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114th Congress} { Rept. 114-546
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
======================================================================
PROMOTING RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING SCIENTIFIC
EXPERTISE ACT
_______
May 10, 2016.--Committed to the Committee of the Whole House on the
state of the Union and ordered to be printed
_______
Mr. Miller of Florida, from the Committee on Veterans' Affairs,
submitted the following
R E P O R T
[To accompany H.R. 4063]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 4063) to improve the use by the Secretary of
Veterans Affairs of opioids in treating veterans, to improve
patient advocacy by the Secretary, and to expand the
availability of complementary and integrative health, and for
other purposes, having considered the same, report favorably
thereon with an amendment and recommend that the bill as
amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 15
Background and Need for Legislation.............................. 16
Hearings......................................................... 26
Subcommittee Consideration....................................... 27
Committee Consideration.......................................... 27
Committee Votes.................................................. 27
Committee Oversight Findings..................................... 27
Statement of General Performance Goals and Objectives............ 27
New Budget Authority, Entitlement Authority, and Tax Expenditures 28
Earmarks and Tax and Tariff Benefits............................. 28
Committee Cost Estimate.......................................... 28
Congressional Budget Office Estimate............................. 28
Federal Mandates Statement....................................... 32
Advisory Committee Statement..................................... 32
Constitutional Authority Statement............................... 32
Applicability to Legislative Branch.............................. 32
Exchange of Committee Correspondence............................. 34
Statement on Duplication of Federal Programs..................... 35
Disclosure of Directed Rulemaking................................ 35
Section-by-Section Analysis of the Legislation................... 35
Changes in Existing Law Made by the Bill as Reported............. 45
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Promoting
Responsible Opioid Management and Incorporating Scientific Expertise
Act'' or the ``Jason Simcakoski PROMISE Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--OPIOID THERAPY AND PAIN MANAGEMENT
Sec. 101. Establishment of Advisory Committee to review guidelines on
management of opioid therapy by Department of Veterans Affairs and
Department of Defense.
Sec. 102. Improvement of opioid safety measures by Department of
Veterans Affairs.
Sec. 103. Strengthening of joint working group on pain management of
the Department of Veterans Affairs and the Department of Defense.
Sec. 104. Review, investigation, and report on use of opioids in
treatment by Department of Veterans Affairs.
Sec. 105. Mandatory disclosure of certain veteran information to State
controlled substance monitoring programs.
TITLE II--PATIENT ADVOCACY
Sec. 201. Community meetings on improving care furnished by Department
of Veterans Affairs.
Sec. 202. Improvement of awareness of patient advocacy program and
patient bill of rights of Department of Veterans Affairs.
Sec. 203. Comptroller general report on patient advocacy program of
Department of Veterans Affairs.
TITLE III--COMPLEMENTARY AND INTEGRATIVE HEALTH
Sec. 301. Expansion of research and education on and delivery of
complementary and integrative health to veterans.
Sec. 302. Pilot program on integration of complementary alternative
medicines and related issues for veterans and family members of
veterans.
TITLE IV--FITNESS OF HEALTH CARE PROVIDERS
Sec. 401. Additional requirements for hiring of health care providers
by Department of Veterans Affairs.
Sec. 402. Provision of information on health care providers of
Department of Veterans Affairs to State Medical Boards.
Sec. 403. Report on compliance by Department of Veterans Affairs with
reviews of health care providers leaving the Department or transferring
to other facilities.
TITLE V--OTHER VETERANS MATTERS
Sec. 501. Audit of Veterans Health Administration programs of
Department of Veterans Affairs.
TITLE I--OPIOID THERAPY AND PAIN MANAGEMENT
SEC. 101. ESTABLISHMENT OF ADVISORY COMMITTEE TO REVIEW GUIDELINES ON
MANAGEMENT OF OPIOID THERAPY BY DEPARTMENT OF
VETERANS AFFAIRS AND DEPARTMENT OF DEFENSE.
(a) Advisory Committee.--Not later than 120 days after the date of
the enactment of this Act, the Secretary of Veterans Affairs and the
Secretary of Defense shall jointly convene an advisory committee to--
(1) conduct a thorough review of the most recent VA/DOD
Clinical Practice Guideline for Management of Opioid Therapy
for Chronic Pain; and
(2) make recommendations to the Secretaries with respect to
updating the Clinical Practice Guideline.
(b) Matters Included.--In conducting the review under subsection
(a)(1), the Advisory Committee shall examine whether the Clinical
Practical Guideline should include the following:
(1) Enhanced guidance with respect to--
(A) the coadministration of an opioid and other
drugs, including benzodiazepines, that may result in
life-limiting drug interactions;
(B) the treatment of patients with current acute
psychiatric instability or substance use disorder or
patients at risk of suicide; and
(C) the use of opioid therapy to treat mental health
disorders other than opioid use disorder.
(2) Enhanced guidance with respect to the treatment of
patients with behaviors or comorbidities, such as post-
traumatic stress disorder or other psychiatric disorders, or a
history of substance abuse or addiction, that requires a
consultation or comanagement of opioid therapy with one or more
specialists in pain management, mental health, or addictions.
(3) Enhanced guidance with respect to health care providers--
(A) conducting an effective assessment for patients
beginning or continuing opioid therapy, including
understanding and setting realistic goals with respect
to achieving and maintaining an expected level of pain
relief, improved function, or a clinically appropriate
combination of both; and
(B) effectively assessing whether opioid therapy is
achieving or maintaining the established treatment
goals of the patient or whether the patient and health
care provider should discuss adjusting, augmenting , or
discontinuing the opioid therapy.
(4) Guidance that each health care provider of the Department
of Veterans Affairs and the Department of Defense, before
initiating opioid therapy to treat a patient as part of the
comprehensive assessment conducted by the health care provider,
use the Opioid Therapy Risk Report tool of the Department of
Veterans Affairs (or similar monitoring tool), which shall
include information from the prescription drug monitoring
program of each State that includes the most recent information
to date relating to the patient that accessed such program to
assess the risk for adverse outcomes of opioid therapy for the
patient, including the concurrent use of controlled substances
such as benzodiazepines, as part of the comprehensive
assessment conducted by the health care provider.
(5) Guidelines to govern the methodologies used by health
care providers of the Department of Veterans Affairs and the
Department of Defense to taper opioid therapy when adjusting or
discontinuing the use of opioid therapy.
(6) Guidelines with respect to appropriate case management
for patients receiving opioid therapy who transition between
inpatient and outpatient health care settings, which may
include the use of care transition plans.
(7) Guidelines with respect to appropriate case management
for patients receiving opioid therapy who transition from
receiving care during active duty to post-military health care
networks.
(8) Enhanced standards with respect to the use of routine and
random urine drug tests for all patients before and during
opioid therapy to help prevent substance abuse, dependence, and
diversion, including--
(A) that such tests occur not less frequently than
once each year; and
(B) that health care providers appropriately order,
interpret and respond to the results from such tests to
tailor pain therapy, safeguards, and risk management
strategies to each patient.
(9) Guidance that health care providers discuss with
patients, before initiating opioid therapy, options for pain
management therapies without the use of opioids and options to
augment opioid therapy with other clinical and complementary
and integrative health services to minimize opioid dependence.
(10) Guidance for health care providers with respect to
evidence-based non-opioid treatments within the Department of
Veterans Affairs and the Department of Defense, including
medical devices and other therapies approved or cleared by the
Food and Drug Administration for the treatment of chronic pain
as an alternative to or to augment opioid therapy.
(c) Consultation.--In carrying out the review under paragraph (1) of
subsection (a), and before making the recommendations under paragraph
(2) of such subsection, the Advisory Committee shall consult with the
VA/DOD Management of Opioid Therapy for Chronic Pain Working Group.
(d) Submission.--Not later than one year after the date of the
enactment of this Act, the Advisory Committee shall submit to the
Secretaries the review and recommendations described in subsection
(a)(1).
(e) Application of Federal Advisory Committee Act.--The provisions of
the Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the
Advisory Committee.
(f) Definitions.--In this section:
(1) The term ``Advisory Committee'' means the advisory
committee established under subsection (a).
(2) The term ``Clinical Practice Guideline'' means the VA/DOD
Clinical Practice Guideline for Management of Opioid Therapy
for Chronic Pain.
(3) The term ``controlled substance'' has the meaning given
that term in section 102 of the Controlled Substances Act (21
U.S.C. 802).
(4) The term ``State'' means each of the several States,
territories, and possessions of the United States, the District
of Columbia, and the Commonwealth of Puerto Rico.
SEC. 102. IMPROVEMENT OF OPIOID SAFETY MEASURES BY DEPARTMENT OF
VETERANS AFFAIRS.
(a) Expansion of Opioid Safety Initiative.--Not later than 180 days
after the date of the enactment of this Act, the Secretary of Veterans
Affairs shall expand the Opioid Safety Initiative of the Department of
Veterans Affairs to include all medical facilities of the Department.
(b) Pain Management Education and Training.--
(1) In general.--In carrying out the Opioid Safety Initiative
of the Department, the Secretary shall require all employees of
the Department responsible for prescribing opioids to receive
education and training described in paragraph (2).
(2) Education and training.--Education and training described
in this paragraph is education and training on pain management
and safe opioid prescribing practices for purposes of safely
and effectively managing patients with chronic pain, including
education and training on the following:
(A) The implementation of and full compliance with
the VA/DOD Clinical Practice Guideline for Management
of Opioid Therapy for Chronic Pain, including any
update to such guideline.
