professionals who are responsible for around-the-clock care of 
VA patients. VA has considerable flexibility to ensure coverage 
of these three professions and no longer uses this authority to 
provide coverage.
S. 1753
    S. 1753 would authorize VA to suspend the special pay 
agreement of a physician or dentist who enters a residency 
training program, whether VA-sponsored or not. Currently, a VA 
physician or dentist (receiving special pay pursuant to a 
special pay agreement) who enters a residency training program 
must convert to a special appointment category that is excluded 
from receiving special pay. Thus, a VA physician who is 
receiving special pay cannot accept a residency training 
position or enter a non-VA sponsored residency prior to the 
expiration of the special pay agreement without breaching his 
or her agreement and triggering an obligation to repay the 
special pay received in that year. VA requested enactment of 
this bill to remove adverse financial consequences for those 
who wish to enter residency training programs to increase and 
develop their professional knowledge and skills. The bill 
waives the repayment requirement for staff who return to VA 
after their training is complete.
    This concludes my statement, Mr. Chairman. I would be 
pleased to answer any questions that you or the members of the 
Committee may have.

          Changes in Existing Law Made by S. 1359 as Reported

    In compliance with paragraph 12 of Rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the Committee bill, as reported, are shown as follows (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--VETERANS' BENEFITS

          * * * * * * *

                       PART I--GENERAL PROVISIONS

          * * * * * * *

            CHAPTER 5--AUTHORITY AND DUTIES OF THE SECRETARY

          * * * * * * *

                  Subchapter III--Advisory Committees

541. * * *
          * * * * * * *
545.  Advisory Committee on the Readjustment of Veterans.
          * * * * * * *

Sec. 510. Authority to reorganize offices

    (a) * * *
    (b) The Secretary may not in any fiscal year implement an 
administrative reorganization described in subsection (c) 
unless the Secretary first submits to the appropriate 
committees of the Congress a report containing a detailed plan 
and justification for the administrative reorganization. No 
action to carry out such reorganization may be taken after the 
submission of such report until the end of a [90-day period of 
continuous session of Congress following] 45-day period (30 
days of which shall be days during which Congress shall have 
been in continuous session) beginning on the date of the 
submission of the report. For purposes of the preceding 
sentence, continuity of a session of Congress is broken only by 
adjournment sine die, and there shall be excluded from the 
computation of such 90-day period any day during which either 
House of Congress is not in session during an adjournment of 
more than three days to a day certain.
          * * * * * * *

                  Subchapter III--Advisory Committees

          * * * * * * *

Sec. 545. Advisory Committee on the Readjustment of Veterans

    (a)(1) There is in the Department the Advisory Committee on 
the Readjustment of Veterans (hereinafter in this section 
referred to as the ``Committee'').
    (2) The Committee shall consist of not more than 18 members 
appointed by the Secretary from among individuals who--
          (A) have demonstrated significant civic or 
        professional achievement; and
          (B) have experience with the provision of veterans 
        benefits and services by the Department.
    (3) The Secretary shall seek to ensure that members 
appointed to the Committee include individuals from a wide 
variety of geographic areas and ethnic backgrounds, individuals 
from veterans service organizations, individuals with combat 
experience, and women.
    (4) The Secretary shall determine the terms of service and 
pay and allowances of the members of the Committee, except that 
a term of service may not exceed 2 years. The Secretary may 
reappoint any member for additional terms of service.
    (b)(1) The Secretary shall, on a regular basis, consult 
with and seek the advice of the Committee with respect to the 
provision by the Department of benefits and services to 
veterans in order to assist veterans in the readjustment to 
civilian life.
    (2)(A) In providing advice to the Secretary under this 
subsection, the Committee shall--
          (i) assemble and review information relating to the 
        needs of veterans in readjusting to civilian life;
          (ii) provide information relating to the nature and 
        character of psychological problems arising from 
        service in the Armed Forces;
          (iii) provide an on-going assessment of the 
        effectiveness of the policies, organizational 
        structures, and services of the Department in assisting 
        veterans in readjusting to civilian life; and
          (iv) provide on-going advice on the most appropriate 
        means of responding to the readjustment needs of 
        veterans in the future.
    (B) In carrying out its duties under subparagraph (A), the 
Committee shall take into special account the needs of veterans 
who have served in a theater of combat operations.
    (c)(1) Not later than March 31 of each year, the Committee 
shall submit to the Secretary a report on the programs and 
activities of the Department that relate to the readjustment of 
veterans to civilian life. Each such report shall include--
          (A) an assessment of the needs of veterans with 
        respect to readjustment to civilian life;
          (B) a review of the programs and activities of the 
        Department designed to meet such needs; and
          (C) such recommendations (including recommendations 
        for administrative and legislative action) as the 
        Committee considers appropriate.
    (2) Not later than 90 days after the receipt of a report 
under paragraph (1), the Secretary shall transmit to the 
Committees on Veterans' Affairs of the Senate and House of 
Representatives a copy of the report, together with any 
comments and recommendations concerning the report that the 
Secretary considers appropriate.
    (3) The Committee may also submit to the Secretary such 
other reports and recommendations as the Committee considers 
appropriate.
    (4) The Secretary shall submit with each annual report 
submitted to the Congress pursuant to section 529 of this title 
a summary of all reports and recommendations of the Committee 
submitted to the Secretary since the previous annual report of 
the Secretary submitted pursuant to that section.
    (d)(1) Except as provided in paragraph (2), the provisions 
of the Federal Advisory Committee Act (5 U.S.C. App.) shall 
apply to the activities of the Committee under this section.
    (2) Section 14 of such Act shall not apply to the 
Committee.
          * * * * * * *

                       PART II--GENERAL BENEFITS

          * * * * * * *

   CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

          * * * * * * *

   Subchapter VII--Hospice Care Pilot Program; Hospice Care Services

1761. Definitions.
1762. Hospice care: pilot program requirements.
1763. Care for terminally ill veterans.
1764. Information relating to hospice care services.
1765. Evaluation and reports.
     * * * * * * *

Subchapter II--Hospital, Nursing Home, or Domiciliary Care and Medical 
                               Treatment

          * * * * * * *

Sec. 1712A. Eligibility for readjustment counseling and related mental 
                    health services

    [(a)(1) Upon the request of any veteran who served on 
active duty during the Vietnam era, the Secretary shall, within 
the limits of Department facilities, furnish counseling to such 
veteran to assist such veteran in readjusting to civilian life. 
Such counseling shall include a general mental and 
psychological assessment to ascertain whether such veteran has 
mental or psychological problems associated with readjustment 
to civilian life.
    [(2)(A) The Secretary shall furnish counseling as described 
in paragraph (1), upon request, to any veteran who served on 
active duty after May 7, 1975, in an area at a time during 
which hostilities occurred in such area.
    [(B) For the purposes of subparagraph (A) of this 
paragraph, the term ``hostilities'' means an armed conflict in 
which members of the Armed Forces are subjected to danger 
comparable to the danger to which members of the Armed Forces 
have been subjected in combat with enemy armed forces during a 
period of war, as determined by the Secretary in consultation 
with the Secretary of Defense.]
    (a)(1)(A) Upon the request of any veteran referred to in 
subparagraph (B) of this paragraph, the Secretary shall furnish 
counseling to the veteran to assist the veteran in readjusting 
to civilian life.
    (B) Subparagraph (A) applies to the following veterans:
          (i) Any veteran who served on active duty in a 
        theater of combat operations (as determined by the 
        Secretary in consultation with the Secretary of 
        Defense) during the Vietnam era.
          (ii) Any veteran who served on active duty during the 
        Vietnam era if the veteran seeks such counseling before 
        January 1, 2000.
          (iii) Any veteran referred to in clause (ii) of this 
        subparagraph if the veteran is furnished counseling 
        under this subsection before the date referred to in 
        that clause.
          (iv) Any veteran who served on active military, 
        naval, or air service in a theater of combat operations 
        (as so determined) during a period of war, or in any 
        other area during a period in which hostilities (as 
        defined in subparagraph (D) of this paragraph) occurred 
        in such area.
    (C) Upon the request of any veteran other than a veteran 
covered by subparagraph (A) of this paragraph, the Secretary 
may furnish counseling to the veteran to assist the veteran in 
readjusting to civilian life.
    (D) For the purposes of subparagraph (B) of this paragraph, 
the term ``hostilities'' means an armed conflict in which the 
members of the Armed Forces are subjected to danger comparable 
to the danger to which members of the Armed Forces have been 
subjected in combat with enemy armed forces during a period of 
war, as determined by the Secretary in consultation with the 
Secretary of Defense.
    (2) The counseling referred to in paragraph (1) of this 
subsection shall include a general mental and psychological 
assessment of a covered veteran to ascertain whether such 
veteran has mental or psychological problems associated with 
readjustment to civilian life.
    (b)(1) * * *
          * * * * * * *
    [(c) Upon receipt of a request for counseling under this 
section from any individual who has been discharged or released 
from active military, naval, or air service but who is not 
eligible for such counseling, the Secretary shall--
          [(1) provide referral services to assist such 
        individual, to the maximum extent practicable, in 
        obtaining mental health care and services from sources 
        outside the Department; and
          [(2) if pertinent, advise such individual of such 
        individual's rights to apply to the appropriate 
        military, naval, or air service and the Department for 
        review of such individual's discharge or release from 
        such service.]
    (c)(1) The Secretary shall provide the counseling services 
described in section 1701(6)(B)(ii) of this title to the 
surviving parents, spouse, and children of any member of the 
Armed Forces who dies--
          (A) in a theater of combat operations (as determined 
        by the Secretary in consultation with the Secretary of 
        Defense) while on active military, naval, or air 
        service during a period of war;
          (B) in an area in which hostilities (as defined in 
        subsection (a)(1)(D) of this section) are occurring 
        while on such service during such hostilities;
          (C) as a result of a disease, injury, or condition 
        incurred while on such service in a theater of combat 
        operations (as so determined)
    (2) The Secretary may provide the counseling services 
referred to in paragraph (1) of this subsection to the 
surviving parents, spouse, and children of any member of the 
Armed Forces who dies while serving on active duty or from a 
condition (as determined by the Secretary) incurred in or 
aggravated by such service.
    (d) * * *
    (e)(1) In furnishing counseling and related mental health 
services under [subsections (a) and (b)] subsections (a), (b), 
and (c) of this section, the Secretary shall have available the 
same authority to enter into contracts with private facilities 
that is available to the Secretary (under sections 
1712(a)(1)(B) and 1703(a)(2) of this title) in furnishing 
medical services to veterans suffering from total service-
connected disabilities.
    (2) Before furnishing counseling or related mental health 
services described in [subsections (a) and (b)] subsections 
(a), (b), and (c) of this section through a contract facility, 
as authorized by this subsection, the Secretary shall approve 
(in accordance with criteria which the Secretary shall 
prescribe by regulation) the quality and effectiveness of the 
program operated by such facility for the purpose for which the 
counseling or services are to be furnished.
          * * * * * * *

                 Subchapter V--Payments to State Homes

Sec. 1741. Criteria for payment

    (a)(1) The Secretary shall pay each State at the per diem 
rate of--
          [(1)] (A) $8.70 for domiciliary care; and
          [(2)] (B) $20.35 for nursing home care and hospital 
        care, for each veteran receiving such care in a State 
        home, if such veteran is eligible for such care in a 
        Department facility.
    (2) The Secretary may pay each State per diem at a rate 
determined by the Secretary for each veteran receiving adult 
day health care in a State home, if such veteran is eligible 
for such care under laws administered by the Secretary.
          * * * * * * *

   Subchapter VII--Hospice Care Pilot Program; Hospice Care Services

Sec. 1761. Definitions

    For the purposes of this subchapter--
          (1) The term ``terminally ill veteran'' means any 
        veteran--
                  (A) who is (i) entitled to receive hospital 
                care in a medical facility of the Department 
                under section 1710(a)(1) of this title, (ii) 
                eligible for hospital or nursing home care in 
                such a facility and receiving such care, (iii) 
                receiving care in a State home facility for 
                which care the Secretary is paying per diem 
                under section 1741 of this title, or (iv) 
                transferred to a non-Department nursing home 
                for nursing home care under section 1720 of 
                this title and receiving such care; and
                  (B) who has a medical prognosis (as certified 
                by a Department physician) of a life expectancy 
                of six months or less.
          (2) The term ``hospice care services'' means--
                  (A) the care, items, and services referred to 
                in subparagraphs (A) through (H) of section 
                1861(dd)(1) of the Social Security Act (42 
                U.S.C. 1395x(dd)(1)); and
                  (B) personal care services.
          (3) The term ``hospice program'' means any program 
        that satisfies the requirements of section 1861(dd)(2) 
        of the Social Security Act (42 U.S.C. 1395x(dd)(2)).
          (4) The term ``medical facility of the Department'' 
        means a facility referred to in section 1701(3)(A) of 
        this title.
          (5) The term ``non-Department facility'' means a 
        facility (other than a medical facility of the 
        Department) at which care to terminally ill veterans is 
        furnished, regardless of whether such care is furnished 
        pursuant to a contract, agreement, or other arrangement 
        referred to in section 1762(b)(1)(D) of this title.
          (6) The term ``personal care services'' means any 
        care or service furnished to a person that is necessary 
        to maintain a person's health and safety within the 
        home or nursing home of the person, including care or 
        services related to dressing and personal hygiene, 
        feeding and nutrition, and environmental support.