(B) The use of evidence-based pain management
therapies, including cognitive-behavioral therapy, non-
opioid alternatives, and non-drug methods and
procedures to managing pain and related health
conditions including medical devices approved or
cleared by the Food and Drug Administration for the
treatment of patients with chronic pain and
complementary alternative medicines.
(C) Screening and identification of patients with
substance use disorder, including drug-seeking
behavior, before prescribing opioids, assessment of
risk potential for patients developing an addiction,
and referral of patients to appropriate addiction
treatment professionals if addiction is identified or
strongly suspected.
(D) Communication with patients on the potential harm
associated with the use of opioids and other controlled
substances, including the need to safely store and
dispose of supplies relating to the use of opioids and
other controlled substances.
(E) Such other education and training as the
Secretary considers appropriate to ensure that veterans
receive safe and high-quality pain management care from
the Department.
(3) Use of existing program.--In providing education and
training described in paragraph (2), the Secretary shall use
the Interdisciplinary Chronic Pain Management Training Team
Program of the Department (or success program).
(c) Pain Management Teams.--
(1) In general.--In carrying out the Opioid Safety Initiative
of the Department, the director of each medical facility of the
Department shall identify and designate a pain management team
of health care professionals, which may include board certified
pain medicine specialists, responsible for coordinating and
overseeing pain management therapy at such facility for
patients experiencing acute and chronic pain that is non-cancer
related.
(2) Establishment of protocols.--
(A) In general.--In consultation with the Directors
of each Veterans Integrated Service Network, the
Secretary shall establish standard protocols for the
designation of pain management teams at each medical
facility within the Department.
(B) Consultation on prescription of opioids.--Each
protocol established under subparagraph (A) shall
ensure that any health care provider without expertise
in prescribing analgesics or who has not completed the
education and training under subsection (b), including
a mental health care provider, does not prescribe
opioids to a patient unless that health care provider--
(i) consults with a health care provider with
pain management expertise or who is on the pain
management team of the medical facility; and
(ii) refers the patient to the pain
management team for any subsequent
prescriptions and related therapy.
(3) Report.--
(A) In general.--Not later than one year after the
date of enactment of this Act, the director of each
medical facility of the Department shall submit to the
Under Secretary for Health and the director of the
Veterans Integrated Service Network in which the
medical facility is located a report identifying the
health care professionals that have been designated as
members of the pain management team at the medical
facility pursuant to paragraph (1).
(B) Elements.--Each report submitted under
subparagraph (A) with respect to a medical facility of
the Department shall include--
(i) a certification as to whether all members
of the pain management team at the medical
facility have completed the education and
training required under subsection (b);
(ii) a plan for the management and referral
of patients to such pain management team if
health care providers without expertise in
prescribing analgesics prescribe opioid
medications to treat acute and chronic pain
that is non-cancer related; and
(iii) a certification as to whether the
medical facility--
(I) fully complies with the stepped-
care model of pain management and other
pain management policies contained in
Directive 2009-053 of the Veterans
Health Administration, or successor
directive; or
(II) does not fully comply with such
stepped-care model of pain management
and other pain management policies but
is carrying out a corrective plan of
action to ensure such full compliance.
(d) Tracking and Monitoring of Opioid Use.--
(1) Prescription drug monitoring programs of states.--In
carrying out the Opioid Safety Initiative and the Opioid
Therapy Risk Report tool of the Department, the Secretary
shall--
(A) ensure access by health care providers of the
Department to information on controlled substances,
including opioids and benzodiazepines, prescribed to
veterans who receive care outside the Department
through the prescription drug monitoring program of
each State with such a program, including by seeking to
enter into memoranda of understanding with States to
allow shared access of such information between States
and the Department;
(B) include such information in the Opioid Therapy
Risk Report; and
(C) require health care providers of the Department
to submit to the prescription drug monitoring program
of each State information on prescriptions of
controlled substances received by veterans in that
State under the laws administered by the Secretary.
(2) Report on tracking of data on opioid use.--Not later than
18 months after the date of the enactment of this Act, the
Secretary shall submit to the Committee on Veterans' Affairs of
the Senate and the Committee on Veterans' Affairs of the House
of Representatives a report on the feasibility and advisability
of improving the Opioid Therapy Risk Report tool of the
Department to allow for more advanced real-time tracking of and
access to data on--
(A) the key clinical indicators with respect to the
totality of opioid use by veterans;
(B) concurrent prescribing by health care providers
of the Department of opioids in different health care
settings, including data on concurrent prescribing of
opioids to treat mental health disorders other than
opioid use disorder; and
(C) mail-order prescriptions of opioid prescribed to
veterans under the laws administered by the Secretary.
(e) Availability of Opioid Receptor Antagonists.--
(1) Increased availability and use.--
(A) In general.--The Secretary shall maximize the
availability of opioid receptor antagonists approved by
the Food and Drug Administration, including naloxone,
to veterans.
(B) Availability, training, and distributing.--In
carrying out subparagraph (A), not later than 90 days
after the date of the enactment of this Act, the
Secretary shall--
(i) equip each pharmacy of the Department
with opioid receptor antagonists approved by
the Food and Drug Administration to be
dispensed to outpatients as needed; and
(ii) expand the Overdose Education and
Naloxone Distribution program of the Department
to ensure that all veterans in receipt of
health care under laws administered by the
Secretary who are at risk of opioid overdose
may access such opioid receptor antagonists and
training on the proper administration of such
opioid receptor antagonists.
(C) Veterans who are at risk.--For purposes of
subparagraph (B), veterans who are at risk of opioid
overdose include--
(i) veterans receiving long-term opioid
therapy;
(ii) veterans receiving opioid therapy who
have a history of substance use disorder or
prior instances of overdose; and
(iii) veterans who are at risk as determined
by a health care provider who is treating the
veteran.
(2) Report.--Not later than 120 days after the date of the
enactment of this Act, the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report
on carrying out paragraph (1), including an assessment of any
remaining steps to be carried out by the Secretary to carry out
such paragraph.
(f) Inclusion of Certain Information and Capabilities in Opioid
Therapy Risk Report Tool of the Department.--
(1) Information.--The Secretary shall include in the Opioid
Therapy Risk Report tool of the Department--
(A) information on the most recent time the tool was
accessed by a health care provider of the Department
with respect to each veteran; and
(B) information on the results of the most recent
urine drug test for each veteran.
(2) Capabilities.--The Secretary shall include in the Opioid
Therapy Risk Report tool the ability of the health care
providers of the Department to determine whether a health care
provider of the Department prescribed opioids to a veteran
without checking the information in the tool with respect to
the veteran.
(g) Notifications of Risk in Computerized Health Record.--The
Secretary shall modify the computerized patient record system of the
Department to ensure that any health care provider that accesses the
record of a veteran, regardless of the reason the veteran seeks care
from the health care provider, will be immediately notified whether the
veteran--
(1) is receiving opioid therapy and has a history of
substance use disorder or prior instances of overdose;
(2) has a history of opioid abuse; or
(3) is at risk of becoming an opioid abuser as determined by
a health care provider who is treating the veteran.
(h) Definitions.--In this section:
(1) The term ``controlled substance'' has the meaning given
that term in section 102 of the Controlled Substances Act (21
U.S.C. 802).
(2) The term ``State'' means each of the several States,
territories, and possessions of the United States, the District
of Columbia, and the Commonwealth of Puerto Rico.
SEC. 103. STRENGTHENING OF JOINT WORKING GROUP ON PAIN MANAGEMENT OF
THE DEPARTMENT OF VETERANS AFFAIRS AND THE
DEPARTMENT OF DEFENSE.
(a) In General.--Not later than 90 days after the date of enactment
of this Act, the Secretary of Veterans Affairs and the Secretary of
Defense shall ensure that the Pain Management Working Group of the
Health Executive Committee of the Department of Veterans Affairs-
Department of Defense Joint Executive Committee established under
section 320 of title 38, United States Code, includes a focus on the
following:
(1) The opioid prescribing practices of health care providers
of each Department.
(2) The ability of each Department to manage acute and
chronic pain among individuals receiving health care from the
Department, including training health care providers with
respect to pain management.
(3) The use by each Department of complementary and
integrative health and complementary alternative medicines in
treating such individuals.
(4) The concurrent use by health care providers of each
Department of opioids and prescription drugs to treat mental
health disorders, including benzodiazepines.
(5) The practice by health care providers of each Department
of prescribing opioids to treat mental health disorders.
(6) The coordination in coverage of and consistent access to
medications prescribed for patients transitioning from
receiving health care from the Department of Defense to
receiving health care from the Department of Veterans Affairs.
(7) The ability of each Department to identify and treat
substance use disorders among individuals receiving health care
from that Department.
(b) Coordination and Consultation.--The Secretary of Veterans Affairs
and the Secretary of Defense shall ensure that the working group
described in subsection (a)--
(1) coordinates the activities of the working group with
other relevant working groups established under section 320 of
title 38, United States Code, including the working groups on
evidence-based practice, patient safety, pharmacy,
psychological health, and psychological health;
(2) consults with other relevant Federal agencies, including
the Centers for Disease Control and Prevention, with respect to
the activities of the working group; and
(3) consults with the Department of Veterans Affairs and the
Department of Defense with respect to, reviews, and comments on
the VA/DOD Clinical Practice Guideline for Management of Opioid
Therapy for Chronic Pain, or any successor guideline, before
any update to the guideline is released.
(c) Consultations.--The Secretary of Veterans Affairs and the
Secretary of Defense shall ensure that the working group described in
subsection (a) is able to meaningfully consult with respect to the
updated guideline required under subsection (a) of section 101, as
required by subsection (b) of such section, not later than 1 year after
the date of enactment of this Act.