Sec. 1762. Hospice care: pilot program requirements

    (a)(1) During the period beginning on October 1, 1996, and 
ending on December 31, 2001, the Secretary shall conduct a 
pilot program in order--
          (A) to assess the desirability of furnishing hospice 
        care services to terminally ill veterans; and
          (B) to determine the most effective and efficient 
        means of furnishing such services to such veterans.
    (2) The Secretary shall conduct the pilot program in 
accordance with this section.
    (b)(1) Under the pilot program, the Secretary shall--
          (A) designate not less than 15 nor more than 30 
        medical facilities of the Department at or through 
        which to conduct hospice care services demonstration 
        projects;
          (B) designate the means by which hospice care 
        services shall be provided to terminally ill veterans 
        under each demonstration project pursuant to subsection 
        (c);
          (C) allocate such personnel and other resources of 
        the Department as the Secretary considers necessary to 
        ensure that services are provided to terminally ill 
        veterans by the designated means under each 
        demonstration project; and
          (D) enter into any contract, agreement, or other 
        arrangement that the Secretary considers necessary to 
        ensure the provision of such services by the designated 
        means under each such project.
    (2) In carrying out the responsibilities referred to in 
paragraph (1) the Secretary shall take into account the need to 
provide for and conduct the demonstration projects so as to 
provide the Secretary with such information as is necessary for 
the Secretary to evaluate and assess the furnishing of hospice 
care services to terminally ill veterans by a variety of means 
and in a variety of circumstances.
    (3) In carrying out the requirement described in paragraph 
(2), the Secretary shall, to the maximum extent feasible, 
ensure that--
          (A) the medical facilities of the Department selected 
        to conduct demonstration projects under the pilot 
        program include facilities located in urban areas of 
        the United States and rural areas of the United States;
          (B) the full range of affiliations between medical 
        facilities of the Department and medical schools is 
        represented by the facilities selected to conduct 
        demonstration projects under the pilot program, 
        including no affiliation, minimal affiliation, and 
        extensive affiliation;
          (C) such facilities vary in the number of beds that 
        they operate and maintain; and
          (D) the demonstration projects are located or 
        conducted in accordance with any other criteria or 
        standards that the Secretary considers relevant or 
        necessary to furnish and to evaluate and assess fully 
        the furnishing of hospice care services to terminally 
        ill veterans.
    (c)(1) Subject to paragraph (2), hospice care to terminally 
ill veterans shall be furnished under a demonstration project 
by one or more of the following means designated by the 
Secretary:
          (A) By the personnel of a medical facility of the 
        Department providing hospice care services pursuant to 
        a hospice program established by the Secretary at that 
        facility.
          (B) By a hospice program providing hospice care 
        services under a contract with that program and 
        pursuant to which contract any necessary inpatient 
        services are provided at a medical facility of the 
        Department.
          (C) By a hospice program providing hospice care 
        services under a contract with that program and 
        pursuant to which contract any necessary inpatient 
        services are provided at a non-Department medical 
        facility.
    (2)(A) The Secretary shall provide that--
          (i) care is furnished by the means described in 
        paragraph (1)(A) at not less than five medical 
        facilities of the Department; and
          (ii) care is furnished by the means described in 
        subparagraphs (B) and (C) of paragraph (1) in 
        connection with not less than five such facilities for 
        each such means.
    (B) The Secretary shall provide in any contract under 
subparagraph (B) or (C) of paragraph (1) that inpatient care 
may be provided to terminally ill veterans at a medical 
facility other than that designated in the contract if the 
provision of such care at such other facility is necessary 
under the circumstances.
    (d)(1) Except as provided in paragraph (2), the amount paid 
to a hospice program for care furnished pursuant to 
subparagraph (B) or (C) of subsection (c)(1) may not exceed the 
amount that would be paid to that program for such care under 
section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) 
if such care were hospice care for which payment would be made 
under part A of title XVIII of such Act.
    (2) The Secretary may pay an amount in excess of the amount 
referred to in paragraph (1) (or furnish services whose value, 
together with any payment by the Secretary, exceeds such 
amount) to a hospice program for furnishing care to a 
terminally ill veteran pursuant to subparagraph (B) or (C) of 
subsection (c)(1) if the Secretary determines, on a case-by-
case basis, that--
          (A) the furnishing of such care to the veteran is 
        necessary and appropriate; and
          (B) the amount that would be paid to that program 
        under section 1814(i) of the Social Security Act would 
        not compensate the program for the cost of furnishing 
        such care.

Sec. 1763. Care for terminally ill veterans

    (a) During the period referred to in section 1762(a)(1) of 
this title, the Secretary shall designate not less than 10 
medical facilities of the Department at which hospital care is 
being furnished to terminally ill veterans in order to furnish 
the care referred to in subsection (b)(1).
    (b)(1) Palliative care to terminally ill veterans shall be 
furnished at the facilities referred to in subsection (a) by 
one of the following means designated by the Secretary:
          (A) By personnel of the Department providing one or 
        more hospice care services to such veterans at or 
        through medical facilities of the Department.
          (B) By personnel of the Department monitoring the 
        furnishing of one or more of such services to such 
        veterans at or through non-Department facilities.
    (2) The Secretary shall furnish care by the means referred 
to in each of subparagraphs (A) and (B) of paragraph (1) at not 
less than five medical facilities designated under subsection 
(a).