SEC. 104. REVIEW, INVESTIGATION, AND REPORT ON USE OF OPIOIDS IN
TREATMENT BY DEPARTMENT OF VETERANS AFFAIRS.
(a) Comptroller General Report.--
(1) In general.--Not later than two years after the date of
the enactment of this Act, the Comptroller General of the
United States shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs of
the House of Representatives a report on the Opioid Safety
Initiative of the Department of Veterans Affairs and the opioid
prescribing practices of health care providers of the
Department.
(2) Elements.--The report submitted under paragraph (1) shall
include the following:
(A) Recommendations on such improvements to the
Opioid Safety Initiative of the Department as the
Comptroller General considers appropriate.
(B) Information with respect to--
(i) deaths resulting from sentinel events
involving veterans prescribed opioids by a
health care provider of the Department;
(ii) overall prescription rates and
prescriptions indications of opioids to treat
non-cancer, non-palliative, and non-hospice
care patients;
(iii) the prescription rates and
prescriptions indications of benzodiazepines
and opioids concomitantly by health care
providers of the Department;
(iv) the practice by health care providers of
the Department of prescribing opioids to treat
patients without any pain, including to treat
patients with mental health disorders other
than opioid use disorder; and
(v) the effectiveness of opioid therapy for
patients receiving such therapy, including the
effectiveness of long-term opioid therapy.
(C) An evaluation of processes of the Department in
place to oversee opioid use among veterans, including
procedures to identify and remedy potential over-
prescribing of opioids by health care providers of the
Department.
(D) An assessment of the implementation by the
Secretary of the VA/DOD Clinical Practice Guideline for
Management of Opioid Therapy for Chronic Pain.
(b) Quarterly Progress Report on Implementation of Comptroller
General Recommendations.--Not later than two years after the date of
the enactment of this Act, and not later than 30 days after the end of
each quarter thereafter, the Secretary of Veterans Affairs shall submit
to the Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a progress report
detailing the actions by the Secretary during the period covered by the
report to address any outstanding findings and recommendations by the
Comptroller General of the United States under subsection (a) with
respect to the Veterans Health Administration.
(c) Annual Review of Prescription Rates.--Not later than one year
after the date of the enactment of this Act, and not less frequently
than annually for the following five years, the Secretary shall submit
to the Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a report, with
respect to each medical facility of the Department of Veterans Affairs,
to collect and review information on opioids prescribed by health care
providers at the facility to treat non-cancer, non-palliative, and non-
hospice care patients that contains, for the one-year period preceding
the submission of the report, the following:
(1) The number of patients and the percentage of the patient
population of the Department who were prescribed
benzodiazepines and opioids concurrently by a health care
provider of the Department.
(2) The number of patients and the percentage of the patient
population of the Department without any pain who were
prescribed opioids by a health care provider of the Department,
including those who were prescribed benzodiazepines and opioids
concurrently.
(3) The number of non-cancer, non-palliative, and non-hospice
care patients and the percentage of such patients who were
treated with opioids by a health care provider of the
Department on an inpatient-basis and who also received
prescription opioids by mail from the Department while being
treated on an inpatient-basis.
(4) The number of non-cancer, non-palliative, and non-hospice
care patients and the percentage of such patients who were
prescribed opioids concurrently by a health care provider of
the Department and a health care provider that is not health
care provider of the Department.
(5) With respect to each medical facility of the Department,
information on opioids prescribed by health care providers at
the facility to treat non-cancer, non-palliative, and non-
hospice care patients, including information on--
(A) the prescription rate at which each health care
provider at the facility prescribed benzodiazepines and
opioids concurrently to such patients and the aggregate
such prescription rate for all health care providers at
the facility;
(B) the prescription rate at which each health care
provider at the facility prescribed benzodiazepines or
opioids to such patients to treat conditions for which
benzodiazepines or opioids are not approved treatment
and the aggregate such prescription rate for all health
care providers at the facility;
(C) the prescription rate at which each health care
provider at the facility prescribed or dispensed mail-
order prescriptions of opioids to such patients while
such patients were being treated with opioids on an
inpatient-basis and the aggregate of such prescription
rate for all health care providers at the facility; and
(D) the prescription rate at which each health care
provider at the facility prescribed opioids to such
patients who were also concurrently prescribed opioids
by a health care provider that is not a health care
provider of the Department and the aggregate of such
prescription rates for all health care providers at the
facility.
(6) With respect to each medical facility of the Department,
the number of times a pharmacist at the facility overrode a
critical drug interaction warning with respect to an
interaction between opioids and another medication before
dispensing such medication to a veteran.
(d) Investigation of Prescription Rates.--If the Secretary determines
that a prescription rate with respect to a health care provider or
medical facility of the Department conflicts with or is otherwise
inconsistent with the standards of appropriate and safe care, the
Secretary shall--
(1) immediately notify the Committee on Veterans' Affairs of
the Senate and the Committee on Veterans' Affairs of the House
of Representatives of such determination, including information
relating to such determination, prescription rate, and health
care provider or medical facility, as the case may be; and
(2) through the Office of the Medical Inspector of the
Veterans Health Administration, conduct a full investigation of
the health care provider or medical facility, as the case may
be.
(e) Prescription Rate Defined.--In this section, the term
``prescription rate'' means, with respect to a health care provider or
medical facility of the Department, each of the following:
(1) The number of patients treated with opioids by the health
care provider or at the medical facility, as the case may be,
divided by the total number of pharmacy users of that health
care provider or medical facility.
(2) The average number of morphine equivalents per day
prescribed by the health care provider or at the medical
facility, as the case may be, to patients being treated with
opioids.
(3) Of the patients being treated with opioids by the health
care provider or at the medical facility, as the case may be,
the average number of prescriptions of opioids per patient.
SEC. 105. MANDATORY DISCLOSURE OF CERTAIN VETERAN INFORMATION TO STATE
CONTROLLED SUBSTANCE MONITORING PROGRAMS.
Section 5701(l) of title 38, United States Code, is amended by
striking ``may'' and inserting ``shall''.
TITLE II--PATIENT ADVOCACY
SEC. 201. COMMUNITY MEETINGS ON IMPROVING CARE FURNISHED BY DEPARTMENT
OF VETERANS AFFAIRS.
(a) Community Meetings.--
(1) Medical centers.--Not later than 90 days after the date
of the enactment of this Act, and not less frequently than once
every 90 days thereafter, the Secretary shall ensure that each
medical facility of the Department of Veterans Affairs hosts a
community meeting open to the public on improving health care
furnished by the Secretary.
(2) Community based outpatient clinics.--Not later than one
year after the date of the enactment of this Act, and not less
frequently than annually thereafter, the Secretary shall ensure
that each community based outpatient clinic of the Department
hosts a community meeting open to the public on improving
health care furnished by the Secretary.
(b) Attendance by Director of Veterans Integrated Service Network or
Designee.--
(1) In general.--Each community meeting hosted by a medical
facility or community based outpatient clinic under subsection
(a) shall be attended by the Director of the Veterans
Integrated Service Network in which the medical facility or
community based outpatient clinic, as the case may be, is
located. Subject to paragraph (2), the Director may delegate
such attendance only to an employee who works in the Office of
the Director.
(2) Attendance by director.--Each Director of a Veterans
Integrated Service Network shall personally attend not less
than one community meeting under subsection (a) hosted by each
medical facility located in the Veterans Integrated Service
Network each year.
(c) Notice.--The Secretary shall notify the Committee on Veterans'
Affairs of the Senate, the Committee on Veterans' Affairs of the House
of Representatives, and each Member of Congress (as defined in section
104) who represents the area in which the medical facility is located
of a community meeting under subsection (a) by not later than 10 days
before such community meeting occurs.
SEC. 202. IMPROVEMENT OF AWARENESS OF PATIENT ADVOCACY PROGRAM AND
PATIENT BILL OF RIGHTS OF DEPARTMENT OF VETERANS
AFFAIRS.
Not later than 90 days after the date of the enactment of this Act,
the Secretary of Veterans Affairs shall, in as many prominent locations
as the Secretary determines appropriate to be seen by the largest
percentage of patients and family members of patients at each medical
facility of the Department of Veterans Affairs--
(1) display the purposes of the Patient Advocacy Program of
the Department and the contact information for the patient
advocate at such medical facility; and
(2) display the rights and responsibilities of--
(A) patients and family members and patients at such
medical facility; and
(B) with respect to community living centers and
other residential facilities of the Department,
residents and family members of residents at such
medical facility.
SEC. 203. COMPTROLLER GENERAL REPORT ON PATIENT ADVOCACY PROGRAM OF
DEPARTMENT OF VETERANS AFFAIRS.
(a) In General.--Not later than two years after the date of the
enactment of this Act, the Comptroller General of the United States
shall submit to the Committee on Veterans' Affairs of the Senate and
the Committee on Veterans' Affairs of the House of Representatives a
report on the Patient Advocacy Program of the Department of Veterans
Affairs (in this section referred to as the ``Program'').
(b) Elements.--The report required by subsection (a) shall include
the following:
(1) A description of the Program, including--
(A) the purpose of the Program;
(B) the activities carried out under the Program; and
(C) the sufficiency of the Program in achieving the
purpose of the Program.
(2) An assessment of the sufficiency of staffing of employees
of the Department responsible for carrying out the Program.
(3) An assessment of the sufficiency of the training of such
employees.
(4) An assessment of--
(A) the awareness of the Program among veterans and
family members of veterans; and
(B) the use of the Program by veterans and family
members of veterans.
(5) Such recommendations and proposals for improving or
modifying the Program as the Comptroller General considers
appropriate.
(6) Such other information with respect to the Program as the
Comptroller General considers appropriate.