Sec. 1764. Information relating to hospice care services

    The Secretary shall ensure to the extent practicable that 
terminally ill veterans who have been informed of their medical 
prognosis receive information relating to the eligibility, if 
any, of such veterans for hospice care and services under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

Sec. 1765. Evaluation and reports

    (a) Not later than September 30, 1997, and on an annual 
basis thereafter until October 1, 2002, the Secretary shall 
submit a written report to the Committees on Veterans' Affairs 
of the Senate and House of Representatives relating to the 
conduct of the pilot program under section 1762 of this title 
and the furnishing of hospice care services under section 1763 
of this title. Each report shall include the following 
information:
          (1) The location of the sites of the demonstration 
        projects provided for under the pilot program.
          (2) The location of the medical facilities of the 
        Department at or through which hospice care services 
        are being furnished under section 1763 of this title.
          (3) The means by which care to terminally ill 
        veterans is being furnished under each such project and 
        at or through each such facility.
          (4) The number of veterans being furnished such care 
        under each such project and at or through each such 
        facility.
          (5) An assessment by the Secretary of any 
        difficulties in furnishing such care and the actions 
        taken to resolve such difficulties.
    (b) Not later than August 1, 2000, the Secretary shall 
submit to the committees referred to in subsection (a) a report 
containing an evaluation and assessment by the Under Secretary 
for Health of the hospice care pilot program under section 1762 
of this title and the furnishing of hospice care services under 
section 1763 of this title. The report shall contain such 
information (and shall be presented in such form) as will 
enable the committees to evaluate fully the desirability of 
furnishing hospice care services to terminally ill veterans.
    (c) The report under subsection (b) shall include the 
following:
          (1) A description and summary of the pilot program.
          (2) With respect to each demonstration project 
        conducted under the pilot program--
                  (A) a description and summary of the project;
                  (B) a description of the facility conducting 
                the demonstration project and a discussion of 
                how such facility was selected in accordance 
                with the criteria set out in, or prescribed by 
                the Secretary pursuant to, subparagraphs (A) 
                through (D) of section 1762(b)(3) of this 
                title;
                  (C) the means by which hospice care services 
                care are being furnished to terminally ill 
                veterans under the demonstration project;
                  (D) the personnel used to furnish such 
                services under the demonstration project;
                  (E) a detailed factual analysis with respect 
                to the furnishing of such services, including 
                (i) the number of veterans being furnished such 
                services, (ii) the number, if any, of inpatient 
                admissions for each veteran being furnished 
                such services and the length of stay for each 
                such admission, (iii) the number, if any, of 
                outpatient visits for each such veteran, and 
                (iv) the number, if any, of home-care visits 
                provided to each such veteran;
                  (F) the direct costs, if any, incurred by 
                terminally ill veterans, the members of the 
                families of such veterans, and other 
                individuals in close relationships with such 
                veterans in connection with the participation 
                of veterans in the demonstration project;
                  (G) the costs incurred by the Department in 
                conducting the demonstration project, including 
                an analysis of the costs, if any, of the 
                demonstration project that are attributable to 
                (i) furnishing such services in facilities of 
                the Department, (ii) furnishing such services 
                in non-Department facilities, and (iii) 
                administering the furnishing of such services; 
                and
                  (H) the unreimbursed costs, if any, incurred 
                by any other entity in furnishing services to 
                terminally ill veterans under the project 
                pursuant to section 1762(c)(1)(C) of this 
                title.
          (3) An analysis of the level of the following 
        persons' satisfaction with the services furnished to 
        terminally ill veterans under each demonstration 
        project:
                  (A) Terminally ill veterans who receive such 
                services, members of the families of such 
                veterans, and other individuals in close 
                relationships with such veterans.
                  (B) Personnel of the Department responsible 
                for furnishing such services under the project.
                  (C) Personnel of non-Department facilities 
                responsible for furnishing such services under 
                the project.
          (4) A description and summary of the means of 
        furnishing hospice care services at or through each 
        medical facility of the Department designated under 
        section 1763(a) of this title.
          (5) With respect to each such means, the information 
        referred to in paragraphs (2) and (3).
          (6) A comparative analysis by the Under Secretary for 
        Health of the services furnished to terminally ill 
        veterans under the various demonstration projects 
        referred to in section 1762 of this title and at or 
        through the designated facilities referred to in 
        section 1763 of this title, with an emphasis in such 
        analysis on a comparison relating to--
                  (A) the management of pain and health 
                symptoms of terminally ill veterans by such 
                projects and facilities;
                  (B) the number of inpatient admissions of 
                such veterans and the length of inpatient stays 
                for such admissions under such projects and 
                facilities;
                  (C) the number and type of medical procedures 
                employed with respect to such veterans by such 
                projects and facilities; and
                  (D) the effectiveness of such projects and 
                facilities in providing care to such veterans 
                at the homes of such veterans or in nursing 
                homes.
          (7) An assessment by the Under Secretary for Health 
        of the desirability of furnishing hospice care services 
        by various means to terminally ill veterans, including 
        an assessment by the Director of the optimal means of 
        furnishing such services to such veterans.
          (8) Any recommendations for additional legislation 
        regarding the furnishing of care to terminally ill 
        veterans that the Secretary considers appropriate.
          * * * * * * *

             PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

 CHAPTER 73--VETERANS HEALTH ADMINISTRATION--ORGANIZATION AND FUNCTIONS

          * * * * * * *

          Subchapter II--General Authority and Administration

7311. * * *
     * * * * * * *
7319. Mental illness research, education, and clinical centers
     * * * * * * *

Sec. 7319. Mental illness research, education, and clinical centers

    (a) The purpose of this section is to improve the provision 
of health-care services and related counseling services to 
eligible veterans suffering from mental illness, especially 
mental illness related to service-related conditions, through 
research (including research on improving mental health service 
facilities of the Department and on improving the delivery of 
mental health services by the Department), education and 
training of personnel, and the development of improved models 
and systems for the furnishing of mental health services by the 
Department.
    (b)(1) In order to carry out the purpose of this section, 
the Secretary, upon the recommendation of the Under Secretary 
for Health and pursuant to the provisions of this subsection, 
shall--
          (A) designate not more than five health-care 
        facilities of the Department as the locations for a 
        center of research on mental health services, on the 
        use by the Department of specific models for furnishing 
        such services, on education and training, and on the 
        development and implementation of innovative clinical 
        activities and systems of care with respect to the 
        delivery of such services by the Department; and
          (B) subject to the appropriation of funds for such 
        purpose, establish and operate such centers at such 
        locations in accordance with this section.
    (2) The Secretary shall designate at least one facility 
under paragraph (1) not later than January 1, 1997.
    (3) The Secretary shall, upon the recommendation of the 
Under Secretary for Health, ensure that the facilities 
designated for centers under paragraph (1) are located in 
various geographic regions.
    (4) The Secretary may not designate any health-care 
facility as a location for a center under paragraph (1) 
unless--
          (A) the peer review panel established under paragraph 
        (5) has determined under that paragraph that the 
        proposal submitted by such facility as a location for a 
        new center under this subsection is among those 
        proposals which have met the highest competitive 
        standards of scientific and clinical merit; and
          (B) the Secretary, upon the recommendation of the 
        Under Secretary for Health, determines that the 
        facility has developed (or may reasonably be 
        anticipated to develop)--
                  (i) an arrangement with an accredited medical 
                school which provides education and training in 
                psychiatry and with which the facility is 
                affiliated under which arrangement residents 
                receive education and training in psychiatry 
                through regular rotation through the facility 
                so as to provide such residents with training 
                in the diagnosis and treatment of mental 
                illness;
                  (ii) an arrangement with an accredited 
                graduate program of psychology under which 
                arrangement students receive education and 
                training in clinical, counseling, or 
                professional psychology through regular 
                rotation through the facility so as to provide 
                such students with training in the diagnosis 
                and treatment of mental illness;
                  (iii) an arrangement under which nursing, 
                social work, counseling, or allied health 
                personnel receive training and education in 
                mental health care through regular rotation 
                through the facility;
                  (iv) the ability to attract scientists who 
                have demonstrated creativity and achievement in 
                research--
                          (I) into the evaluation of innovative 
                        approaches to the design of mental 
                        health services; or
                          (II) into the causes, prevention, and 
                        treatment of mental illness;
                  (v) a policymaking advisory committee 
                composed of appropriate mental health-care and 
                research personnel of the facility and of the 
                affiliated school or schools to advise the 
                directors of the facility and the center on 
                policy matters pertaining to the activities of 
                the center during the period of the operation 
                of the center; and
                  (vi) the capability to evaluate effectively 
                the activities of the center, including the 
                evaluation of specific efforts to improve the 
                quality and effectiveness of mental health 
                services provided by the Department at or 
                through individual facilities.
    (5)(A) In order to provide advice to assist the Under 
Secretary for Health and the Secretary to carry out their 
responsibilities under this section, the official within the 
Central Office of the Veterans Health Administration 
responsible for mental health and behavioral sciences matters 
shall establish a panel to assess the scientific and clinical 
merit of proposals that are submitted to the Secretary for the 
establishment of new centers under this subsection.
    (B) The membership of the panel shall consist of experts in 
the fields of mental health research, education and training, 
and clinical care. Members of the panel shall serve as 
consultants to the Department for a period of no longer than 
six months.
    (C) The panel shall review each proposal submitted to the 
panel by the official referred to in subparagraph (A) and shall 
submit its views on the relative scientific and clinical merit 
of each such proposal to that official.
    (D) The panel shall not be subject to the provisions of the 
Federal Advisory Committee Act (5 U.S.C. App.).
    (c) Clinical and scientific investigation activities at 
each center established under subsection (b)(1) may compete for 
the award of funding from amounts appropriated for the 
Department of Veterans Affairs medical and prosthetics research 
account and shall receive priority in the award of funding from 
such account insofar as funds are awarded to projects and 
activities relating to mental illness.
    (d) The Under Secretary for Health shall ensure that at 
least three centers designated under subsection (b)(1)(A) 
emphasize research into means of improving the quality of care 
for veterans suffering from mental illness through the 
development of community-based alternatives to institutional 
treatment for such illness.
    (e) The Under Secretary for Health shall ensure that useful 
information produced by the research, education and training, 
and clinical activities of the centers established under 
subsection (b)(1) is disseminated throughout the Veterans 
Health Administration through publications and through programs 
of continuing medical and related education provided through 
regional medical education centers under subchapter VI of 
chapter 74 of this title and through other means.
    (f) The official within the Central Office of the Veterans 
Health Administration responsible for mental health and 
behavioral sciences matters shall be responsible for 
supervising the operation of the centers established pursuant 
to subsection (b)(1).
    (g)(1) There are authorized to be appropriated for the 
Department of Veterans Affairs for the basic support of the 
research and education and training activities of the centers 
established pursuant to subsection (b)(1) the following:
          (A) $3,125,000 for fiscal year 1997.
          (B) $6,250,000 for each of fiscal years 1998 through 
        2000.
    (2) In addition to the funds available under the 
authorization of appropriations in paragraph (1), the Under 
Secretary for Health shall allocate to such centers from other 
funds appropriated generally for the Department of Veterans 
Affairs medical care account and the Department of Veterans 
Affairs medical and prosthetics research account such amounts 
as the Under Secretary for Health determines appropriate in 
order to carry out the purposes of this section.
          * * * * * * *

                  Subchapter IV--Research Corporations

Sec. 7361. Authority to establish; status

    (a) * * *
    (b) If by the end of the four-year period beginning on the 
date of the establishment of a corporation under this 
subchapter the corporation is not recognized as an entity the 
income of which is exempt from taxation under [section 
501(c)(3) of] the Internal Revenue Code of 1986, the Secretary 
shall dissolve the corporation.
          * * * * * * *

Sec. 7363. Board of directors; executive director

    (a) * * *
          * * * * * * *
    (c) An individual appointed under subsection (a)(2) to the 
board of directors of a corporation established under this 
subchapter may not be affiliated with, employed by, or have any 
other financial relationship with any entity that is a source 
of funding for research by the Department unless that source of 
funding is a governmental entity or an entity the income of 
which is exempt from taxation under [section 501(c)(3) of] the 
Internal Revenue Code of 1986.
          * * * * * * *

Sec. 7366. Accountability and oversight

    (a)(1)(A) * * *
          * * * * * * *
    [(d) The Secretary shall submit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives an 
annual report on the number and location of corporations 
established and the amount of the contributions made to each 
such corporation.]
    (d) The Secretary shall submit to the Committees on 
Veterans' Affairs of the Senate and the House of 
Representatives an annual report on the corporations 
established under this subchapter. The report shall set forth 
the following information:
          (1) The location of each corporation.
          (2) The amount received by each corporation during 
        the previous year, including--
                  (A) the total amount received;
                  (B) the amount received from governmental 
                entities;
                  (C) the amount received from entities the 
                income of which is exempt from taxation under 
                section 501(c)(3) of the Internal Revenue Code 
                of 1986 (26 U.S.C. 501(c)(3));
                  (D) the amount received from all other 
                sources; and
                  (E) if the amount received from a source 
                referred to in subparagraph (D) exceeded 
                $25,000, information that identifies the 
                source.
          (3) The amount expended by each corporation during 
        the year, including--
                  (A) the amount expended for salary for 
                research staff and for salary for support 
                staff;
                  (B) the amount expended for other direct 
                support of research; and
                  (C) if the amount expended with respect to 
                any source exceeded $10,000, information that 
                identifies the source.
          * * * * * * *

Sec. 7368. Expiration of authority

    No corporation may be established under this subchapter 
after [December 31, 1992] December 31, 2000.