TITLE III--COMPLEMENTARY AND INTEGRATIVE HEALTH
SEC. 301. EXPANSION OF RESEARCH AND EDUCATION ON AND DELIVERY OF
COMPLEMENTARY AND INTEGRATIVE HEALTH TO VETERANS.
(a) Establishment.--There is established a commission to be known as
the ``Creating Options for Veterans' Expedited Recovery'' or the
``COVER Commission'' (in this Act referred to as the ``Commission'').
The Commission shall examine the evidence-based therapy treatment model
used by the Secretary of Veterans Affairs for treating mental health
conditions of veterans and the potential benefits of incorporating
complementary alternative treatments available in non-Department
facilities (as defined in section 1701 of title 38, United States
Code).
(b) Duties.--The Commission shall perform the following duties:
(1) Examine the efficacy of the evidence-based therapy model
used by the Secretary for treating mental health illnesses of
veterans and identify areas to improve wellness-based outcomes.
(2) Conduct a patient-centered survey within each of the
Veterans Integrated Service Networks to examine--
(A) the experience of veterans with the Department of
Veterans Affairs when seeking medical assistance for
mental health issues through the health care system of
the Department;
(B) the experience of veterans with non-Department
facilities and health professionals for treating mental
health issues;
(C) the preference of veterans regarding available
treatment for mental health issues and which methods
the veterans believe to be most effective;
(D) the experience, if any, of veterans with respect
to the complementary alternative treatment therapies
described in paragraph (3);
(E) the prevalence of prescribing prescription
medication among veterans seeking treatment through the
health care system of the Department as remedies for
addressing mental health issues; and
(F) the outreach efforts of the Secretary regarding
the availability of benefits and treatments for
veterans for addressing mental health issues, including
by identifying ways to reduce barriers to gaps in such
benefits and treatments.
(3) Examine available research on complementary alternative
treatment therapies for mental health issues and identify what
benefits could be made with the inclusion of such treatments
for veterans, including with respect to--
(A) music therapy;
(B) equine therapy;
(C) training and caring for service dogs;
(D) yoga therapy;
(E) acupuncture therapy;
(F) meditation therapy;
(G) outdoor sports therapy;
(H) hyperbaric oxygen therapy;
(I) accelerated resolution therapy;
(J) art therapy;
(K) magnetic resonance therapy; and
(L) other therapies the Commission determines
appropriate.
(4) Study the sufficiency of the resources of the Department
to ensure the delivery of quality health care for mental health
issues among veterans seeking treatment within the Department.
(5) Study the current treatments and resources available
within the Department and assess--
(A) the effectiveness of such treatments and
resources in decreasing the number of suicides per day
by veterans;
(B) the number of veterans who have been diagnosed
with mental health issues;
(C) the percentage of veterans using the resources of
the Department who have been diagnosed with mental
health issues;
(D) the percentage of veterans who have completed
counseling sessions offered by the Department; and
(E) the efforts of the Department to expand
complementary alternative treatments viable to the
recovery of veterans with mental health issues as
determined by the Secretary to improve the
effectiveness of treatments offered with the
Department.
(c) Membership.--
(1) In general.--The Commission shall be composed of 10
members, appointed as follows:
(A) Two members appointed by the Speaker of the House
of Representatives, at least one of whom shall be a
veteran.
(B) Two members appointed by the Minority Leader of
the House of Representatives, at least one of whom
shall be a veteran.
(C) Two members appointed by the Majority Leader of
the Senate, at least one of whom shall be a veteran.
(D) Two members appointed by the Minority Leader of
the Senate, at least one of whom shall be a veteran.
(E) Two members appointed by the President, at least
one of whom shall be a veteran.
(2) Qualifications.--Members of the Commission shall be--
(A) individuals who are of recognized standing and
distinction within the medical community with a
background in treating mental health;
(B) individuals with experience working with the
military and veteran population; and
(C) individuals who do not have a financial interest
in any of the complementary alternative treatments
reviewed by the Commission.
(3) Chairman.--The President shall designate a member of the
Commission to be the Chairman.
(4) Period of appointment.--Members of the Commission shall
be appointed for the life of the Commission.
(5) Vacancy.--A vacancy in the Commission shall be filled in
the manner in which the original appointment was made.
(6) Appointment deadline.--The appointment of members of the
Commission in this section shall be made not later than 90 days
after the date of the enactment of this Act.
(d) Powers of Commission.--
(1) Meetings.--
(A) Initial meeting.--The Commission shall hold its
first meeting not later than 30 days after a majority
of members are appointed to the Commission.
(B) Meeting.--The Commission shall regularly meet at
the call of the Chairman. Such meetings may be carried
out through the use of telephonic or other appropriate
telecommunication technology if the Commission
determines that such technology will allow the members
to communicate simultaneously.
(2) Hearings.--The Commission may hold such hearings, sit and
act at such times and places, take such testimony, and receive
evidence as the Commission considers advisable to carry out the
responsibilities of the Commission.
(3) Information from federal agencies.--The Commission may
secure directly from any department or agency of the Federal
Government such information as the Commission considers
necessary to carry out the duties of the Commission.
(4) Information from nongovernmental organizations.--In
carrying out its duties, the Commission may seek guidance
through consultation with foundations, veteran service
organizations, nonprofit groups, faith-based organizations,
private and public institutions of higher education, and other
organizations as the Commission determines appropriate.
(5) Commission records.--The Commission shall keep an
accurate and complete record of the actions and meeting of the
Commission. Such record shall be made available for public
inspection and the Comptroller General of the United States may
audit and examine such record.
(6) Personnel records.--The Commission shall keep an accurate
and complete record of the actions and meetings of the
Commission. Such record shall be made available for public
inspection and the Comptroller General of the United States may
audit and examine such records.
(7) Compensation of members; travel expenses.--Each member
shall serve without pay but shall receive travel expenses to
perform the duties of the Commission, including per diem in
lieu of substances, at rates authorized under subchapter I of
chapter 57 of title 5, United States Code.
(8) Staff.--The Chairman, in accordance with rules agreed
upon the Commission, may appoint fix the compensation of a
staff director and such other personnel as may be necessary to
enable the Commission to carry out its functions, without
regard to the provisions of title 5, United States Code,
governing appointments in the competitive service, without
regard to the provision of chapter 51 and subchapter III of
chapter 53 of such title relating to classification and General
Schedule pay rates, except that no rate of pay fixed under this
paragraph may exceed the equivalent of that payable for a
position at a level IV of the Executive Schedule under section
5316 of title 5, United States Code.
(9) Personnel as federal employees.--
(A) In general.--The executive director and any
personnel of the Commission are employees under section
2105 of title 5, United States Code, for purpose of
chapters 63, 81, 83, 84, 85, 87, 89, and 90 of such
title.
(B) Members of the commission.--Subparagraph (A)
shall not be construed to apply to members of the
Commission.
(10) Contracting.--The Commission may, to such extent and in
such amounts as are provided in appropriations Acts, enter into
contracts to enable the Commission to discharge the duties of
the Commission under this Act.
(11) Expert and consultant service.--The Commission may
procure the services of experts and consultants in accordance
with section 3109 or title 5, United States Code, at rates not
to exceed the daily rate paid to a person occupying a position
at level IV of the Executive Schedule under section 3109 of
title 5, United States Code.
(12) Postal service.--The Commission may use the United
States mails in the same manner and under the same conditions
as departments and agencies of the United States.
(13) Physical facilities and equipment.--Upon the request of
the Commission, the Administrator of General Services shall
provide to the Commission, on a reimbursable basis, the
administrative support services necessary for the Commission to
carry out its responsibilities under this Act. These
administrative services may include human resource management,
budget, leasing accounting, and payroll services.
(e) Report.--
(1) Interim reports.--
(A) In general.--Not later than 60 days after the
date on which the Commission first meets, and each 30-
day period thereafter ending on the date on which the
Commission submits the final report under paragraph
(2), the Commission shall submit to the Committees on
Veterans' Affairs of the House of Representatives and
the Senate and the President a report detailing the
level of cooperation the Secretary of Veterans Affairs
(and the heads of other departments or agencies of the
Federal Government) has provided to the Commission.
(B) Other reports.--In carrying out its duties, at
times that the Commission determines appropriate, the
Commission shall submit to the Committee on Veterans'
Affairs of the House of Representatives and the Senate
and any other appropriate entities an interim report
with respect to the findings identified by the
Commission.
(2) Final report.--Not later than 18 months after the first
meeting of the Commission, the Commission shall submit to the
Committee on Veterans' Affairs of the House of Representatives
and the Senate, the President, and the Secretary of Veterans
Affairs a final report on the findings of the Commission. Such
report shall include the following:
(A) Recommendations to implement in a feasible,
timely, and cost efficient manner the solutions and
remedies identified within the findings of the
Commission pursuant to subsection (b).
(B) An analysis of the evidence-based therapy model
used by the Secretary of Veterans Affairs for treating
veterans with mental health care issues, and an
examination of the prevalence and efficacy of
prescription drugs as a means for treatment.
(C) The findings of the patient-centered survey
conducted within each of the Veterans Integrated
Service Networks pursuant to subsection (b)(2).
(D) An examination of complementary alternative
treatments described in subsection (b)(3) and the
potential benefits of incorporating such treatments in
the therapy models used by the Secretary for treating
veterans with mental health issues.
(3) Plan.--Not later than 90 days after the date on which the
Commission submits the final report under paragraph (2), the
Secretary of Veterans Affairs shall submit to the Committee on
Veterans' Affairs of the House of Representatives and the
Senate a report on the following:
(A) An action plan for implementing the
recommendations established by the Commission on such
solutions and remedies for improving wellness-based
outcomes for veterans with mental health care issues.