         CHAPTER 74--VETERANS HEALTH ADMINISTRATION--PERSONNEL

                       Subchapter I--Appointments

          * * * * * * *

Sec. 7406. Residencies and internships

    (a)(1) * *  *
          * * * * * * *
    (c)(1) * * *
          * * * * * * *
    (2) The Secretary may pay to such designated agency, 
without regard to any other law or regulation governing the 
expenditure of Government moneys either in advance or in 
arrears, an amount to cover the cost for the period such intern 
or resident serves in a [Department hospital] Department 
facility furnishing hospital care or medical services of--
          (A) * * *
          (B) hospitalization, medical care, and life insurance 
        and any other employee benefits as are agreed upon by 
        the participating institutions for the period that such 
        intern or resident serves in a [Department hospital] 
        Department facility;
           * * * * * * *
    (3)(A) * * *
    (B) Notwithstanding subparagraph (A), any period of service 
of any such intern or resident in a [Department hospital] 
Department facility furnishing hospital care or medical 
services shall be deemed creditable service for the purposes of 
section 8332 of title 5.
    (4) The agreement with such central administrative agency 
may further provide that the designated central administrative 
agency shall--
          (A) * * *
           * * * * * * *
          (C) maintain all records pertinent to the leave 
        accrued by such intern and resident for the period 
        during which such recipient serves in a [participating 
        hospital, including a Department hospital] 
        participating facility, including a Department 
        facility.
    (5) Leave described in paragraph (4)(C) may be pooled, and 
the intern or resident may be afforded leave by the [hospital] 
facility in which such person is serving at the time the leave 
is to be used to the extent of such person's total accumulated 
leave, whether or not earned at the [hospital] facility in 
which such person is serving at the time the leave is to be 
afforded.
           * * * * * * *

   Subchapter II--Collective Bargaining and Personnel Administration

Sec. 7423. Personnel administration: full-time employees

    (a) * * *
    (b) A person covered by subsection (a) may not do any of 
the following:
          [(1) Assume responsibility for the medical care of 
        any patient other than a patient admitted for treatment 
        at a Department facility, except in those cases where 
        the person, upon request and with the approval of the 
        Under Secretary for Health, assumes such 
        responsibilities to assist communities or medical 
        practice groups to meet medical needs which would not 
        otherwise be available for a period not to exceed 180 
        calendar days, which may be extended by the Under 
        Secretary for Health for additional periods not to 
        exceed 180 calendar days each.]
          [(2)] (1) Teach or provide consultative services at 
        any affiliated institution if such teaching or 
        consultation will, because of its nature or duration, 
        conflict with such person's responsibilities under this 
        title.
          [(3)] (2) Accept payment under any insurance or 
        assistance program established under title XVIII or XIX 
        of the Social Security Act or under chapter 55 of title 
        10 for professional services rendered by such person 
        while carrying out such person's responsibilities under 
        this title.
          [(4)] (3) Accept from any source, with respect to any 
        travel performed by such person in the course of 
        carrying out such person's responsibilities under this 
        title, any payment or per diem for such travel, other 
        than as provided for in section 4111 of title 5.
          [(5)] (4) Request or permit any individual or 
        organization to pay, on such person's behalf for 
        insurance insuring such person against malpractice 
        claims arising in the course of carrying out such 
        person's responsibilities under this title or for such 
        person's dues or similar fees for membership in medical 
        or dental societies or related professional 
        associations, except where such payments constitute a 
        part of such person's remuneration for the performance 
        of professional responsibilities permitted under this 
        section, other than those carried out under this title.
          [(6)] (5) Perform, in the course of carrying out such 
        person's responsibilities under this title, 
        professional services for the purpose of generating 
        money for any fund or account which is maintained by an 
        affiliated institution for the benefit of such 
        institution, or for such person's personal benefit, or 
        both.
    (c) In the case of any fund or account described in 
[subsection (b)(6)] subsection (b)(5) that was established 
before September 1, 1973--
          (1) * * *
           * * * * * * *

        Subchapter III--Special Pay for Physicians and Dentists

SEC. 7432. SPECIAL PAY: WRITTEN AGREEMENTS.

    (a) * * *
    (b)(1) * * *
    (2)(A) The Secretary may waive (in whole or in part) the 
requirement for a refund under paragraph (1) in any case if the 
Secretary determines (in accordance with regulations prescribed 
under section 7431(a) of this title) that the failure to 
complete such period of service is the result of circumstances 
beyond the control of the physician or dentist.
    (B) The Secretary may suspend the applicability of an 
agreement under this subchapter in the case of a physician or 
dentist who enters a residency training program for the period 
of the participation of the physician or dentist, as the case 
may be, in the program. The physician or dentist shall not be 
subject to the refund requirements with respect to the 
agreement under paragraph (1) during the period of the 
suspension.
           * * * * * * *

            PART VI--ACQUISITION AND DISPOSITION OF PROPERTY

   CHAPTER 81--ACQUISITION AND OPERATION OF HOSPITAL AND DOMICILIARY 
    FACILITIES; PROCUREMENT AND SUPPLY; ENHANCED-USE LEASES OF REAL 
                                PROPERTY

           * * * * * * *

     Subchapter IV--Sharing of Medical Facilities, Equipment, and 
                              Information

8151. * * *
      * * * * * * *
8153. [Specialized medical resources.] Sharing of health-care resources.
          * * * * * * *