(B) A feasible timeframe on when the complementary
alternative treatments described in subsection (b)(3)
can be implemented Department-wide.
(C) With respect to each recommendation established
by the Commission, including any complementary
alternative treatment, that the Secretary determines is
not appropriate or feasible to implement, a
justification for such determination and an alternative
solution to improve the efficacy of the therapy models
used by the Secretary for treating veterans with mental
health issues.
(f) Termination of Commission.--The Commission shall terminate 30
days after the Commission submits the final report under subsection
(e)(2).
SEC. 302. PILOT PROGRAM ON INTEGRATION OF COMPLEMENTARY ALTERNATIVE
MEDICINES AND RELATED ISSUES FOR VETERANS AND
FAMILY MEMBERS OF VETERANS.
(a) Pilot Program.--
(1) In general.--Not later than 180 days after the date on
which the Secretary of Veterans Affairs receives the final
report under section 301(e), the Secretary shall commence a
pilot program to assess the feasibility and advisability of
using wellness-based programs (as defined by the Secretary) to
complement the provision of pain management and related health
care services, including mental health care services, to
veterans.
(2) Matters addressed.--In carrying out the pilot program,
the Secretary shall assess the following:
(A) Means of improving coordination between Federal,
State, local, and community providers of health care in
the provision of pain management and related health
care services to veterans.
(B) Means of enhancing outreach, and coordination of
outreach, by and among providers of health care
referred to in subparagraph (A) on the pain management
and related health care services available to veterans.
(C) Means of using wellness-based programs of
providers of health care referred to in subparagraph
(A) as complements to the provision by the Department
of pain management and related health care services to
veterans.
(D) Whether wellness-based programs described in
subparagraph (C)--
(i) are effective in enhancing the quality of
life and well-being of veterans;
(ii) are effective in increasing the
adherence of veterans to the primary pain
management and related health care services
provided such veterans by the Department;
(iii) have an effect on the sense of well-
being of veterans who receive primary pain
management and related health care services
from the Department; and
(iv) are effective in encouraging veterans
receiving health care from the Department to
adopt a more healthy lifestyle.
(b) Duration.--The Secretary shall carry out the pilot program under
subsection (a)(1) for a period of three years.
(c) Locations.--
(1) Facilities.--The Secretary shall carry out the pilot
program under subsection (a)(1) at facilities of the Department
providing pain management and related health care services,
including mental health care services, to veterans. In
selecting such facilities to carry out the pilot program, the
Secretary shall select not fewer than 15 medical centers of the
Department, of which not fewer than two shall be polytrauma
rehabilitation centers of the Department.
(2) Medical centers with prescription rates of opioids that
conflict with care standards.--In selecting the medical centers
under paragraph (1), the Secretary shall give priority to
medical centers of the Department at which there is a
prescription rate of opioids that conflicts with or is
otherwise inconsistent with the standards of appropriate and
safe care.
(d) Provision of Services.--Under the pilot program under subsection
(a)(1), the Secretary shall provide covered services to covered
veterans by integrating complementary and alternative medicines and
integrative health services with other services provided by the
Department at the medical centers selected under subsection (c).
(e) Covered Veterans.--For purposes of the pilot program under
subsection (a)(1), a covered veteran is any veteran who--
(1) has a mental health condition diagnosed by a clinician of
the Department;
(2) experiences chronic pain;
(3) has a chronic condition being treated by a clinician of
the Department; or
(4) is not described in paragraph (1), (2), or (3) and
requests to participate in the pilot program or is referred by
a clinician of the Department who is treating the veteran.
(f) Covered Services.--
(1) In general.--For purposes of the pilot program, covered
services are services consisting of complementary and
integrative health services as selected by the Secretary.
(2) Administration of services.--Covered services shall be
administered under the pilot program as follows:
(A) Covered services shall be administered by
professionals or other instructors with appropriate
training and expertise in complementary and integrative
health services who are employees of the Department or
with whom the Department enters into an agreement to
provide such services.
(B) Covered services shall be included as part of the
Patient Aligned Care Teams initiative of the Office of
Patient Care Services, Primary Care Program Office, in
coordination with the Office of Patient Centered Care
and Cultural Transformation.
(C) Covered services shall be made available to--
(i) covered veterans who have received
conventional treatments from the Department for
the conditions for which the covered veteran
seeks complementary and integrative health
services under the pilot program; and
(ii) covered veterans who have not received
conventional treatments from the Department for
such conditions.
(g) Reports.--
(1) In general.--Not later than 30 months after the date on
which the Secretary commences the pilot program under
subsection (a)(1), the Secretary shall submit to the Committee
on Veterans' Affairs of the Senate and the Committee on
Veterans' Affairs of the House of Representatives a report on
the pilot program.
(2) Elements.--The report under paragraph (1) shall include
the following:
(A) The findings and conclusions of the Secretary
with respect to the pilot program under subsection
(a)(1), including with respect to--
(i) the use and efficacy of the complementary
and integrative health services established
under the pilot program;
(ii) the outreach conducted by the Secretary
to inform veterans and community organizations
about the pilot program; and
(iii) an assessment of the benefit of the
pilot program to covered veterans in mental
health diagnoses, pain management, and
treatment of chronic illness.
(B) Identification of any unresolved barriers that
impede the ability of the Secretary to incorporate
complementary and integrative health services with
other health care services provided by the Department.
(C) Such recommendations for the continuation or
expansion of the pilot program as the Secretary
considers appropriate.
(h) Complementary and Integrative Health Defined.--In this section,
the term ``complementary and integrative health'' shall have the
meaning given that term by the National Institutes of Health.
TITLE IV--FITNESS OF HEALTH CARE PROVIDERS
SEC. 401. ADDITIONAL REQUIREMENTS FOR HIRING OF HEALTH CARE PROVIDERS
BY DEPARTMENT OF VETERANS AFFAIRS.
As part of the hiring process for each health care provider
considered for a position at the Department of Veterans Affairs after
the date of the enactment of the Act, the Secretary of Veterans Affairs
shall require from the medical board of each State in which the health
care provider has a medical license--
(1) information on any violation of the requirements of the
medical license of the health care provider during the 20-year
period preceding the consideration of the health care provider
by the Department; and
(2) information on whether the health care provider has
entered into any settlement agreement for the disciplinary
charge relating to the practice of medicine by the health care
provider.
SEC. 402. PROVISION OF INFORMATION ON HEALTH CARE PROVIDERS OF
DEPARTMENT OF VETERANS AFFAIRS TO STATE MEDICAL
BOARDS.
Notwithstanding section 552a of title 5, United States Code, with
respect to each health care provider of the Department of Veterans
Affairs who has violated a requirement of the medical license of the
health care provider, the Secretary of Veterans Affairs shall provide
to the medical board of each State in which the health care provider is
licensed detailed information with respect to such violation,
regardless of whether such board has formally requested such
information.
SEC. 403. REPORT ON COMPLIANCE BY DEPARTMENT OF VETERANS AFFAIRS WITH
REVIEWS OF HEALTH CARE PROVIDERS LEAVING THE
DEPARTMENT OR TRANSFERRING TO OTHER FACILITIES.
Not later than 180 days after the date of the enactment of this Act,
the Secretary of Veterans Affairs shall submit to the Committee on
Veterans' Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a report on the compliance by the
Department of Veterans Affairs with the policy of the Department--
(1) to conduct a review of each health care provider of the
Department who transfers to another medical facility of the
Department, retires, or is terminated to determine whether
there are any concerns, complaints, or allegations of
violations relating to the medical practice of the health care
provider; and
(2) to take appropriate action with respect to any such
concern, complaint, or allegation.
TITLE V--OTHER VETERANS MATTERS
SEC. 501. AUDIT OF VETERANS HEALTH ADMINISTRATION PROGRAMS OF
DEPARTMENT OF VETERANS AFFAIRS.
(a) Audit.--The Secretary of Veterans Affairs shall seek to enter
into a contract with a nongovernmental entity under which the entity
shall conduct a audits of the programs of the Veterans Health
Administration of the Department of Veterans Affairs to identify ways
to improve the furnishing of benefits and health care administered by
the Veterans Health Administration to veterans and families of
veterans.
(b) Audit Requirements.--In carrying out each audit under subsection
(a), the entity shall perform the following:
(1) Five-year risk assessments to identify the functions,
staff organizations, and staff offices of the Veterans Health
Administration that would lead towards the greatest improvement
in furnishing of benefits and health care to veterans and
families of veterans.
(2) Development of plans that are informed by the risk
assessment under paragraph (1) to conduct audits of the
functions, staff organizations, and staff offices identified
under paragraph (1).
(3) Conduct audits in accordance with the plans developed
pursuant to paragraph (2).
(c) Reports.--Not later than 90 days after the date on which each
audit is completed under subsection (a), the Secretary shall submit to
the Committees on Veterans' Affairs of the House of Representatives and
the Senate a report that includes--
(1) a summary of the audit;
(2) the findings of the entity that conducted the audit with
respect to the audit; and
(3) such recommendations as the Secretary determines
appropriate for legislative or administrative action to improve
the furnishing of benefits and health care to veterans and
families of veterans..
Purpose and Summary
H.R. 4063, the ``Jason Simcakoski Promoting Responsible
Opioid Management and Incorporating Scientific Expertise
(PROMISE) Act,'' was introduced by Representative Gus Bilirakis
of Florida, the Vice Chairman of the Committee on Veterans'
Affairs, on November 18, 2015. H.R. 4063, as amended, was
ordered to be favorably reported to the full House on February
25, 2016, by voice vote.
H.R. 4063, as amended would: (1) Require the Department of
Veterans Affairs (VA) and the Department of Defense (DOD) to
jointly establish an advisory committee to review and update
the VA/DOD Clinical Practice Guideline for Management of Opioid
Therapy for Chronic Pain; (2) require VA to expand the opioid
safety initiative; (3) strengthen the VA/DOD Pain Management
Working Group; (4) require the Government Accountability Office
(GAO) to report on VA's opioid safety initiative and the opioid
prescribing practices of VA healthcare providers; (5) require
VA to disclose information to state controlled substance
monitoring programs; (6) require VA to ensure that each VA
medical facility hosts regular community meetings on improving
the provision of VA health care; (7) require VA to display
information on the patient advocacy program and the patient
bill of rights; (8) require GAO to report on VA's patient
advocacy program; (9) establish a Commission to examine VA's
evidence-based therapy treatment model and the potential
benefits of incorporating complementary and alternative
medicine; (10) establish a pilot program to assess the
feasibility and advisability of using wellness-based programs
to complement the provision of pain management to veterans;
(11) require VA to ensure that State medical boards receive
information on violations of a provider's medical license; (12)
require VA to provide State medical boards detailed information
with respect to a violation of a requirement of a provider's
medical license; (13) require VA to report on the Department's
compliance with policies to conduct a review of each healthcare
provider who transfers to another VA medical facility, retires,
or is terminated to determine whether there are any concerns,
complaints, or allegations of violations relating to the
provider's medical practice and to take appropriate action;
and, (14) require VA to conduct an audit of Veterans Health
Administration (VHA) programs and identify ways to improve the
provision of benefits and healthcare to veterans and their
families.
Background and Need for Legislation
TITLE I--OPIOID THERAPY AND PAIN MANAGEMENT SECTION
Section 101--Establishment of an Advisory Committee to review
guidelines on management of opioid therapy by Department of
Veterans Affairs and Department of Defense
The effective management of pain is an increasingly
critical issue for the American health care system. Given that
the veteran population experiences chronic pain at a much
higher rate than the general adult population, it is also an
increasingly critical issue for the VA health care system.
Chronic pain, which is defined as pain that persists beyond
expected healing time and generally persists longer than three
to six months, affects veterans of all eras. It is the most
frequent medical condition facing veterans of Iraq and
Afghanistan and, as the incidence and severity of pain increase
with age, it is also common among older generations of
veterans. Chronic pain is a complex condition, involving
cognitive, psychosocial, and substance use issues as well as a
variety of medical and mental health co-morbidities.
DOD and VA have been increasingly reliant on the use of
prescription painkillers--and, in particular, opioids--to treat
servicemembers and veterans experiencing both acute and chronic
pain. Opioids are a commonly abused medication derived from, or
synthesized similar to, the opium poppy and used for pain
relief. Examples of common opioids include: hydrocodone;
oxycodone, fentanyl, methadone, and codeine. According to a CBS
News report based on VA data, the number of patients treated by
VA increased 29%, while the number of opioid prescriptions
written by VA providers increased 259%, from 2002 to 2013.\1\
Additionally, the Center for Investigative Reporting found that
VA prescriptions for certain opioids--hydrocodone, oxycodone,
methadone and morphine--rose 270% from 2001 to 2013.\2\
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\1\CBS News, ``Veterans Dying from Overmedication,'' Sep. 19, 2013,
http://www.cbsnews.com/news/veterans-dying-from-overmedication/.
\2\The Center for Investigative Reporting, ``VA's Opiate Overload
Feeds Veterans' Additions, Overdose Deaths,'' Sep. 28, 2013, http://
cironline.org/reports/vas-opiate-overload-feeds-veterans-addictions-
overdose-deaths-5261.
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To help manage the use of opioid medications for
servicemembers and veterans experiencing chronic pain, VA and
DOD published the Clinical Practice Guideline for the
Management of Opioid Therapy (Guideline) in May 2010.\3\ The
Guideline recommends opioid therapy for servicemembers and
veterans with chronic pain that meet several eligibility
criteria including moderate to severe pain that has failed to
adequately respond to non-opioid and non-drug therapeutic
interventions. However, the Guideline notes the existence of,
``controversy . . . among pain practitioners concerning the use
of opioids for the treatment of chronic pain'' due, in part to,
``. . . a paucity of data regarding long-term opioid
efficacy.''
---------------------------------------------------------------------------
\3\The Department of Veterans Affairs and Department of Defense,
``Management of Opioid Therapy for Chronic pain,'' May 2010, http://
www.va.gov/painmanagement/docs/cpg_opioidtherapy_fulltext.pdf.
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Research has also noted concerns about the use of opioid
prescriptions to treat veteran patients. A study conducted by
VA researchers and published in The Journal of the American
Medical Association on March 7, 2012,\4\ found that veterans
with a mental health diagnosis--in particular, post-traumatic
stress disorder (PTSD)--were significantly more likely than
their peers to receive prescription opioids for pain. These
veterans also were ``more likely to have comorbid drug and
alcohol use disorders; receive higher-dose opioid regimens;
continue taking opioids longer; receive concurrent
prescriptions for opioids, sedative hypnotics, or both; and
obtain early opioid refills,'' which can be a sign of opioid
abuse. Perhaps most troublingly, the study concluded that,
``receiving prescription opioids was associated with increased
risk of adverse clinical outcomes for all veterans returning
from Iraq and Afghanistan, especially veterans with PTSD who
were at highest-risk of alcohol-
, drug-, and opioid-related accidents and overdose as well as
self-inflicted injuries.''\5\
---------------------------------------------------------------------------
\4\The Journal of the American Medical Association, ``Association
of Mental Health Disorders With Prescription Opioids and High-Risk
Opioid Use in US Veterans of Iraq and Afghanistan,'' March 7, 2012,
http://jama.jamanetwork.com/article.aspx?articleid=1105046.
\5\The article also noted that ``in a sample of veterans with
multiple pain problems, those with the highest-risk medical and
psychiatric comorbidity were the most likely to receive the highest-
dose, highest-risk opioid therapy.''
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The Committee is supportive of the Guideline but believes
that it should be updated to reflect the most current research
and best practices regarding the use of opioid medications in
pain care, particularly in light of ongoing concerns regarding
opioid use among veteran patients. As such, Section 101 would
require VA and DOD to jointly establish an advisory committee
to conduct a review of and make recommendations with respect to
updating the Guideline. The advisory committee would be
required to report to VA and DOD not later than one year after
the date of enactment of this Act and to examine whether the
Guideline should include enhanced guidance on a number of
metrics, including the coadministration of opioids and other
medications and the treatment of patients with comorbidities.
In conducting the review of the Guideline, the advisory
committee would be also required to consult with the VA/DOD
Management of Opioid Therapy for Chronic Pain Working Group.
Section 102--Improvement of opioid safety measures by the Department of
Veterans Affairs
VA launched the Opioid Safety Initiative (OSI) in October
2013, to reduce the use of opioids among veterans using the VA
health care system and to improve care for veterans with
chronic pain. According to VA, OSI works by incorporating a
team-based approach, increasing the use of non-prescription
pain management treatments and CAM, and emphasizing patient
education and monitoring. To aid in the effectiveness of OSI,
VA's National Pain Management Program office convened a
national task force of pain management experts across multiple
disciplines to create an accompanying toolkit to help VA
clinicians better manage pain among--and prescribe appropriate
medications to--their veteran patients. OSI was first deployed
in and around Minneapolis, Minnesota, and has since expanded to
many other VA medical facilities, while the OSI toolkit is
available on VA's website for both VA providers and the general
public to access.
Given the prevalence of chronic pain in the veteran
population and ongoing concerns about opioid use and pain care
management throughout VA, the Committee wants to ensure that
OSI and the OSI toolkit are used uniformly across all VA
medical facilities, that VA clinicians are trained in
appropriately managing pain and prescribing opioid medications,
and that VA leaders are effectively overseeing the provision of
pain care and opioid use among veteran patients. To accomplish
these goals, section 102 of the bill would require VA to expand
OSI to all VA medical facilities. It would also require VA to
use the Interdisciplinary Chronic Pain Management Training Team
Program to ensure that all VA employees who are responsible for
prescribing opioids receive education and training on pain
management and safe opioid prescribing practices to enable them
to safely and effectively manage care for patients with chronic
pain. Such education and training would be required to include
the Guideline, the use of evidence-based pain management
therapies, the screening and identification of patients with
substance use disorder, communication with patients on the use
of opioids and other controlled substances, and other training
as the Secretary considers appropriate.
Section 102 of the bill would further require the Director
of each VA medical facility to designate a pain management team
to coordinate and oversee pain management therapy at the
facility and to consult with the Director of each Veterans
Integrated Service Network (VISN) to establish standard
protocols for designating pain management teams. Such protocols
would be required to include assurances that any health care
provider without expertise in prescribing analgesics or who has
not completed education and training on pain management and
safe opioid prescribing practices does not prescribe opioids to
a patient unless such provider consults with a provider with
pain management expertise and refers the patient to the pain
management team for any subsequent prescriptions and related
therapy. VA would also be required to regularly report, track,
and monitor the pain management teams, the use of OSI and other
tools, opioid use among VA patients, and the availability of
opioid receptor antagonists.