     Subchapter I--Acquisition and Operation of Medical Facilities

           * * * * * * *

Sec. 8110. Operation of medical facilities

    (a)(1) * * *
           * * * * * * *
    [(c)(1) Notwithstanding any other provision of law but 
except as provided in paragraph (3) of this subsection--
          [(A) a contract may not be entered into as a result 
        of which an activity at a health-care facility over 
        which the Secretary has direct jurisdiction 
        (hereinafter in this subsection referred to as a 
        ``Department health-care facility'') would be converted 
        from an activity performed by Federal employees to an 
        activity performed by employees of a contractor of the 
        Government unless the Under Secretary for Health has 
        determined that such activity is not a direct patient 
        care activity or an activity incident to direct patient 
        care; and
          [(B) in the case of an activity determined by the 
        Under Secretary for Health under clause (A) of this 
        paragraph to be neither such activity, the Secretary, 
        after considering the advice of the Under Secretary for 
        Health and the results of a study described in 
        paragraph (4) of this subsection, may, in the exercise 
        of the Secretary's sole discretion but subject to 
        paragraph (2) of this subsection, enter into a contract 
        as a result of which the activity would be converted 
        from an activity performed by Federal employees to an 
        activity performed by employees of a contractor of the 
        Government.
    [(2) The Secretary may enter into a contract under the 
circumstances described in paragraph (1)(B) of this subsection 
only if responsive bids are received from at least two 
responsible, financially autonomous bidders and the Secretary 
determines--
          [(A) based on the study described in paragraph (4) of 
        this subsection with respect to the activity involved, 
        that the cost to the Government of the performance of 
        such activity under such a contract over the first five 
        years of such performance (including the cost to the 
        Government of conducting the study) would be lower by 
        15 percent or more than the cost of performance of such 
        activity by Federal employees; and
          [(B) that the quantity and quality of health-care 
        services provided to eligible veterans by the 
        Department at the facility at which the activity is 
        carried out would be maintained or enhanced as a result 
        of such a contract.
    [(3) The provisions of paragraph (1) of this subsection do 
not apply--
          [(A) to a contract or agreement under chapter 17 or 
        section 8111, 8111A, or 8153 of this title or under 
        section 1535 of title 31; or
          [(B) to a contract under section 513 or 7409 of this 
        title if the Under Secretary for Health determines that 
        such contract is necessary in order to provide services 
        to eligible veterans at a Department health-care 
        facility that could not otherwise be provided at such 
        facility.
    [(4) A study referred to in paragraph (1)(B) of this 
subsection is a study that--
          [(A) compares the cost of performing an activity at a 
        Department health-care facility through Federal 
        employees with the cost of performing such activity 
        through a contractor of the Government;
          [(B) is based on an estimate of the most efficient 
        and cost- effective organization for the effective 
        performance of the activity by Federal employees;
          [(C) with respect to the costs of performance of such 
        activity through Federal employees, is based (to the 
        maximum extent feasible) on actual cost factors of the 
        Department for pay and retirement and other fringe 
        benefits for the Federal employees who perform the 
        activity; and
          [(D) takes into account (i) the costs to the 
        Government (including severance pay) that would result 
        from the separation of employees whose Federal 
        employment may be terminated as a result of the 
        Secretary entering into a contract described in 
        paragraph (1)(B) of this subsection, and (ii) all costs 
        to the Government associated with the contracting 
        process.
    [(5) Prior to conducting a study described in paragraph (4) 
of this subsection, the Secretary shall (in a timely manner) 
submit to the appropriate committees of the Congress written 
notice of a decision to study the activity involved for 
possible performance by a contractor.
    [(6) If, after completion of a study described in paragraph 
(4) of this subsection, a decision is made to convert 
performance of the activity involved to contractor performance, 
the Secretary shall promptly submit to the appropriate 
committees of the Congress written notice of such decision and 
a report with respect to such conversion. Each such report 
shall include--
          [(A) a summary of the study described in paragraph 
        (4) of this subsection with respect to such contract;
          [(B) a certification that the study itself is 
        available to such committees and that the results of 
        the study meet the requirements of paragraph (2)(A) of 
        this subsection;
          [(C) a certification that the requirements of 
        paragraph (2)(B) of this subsection would be met with 
        respect to such contract and a summary of the 
        information that supports such certification;
          [(D) if more than 25 jobs are affected, information 
        showing the potential economic impact on the Federal 
        employees affected and the potential economic impact on 
        the local community and the Government of contracting 
        for performance of such activity; and
          [(E) information showing the amount of the bid 
        accepted for a contract for the performance of the 
        activity and the cost of performance of such activity 
        by Federal employees, together with the total estimated 
        cost which the Government will incur because of the 
        contract.
    [(7) Paragraphs (1) through (6) shall not be in effect 
during fiscal years 1995 through 1999.
    [(8) During the period covered by paragraph (7), whenever 
an activity at a Department health-care facility is converted 
from performance by Federal employees to performance by 
employees of a contractor of the Government, the Secretary 
shall--
          [(A) require in the contract for the performance of 
        such activity that the contractor, in hiring employees 
        for the performance of the contract, give priority to 
        former employees of the Department who have been 
        displaced by the award of the contract; and
          [(B) provide to such former employees of the 
        Department all possible assistance in obtaining other 
        Federal employment or entrance into job training and 
        retraining programs.
    [(9) The Secretary shall include in the Secretary's annual 
report to Congress under section 529 of this title, for each 
fiscal year covered by paragraph (7), a report on the use 
during the year covered by the report of contracting-out 
authority made available by reason of paragraph (7). The 
Secretary shall include in each such report a description of 
each use of such authority, together with the rationale for the 
use of such authority and the effect of the use of such 
authority on patient care and on employees of the Department.]
          * * * * * * *

   Subchapter III--State Home Facilities for Furnishing Domiciliary, 
                    Nursing Home, and Hospital Care

Sec. 8131. Definitions

    For the purpose of this subchapter--
          (1) * * *
          * * * * * * *
          (3) The term ``construction'' means the construction 
        of new domiciliary or nursing home buildings, the 
        expansion, remodeling, or alteration of existing 
        buildings for the provision of domiciliary, nursing 
        home, adult day health, or hospital care in State 
        homes, and the provision of initial equipment for any 
        such buildings.