Section 103--Strengthening of joint working group on pain management of
the Department of Veterans Affairs and the Department of
Defense
As explained in the descriptive portion of section 101 of
the bill above, the use of opioid medications for managing
chronic pain has been rapidly increasing in recent years. Data
suggests that veterans are a particularly high-risk population
for prescription misuse, substance use disorder, accidental
overdose, accidents, and/or self-inflicted injury and some
studies have shown that those veterans with the highest-risk
conditions are also the most likely to receive the highest-
dose, highest-risk opioid therapies. As a result, the Committee
believes that, along with updating the Guideline, VA and DOD
must focus their collaborative efforts on improving pain care
for servicemembers and veterans. The Committee is particularly
concerned about how VA and DOD manage patients' needs--and, in
particular, their medication needs--during the transition from
DOD care to VA care, which is an especially vulnerable time for
many.
To assist the Departments in focusing on these specific
areas of need, section 103 of the bill would require VA and DOD
to ensure that the Pain Management Working Group of the Health
Executive Committee of the VA/DOD Joint Executive Committee
focuses on the following: opioid prescribing practices; the
ability to manage acute and chronic pain; the use of CAM; the
concurrent use of opioids and prescription drugs to treat
mental health disorders; the practice of prescribing opioids to
treat mental health disorders; access to medications for
patients transitioning from DOD to VA; and, the ability to
identify and treat substance use disorder. Section 103 of the
bill would also require VA and DOD to ensure that the Working
Group coordinates with other relevant working groups and
Federal agencies and consults with and comments on the updated
Guideline or any successor guideline.
Section 104--Review, investigation, and report on use of opioids in
treatment by Department of Veterans Affairs
As explained in the descriptive portions of section 102 of
the bill above, VA developed and deployed the OSI in October
2013 in Minneapolis, Minnesota. In February 2014--five months
after it was first deployed--VA reported that the OSI had
already demonstrated success in lowering dependency on opioid
medications. According to VA, the eight sites of care where the
OSI was deployed in and around Minneapolis decreased high-dose
opioid prescriptions by more than half. While encouraged by
those results, the Committee wants to ensure that the OSI is
continuously updated and improved as research surrounding pain
management and opioid use is advanced.
In accordance with that goal, section 104 of the bill would
require GAO to submit a report to Congress on the OSI and the
opioid prescribing practices of VA health care providers and
issue recommendations for improvement. VA would be required to
report to Congress quarterly on the Department's progress
implementing GAO's recommendations. VA would also be required
to report to Congress annually--for five years--on opioid
prescriptions for non-cancer, non-palliative, and non-hospice
care patients at each VA medical facility. Section 104 of the
bill would further require VA to notify Congress and conduct a
full investigation through the Office of Medical Inspector if
the Secretary determines that a prescription rate with respect
to either a medical facility or individual provider conflicts
with or is otherwise inconsistent with the standards of
appropriate and safe care.
Section 105--Mandatory disclosure of certain veteran information to
State controlled substances monitoring programs
State prescription drug monitoring programs--which are also
referred to as state controlled substance monitoring programs--
are tools used by State governments to collect, monitor, and
analyze prescribing and dispensing data submitted by pharmacies
and dispensing practitioners to support state efforts in
education, research, law enforcement and substance abuse
prevention. Data collected by state prescription drug
monitoring programs is provided to authorized entities
including healthcare providers, pharmacists, regulatory boards,
and law enforcement agencies. According to the Prescription
Drug Monitoring Program Training and Technical Assistance
Center, 49 states, the District of Columbia, and Guam have
legislation that authorizes a prescription drug monitoring
program, and of those, 49 states and Guam have a prescription
drug monitoring program that is operational.
In 2013, VA promulgated a regulation that allowed but did
not require VA medical facilities to disclose information about
a veteran or dependent of a veteran to a State controlled
prescription drug monitoring program in order to prevent the
misuse and diversion of prescription medicines. Some, but not
all, VA medical facilities are now communicating with their
local State prescription drug monitoring program. However, the
Committee believes that all VA medical facilities should be
disclosing relevant information to State prescription drug
monitoring programs. As such, section 105 would require VA to
disclose information to state controlled substance monitoring
programs.
TITLE II--PATIENT ADVOCACY
Section 201--Community meetings on improving care furnished by
Department of Veterans Affairs
In April 2014, the Committee uncovered the use of
unauthorized waiting lists at the Phoenix VA Health Care System
in Phoenix, Arizona. At that time, at least forty veteran
patients had died while waiting on those lists to receive VA
care. This finding--and the subsequent investigations that
resulted from it--led to a widespread access and accountability
scandal that plagued the entire VA health care system. During
that scandal--the repercussions of which continue today--it
became increasingly clear to the Committee that there was a
disconnect between the leaders responsible for managing the VA
health care system and the veteran patients and their families
who relied on that system to meet their needs.
To correct this disconnect and increase communication
between local and regional VA leaders, veterans, and other
stakeholders, section 201 of the bill would require VA to
ensure that each VA medical facility--to include community-
based outpatient clinics--hosts a community meeting with
members of the public on improving the provision of health care
by VA. Each community meeting would be required to be noticed
at least 10 days in advance to the public and Congress. In
addition, either the Director of the relevant VISN or an
employee the Director delegates must attend each meeting, with
the stipulation that the Director must personally attend at
least one community meeting each year.
Section 202--Improvement of awareness of patient advocacy program and
patient bill of rights of Department of Veterans Affairs
VA operates a patient advocacy program to assist in the
timely resolution of patient complaints and concerns. In
accordance with the patient advocacy program, each VA medical
facility employs one or more patient advocates. Patient
advocates work directly with service-line chiefs and, per the
Patient Advocacy Program Handbook, are responsible for
facilitating resolution to problems beyond the scope of front-
line staff and participating in the resolution of system
problems by presenting the patient's perspective and desired
resolution.\6\ The Handbook also requires that patient rights
and responsibilities as well as information regarding the
patient advocacy program be posted in VA medical facilities and
provided to patients upon admission. Despite this requirement,
the Committee is concerned that veteran patients are not aware
of their rights and responsibilities with regard to their
health care or of their ability to contact a patient advocate
to assist them in resolving complaints and concerns related to
their health care.
---------------------------------------------------------------------------
\6\VHA Handbook 1003.4, VHA Patient Advocacy Program.
---------------------------------------------------------------------------
To remedy this, section 202 of the bill would require VA to
display the following information in each VA medical facility:
The purposes of the patient advocacy program; the contact
information for the facility's patient advocate; and the rights
and responsibilities of the patients and family members of the
patient or--with respect to community living centers or other
VA residential facilities--the rights and responsibilities of
residents and family members of residents. Such information
would be required to be displayed in as many prominent
locations as the Secretary determines is appropriate in order
to be seen by the largest percentage of patients or residents
and family members of patients or residents in each facility.
Section 203--Comptroller general report on patient advocacy program of
Department of Veterans Affairs
The Committee believes that a strong patient advocacy
program is vital to patient satisfaction and to the success of
the VA health care system. However, the Committee has heard
numerous concerns from veterans and their families that VA
patient advocates are not always responsive to a veteran's
needs. In light of those concerns, section 203 of the bill
would require GAO to perform an audit of VA's patient advocacy
program. The report produced by that audit would be required to
include the purpose and activities of the patient advocacy
program, the sufficiency of the patient advocacy program in
achieving its purpose, an assessment of the staffing of the
patient advocacy program, an assessment of the training of VA
patient advocates, an assessment of whether veterans and their
families are aware of and use the patient advocacy program, and
such recommendations and proposals for improving or modifying
the patient advocacy program as GAO considers appropriate.
TITLE III--COMPLEMENTARY AND INTEGRATIVE HEALTH
Section 301--Expansion of research and education on and delivery of
complementary and integrative health to veterans
The National Center for Complementary and Integrative
Health of the National Institutes of Health (NIH) defines
complementary and alternative medicine (CAM) as ``a group of
diverse medical and health care interventions, practices
products, or disciplines that are not generally considered part
of conventional medicine.''\7\ The term ``complementary''
refers to the use of CAM together with conventional medicine,
such as using meditation in addition to traditional
psychotherapy to treat PTSD. The term ``alternative'' refers to
use of CAM in place of conventional medicine, such as using
meditation in place of traditional psychotherapy to treat PTSD.
According to the VA Office of Research and Development, VA most
often uses CAM to help veterans manage stress, to promote
general wellness, or to treat PTSD, depression, back pain,
headache, arthritis, fibromyalgia, or substance abuse. While
the use of CAM has grown significantly throughout VA over the
past decade, the demand for CAM services among veterans
accessing VA care is increasing, and the Committee would like
to see CAM provided to veterans more uniformly across the VA
health care system.
---------------------------------------------------------------------------
\7\National Center for Complementary and Integrative Health,
``Exploring the Science of Complementary and Alternative Medicine,
Third Strategic Plan: 2011-2015,'' https://nccih.nih.gov/sites/
nccam.nih.gov/files/NCCAM_SP_508.pdf.
---------------------------------------------------------------------------
Accordingly, section 301 of the bill would establish the
Creating Options for Veterans' Expedited Recovery (or COVER)
Commission to examine the evidence-based therapy treatment
model used by VA to treat veterans and the potential benefits
of incorporating CAM into that treatment model. The Commission
would have the following duties: To examine the efficacy of
VA's evidence-based treatment model in treatment mental illness
in veterans; to identify areas to improve wellness-based
outcomes; to conduct patient centered surveys within each VISN
on veterans' experiences and preferences; to examine available
research on CAM and what benefits could result from the
inclusion of CAM treatments; to study whether VA's resources
are sufficient for ensuring the delivery of quality care for
veterans with mental health issues who are seeking VA
treatment; and to study and assess the current treatments and
resources available within VA. The Commission's membership
would be composed of appointees from the Speaker and Minority
Leader of the House of Representatives, the Majority Leader and
Minority Leader of the Senate, and the President who have
relevant qualifications. The Commission would be required to
meet and report to Congress regularly. Following the
Commission's final report, VA would be required to submit an
action plan for implementing the Commission's recommendations
and a timeframe for implementing CAM. If VA elects not to
implement a given recommendation, VA would be required to
submit a justification for determining that such recommendation
is not appropriate and an alternative solution to improve the
efficacy of VA's therapy model.