Sec. 8132. Declaration of purpose

    The purpose of this subchapter is to assist the several 
States to construct State home facilities (or to acquire 
facilities to be used as State home facilities) for furnishing 
domiciliary or nursing home care to veterans, and to expand, 
remodel, or alter existing buildings for furnishing 
domiciliary, nursing home, adult day health, or hospital care 
to veterans in State homes.
          * * * * * * *

Sec. 8135. Applications with respect to projects; payments

    (a) * * *
    (b)(1) * * *
    (2) Subject to paragraphs (3) and (5)(C) of this 
subsection, the Secretary shall accord priority to applications 
in the following order:
          (A) * * *
          * * * * * * *
          (C) An application from a State which the Secretary 
        determines, in accordance with criteria and procedures 
        specified in regulations which the Secretary shall 
        prescribe, has a greater need for nursing home or 
        domiciliary beds or adult day health care facilities 
        than other States from which applications are received.
          (D) * * *
    (3) In according priorities to projects under paragraph (2) 
of this subsection, the Secretary--
          (A) shall accord priority only to projects which 
        would involve construction or acquisition of either 
        nursing home or domiciliary buildings or construction 
        (other than new construction) of adult day health care 
        buildings; and
          * * * * * * *

     Subchapter IV--Sharing of Medical Facilities, Equipment, and 
                              Information

Sec. 8151. Statement of congressional purpose

    [It is the purpose of this subchapter to improve the 
quality of hospital care and other medical service provided 
veterans under this title, by authorizing the Secretary to 
enter into agreements with medical schools, health-care 
facilities, and research centers throughout the country in 
order to receive from and share with such medical schools, 
health-care facilities, and research centers the most advanced 
medical techniques and information, as well as certain 
specialized medical resources which otherwise might not be 
feasibly available or to effectively utilize other medical 
resources with the surrounding medical community, without 
diminution of services to veterans. Among other things, it is 
intended, by these means, to strengthen the medical programs at 
those Department hospitals which are located in small cities or 
rural areas and thus are remote from major medical centers. It 
is further the purpose of this subchapter to improve the 
provision of care to veterans under this title by authorizing 
the Secretary to enter into agreements with State veterans 
facilities for the sharing of health-care resources.] It is the 
purpose of this subchapter to improve the quality of health 
care provided veterans under this title by authorizing the 
Secretary to enter into agreements with health-care providers 
in order to share health-care resources with, and receive 
health-care resources from, such providers while ensuring no 
diminution of services to veterans. Among other things, it is 
intended by these means to strengthen the medical programs at 
Department facilities located in small cities or rural areas 
which facilities are remote from major medical centers.

Sec. 8152. Definitions

    For the purposes of this subchapter--
          [(1) The term ``research center'' means an 
        institution (or part of an institution), the primary 
        function of which is research, training of specialists, 
        and demonstrations and which, in connection therewith, 
        provides specialized, high quality diagnostic and 
        treatment services for inpatients and outpatients.
          [(2) The term ``specialized medical resources'' means 
        medical resources (whether equipment, space, or 
        personnel) which, because of cost, limited 
        availability, or unusual nature, are either unique in 
        the medical community or are subject to maximum 
        utilization only through mutual use.
          [(3) The term ``health-care resource'' includes 
        hospital care, medical services, and rehabilitative 
        services, as those terms are defined in paragraphs (5), 
        (6), and (8), respectively, of section 1701 of this 
        title, any other health-care service, and any health-
        care support or administrative resource.]
          (1) The term ``health-care resource'' includes 
        hospital care (as that term is defined in section 
        1701(5) of this title), any other health-care service, 
        and any health-care support or administrative resource.
          (2) The term ``health-care providers'' includes 
        health-care plans and insurers and any organizations, 
        institutions, or other entities or individuals that 
        furnish health-care resources.
          [(4)] (3) The term ``hospital'', unless otherwise 
        specified, includes any Federal, State, local, or other 
        public or private hospital.

Sec. 8153. [Specialized medical resources] Sharing of health-care 
                    resources

    [(a)(1) To secure certain specialized medical resources 
which otherwise might not be feasibly available, or to 
effectively utilize certain other medical resources, the 
Secretary may, when the Secretary determines it to be in the 
best interest of the prevailing standards of the Department 
medical care program, make arrangements, by contract or other 
form of agreement for the mutual use, or exchange of use, of--
          [(A) specialized medical resources between Department 
        health-care facilities and other health-care facilities 
        (including organ banks, blood banks, or similar 
        institutions), research centers, or medical schools; 
        and
          [(B) health-care resources between Department health-
        care facilities and State home facilities recognized 
        under section 1742(a) of this title.]
    (a)(1) The Secretary, when the Secretary determines it to 
be necessary in order to secure health-care resources which 
might not otherwise be feasibly available or to utilize 
effectively health-care resources, may make arrangements, by 
contract or other form of agreement, for the mutual use, or 
exchange of use, of health-care resources between Department 
health-care facilities and non-Department health-care 
providers. The Secretary may make such arrangements without 
regard to any law or regulation relating to competitive 
procedures.
    (2) * * *
          * * * * * * *
    [(e) The Secretary shall submit to the Congress not more 
than 60 days after the end of each fiscal year a report on the 
activities carried out under this section. Each report shall 
include--
          [(1) an appraisal of the effectiveness of the 
        activities authorized in this section and the degree of 
        cooperation from other sources, financial and 
        otherwise; and
          [(2) recommendations for the improvement or more 
        effective administration of such activities.]
                              ----------                              


                    VETERANS HEALTH CARE ACT OF 1992

          * * * * * * *

TITLE II--HEALTH-CARE SHARING AGREEMENTS BETWEEN DEPARTMENT OF VETERANS 
                   AFFAIRS AND DEPARTMENT OF DEFENSE

          * * * * * * *

SEC. 204. EXPIRATION OF AUTHORITY.

    The authority to provide services pursuant to agreements 
entered into under section 201 expires on [October 1, 1996] 
December 31, 1998.
                              ----------                              


              VETERANS' BENEFITS IMPROVEMENTS ACT OF 1994

          * * * * * * *

                   TITLE I--PERSIAN GULF WAR VETERANS

          * * * * * * *

SEC. 107. EVALUATION OF HEALTH STATUS OF SPOUSES AND CHILDREN OF 
                    PERSIAN GULF WAR VETERANS.

    (a) * * *
    (b) Duration of Program.--The program shall be carried out 
during the period beginning on November 1, 1994, and ending on 
[September 30, 1996] December 31, 1998.