Section 302--Pilot program on integration of complementary alternative
medicines and related issues for veterans and family members
As explained in the descriptive portion of section 301 of
the bill, the Committee is interested in increasing the use of
CAM throughout the VA health care system generally. The
Committee is also interested in exploring how CAM may benefit
veterans seeking pain care, specifically. To further this goal,
section 302 of the bill would establish a three-year pilot
program in at least 15 VA medical centers to assess the
feasibility and advisability of using wellness-based programs
to complement the provision of pain and related care to
veterans. The pilot program would be required to assess the
following: the means of improving coordination between Federal,
State, local, and community health care providers in providing
pain and related care; the means of enhancing outreach and
coordination of outreach by and among health care providers
providing pain and related care; the means of using wellness-
based programs to complement pain and related care; and whether
wellness-based programs are effective for veterans receiving
pain and related care. In selecting VA medical centers for the
pilot program, VA would be required to prioritize facilities
with the opioid prescription rates that conflict or are
otherwise inconsistent with usual standards of appropriate and
safe care. In order to be eligible to participate in the pilot,
veterans would have to be diagnosed with a mental health
condition and experience chronic pain that is being treated by
a VA clinician. During the pilot, participating veterans would
be provided with CAM as defined by NIH. VA would be required to
report to Congress not later than 30 months after the beginning
of the pilot program.
TITLE IV--FITNESS OF HEALTH CARE PROVIDERS
Section 401--Additional requirements for hiring of health care
providers by Department of Veterans Affairs
In response to complaints made in 2011 and 2012, the VA
Office of the Inspector General (IG) conducted a review of
alleged inappropriate prescription of controlled substances and
alleged abuse of authority at the Tomah VA Medical Center
(VAMC) in Tomah, Wisconsin. According to the IG, a total of 32
specific allegations were made before and during the course of
the IG's review. These allegations concerned the number of
opioid prescriptions at the facility, in general, and the
opioid prescribing practices of the facility's Chief of Staff,
in particular. According to media reports, veterans commonly
referred to the facility as ``Candy Land'' and to the Chief of
Staff as the ``Candy Man'' because of the high number of opioid
prescriptions that were provided.\8\ While the IG did not
substantiate allegations that opioids were prescribed
inappropriately to specific individuals or in inappropriate
doses, the IG did find that the amounts of opioids prescribed
by the Chief of Staff and select other providers were ``at
considerable variance compared with most opioid prescribers in
VISN 12.''\9\ The IG also substantiated that there were,
``widely held beliefs and concerns among pharmacy staff and
among some other staff,'' of abuse of authority, intimidation,
and retaliation on the part of the Chief of Staff when
controlled substance prescription practices were
questioned.\10\ In conclusion, the IG stated that, ``our
inspection raised potentially serious concerns that should be
brought to the attention of VISN 12 management for further
review.''\11\
---------------------------------------------------------------------------
\8\Chicago Tribune, ``Veterans: VA hospital nicknamed `Candy Land'
because painkillers given out freely,'' January 9, 2015. http://
www.chicagotribune.com/news/ct-tomah-va-hospital-nw-20150109-story.html
\9\VA Office of the Inspector General, ``Administrative Closure--
Alleged Inappropriate Prescribing of Controlled Substances and Alleged
Abuse of Authority, Tomah VA Medical Center, Tomah, WI,'' page 7.
http://www.va.gov/oig/pubs/VAOIG-11-04212-127.pdf.
\10\Id., at page 5.
\11\Id., page 9. http://www.va.gov/oig/pubs/VAOIG-11-04212-127.pdf.
---------------------------------------------------------------------------
Following the public release of the IG's findings in 2015,
VA began a comprehensive review of medication prescription
practices at the Tomah VAMC. VA's review substantiated unsafe
clinical practices in areas such as pain management and
psychiatric care and found that Tomah VAMC patients were: (1)
2.5 times more likely than the national average to be
prescribed opioids greater than 400 morphine equivalents per
day; (2) more likely than the national average to be prescribed
opioid doses between 200-300 morphine equivalents per day; and,
(3) almost double the national average with respect to the use
of benzodiazepines and opioids together. Higher morphine
equivalents per day and the concurrent use of benzodiazepines
and opioids increase the occurrence of complications and
adverse events.
The IG's and VA's investigations into the Tomah VAMC, and
the issues that subsequently came to light regarding the Tomah
VAMC Chief of Staff, started a national conversation about the
prevalence of opioid prescriptions in the VA health care
system, how VA oversees facility's and providers' opioid
prescribing practices, and whether and how VA communicates with
State and local medical licensing bodies regarding patient care
concerns with individual providers.
To ensure that VA has insight into a prospective provider's
history to include any findings of negligent patient care
section 401 of the bill would require that, as part of the
hiring process for incoming providers, VA solicit information
from the medical board of each State in which an incoming
provider is licensed. Information VA would be required to
solicit from the State medical board would include information
regarding any violations of such provider's medical license and
information regarding whether such provider has entered into
any settlement agreements as a result of disciplinary charges
relating to the practice of medicine.
Section 402--Provision of information on health care providers of
Department of Veterans Affairs to State Medical Boards
As stated above, the Committee has concerns regarding the
need for VA to have information regarding allegations or
findings made against a prospective provider's medical license.
The Committee recognizes a similar need for VA to share
information with State and local medical licensing bodies about
allegations or findings that are made about providers during
their tenure at VA. As such, section 402 of the bill would
require VA to provide the medical board of each State in which
a healthcare provider is licensed detailed information with
respect to a violation of a requirement of such provider's
medical license.
Section 403--Report on compliance by Department of Veterans Affairs
with reviews of health care providers leaving the Department or
transferring to other facilities
Following the issues described above regarding the Tomah
VAMC, the Committee heard concerns from many veterans and VA
employees regarding providers who have had complaints made
about their medical practice leaving VA employment or
transferring to another VA facility to avoid negative
repercussions of such complaints. As such, the Committee has
also recognized the need for a heightened level of oversight
regarding VA's policies with respect to outgoing providers and
providers transferring from one VA facility to another. In
light of this, section 403 of the bill would require VA to
submit to Congress a report on the Department's compliance with
policies to conduct a review of each health care provider who
transfers to another VA medical facility, retires, or is
terminated to determine whether there are any concerns,
complaints, or allegations of violations relating to the
provider's medical practice and to take appropriate action with
respect to any such concern, complaint, or allegation.
TITLE V--OTHER VETERANS MATTERS
Section 501--Audit of Veterans Health Administration programs of
Department of Veterans Affairs
The Veterans Access, Choice, and Accountability Act of 2014
(Public Law 113-146; 128 Stat. 1770) required VA to contract
with a private sector entity to conduct an Independent
Assessment of the VHA. To complete the Independent Assessment,
which is composed of twelve individual assessments, VA entered
into a contract with the Centers for Medicare and Medicaid
Services Alliance to Modernize Healthcare (CAMH), a private
federally funded research and development center that is
operated by the MITRE Corporation. CAMH, in turn, partnered
with the RAND Corporation, McKinsey and Company, and Grant
Thornton, to complete eleven of the individual assessments with
the remaining individual assessment (pertaining to access
standards) being completed by the Institute of Medicine. CAMH
and its partners interviewed hundreds of VA, VHA, and private
sector health care staff; visited 87 VA medical facilities
across 30 states, Washington, DC, and Puerto Rico; and reviewed
approximately 500 data sets, reports, and documents from VA.
The Independent Assessment was delivered to VA and to Congress
on September 1, 2015, and released publicly on September 18,
2015.
Assessment L, which was conducted by McKinsey and Company,
focused on the competency of leadership across VHA with respect
to culture, accountability, reform readiness, leadership
development, physician alignment, employee engagement,
succession planning, and performance management. Assessment L
concluded that an expanding scope of activities has led to
confusion around leadership priorities and strategic direction
of VHA, and that VHA's organization is unnecessarily complex.
Assessment L further found that VHA's culture is characterized
by risk-aversion and distrust, and that VHA leadership oversees
a workforce that appears to be steadily losing motivation, and
is consumed by addressing crises that have occurred in the past
at the expense of preparing for the future. As a result,
Assessment L concluded that VHA is unable to improve
performance consistently and fully across the system, is
unprepared for the future, and lacks a leadership pipeline
robust enough to meet current and future needs.
In recognition of the need for further study and
recommendations on how VHA can better service veterans, section
501 of the bill would require VA to enter into a contract with
a non-governmental entity to conduct an audit of VHA's programs
and identify ways to improve the furnishing of benefits and
health care administered by VHA to veterans and their families.
The audit would be required to include five-year risk
assessments to identify the functions and staff organizations
and offices that would lead to the greatest improvements in the
furnishing of health care and benefits to veterans and their
families through VHA; the development of plans that are
informed by such assessments; and for audits to be conducted in
accordance with such plans. VA would be required to submit a
report to Congress 90 days after the audit is complete with a
summary of the audit, the findings of the entity that conducted
the audit, and recommendations as the Secretary determines
appropriate for legislative and administrative action to
improve the furnishing of benefits and health care to veterans
and families of veterans.
Hearings
There were no full Committee hearings held on H.R. 4063, as
amended. On November 17, 2015, the Subcommittee on Health
conducted a legislative hearing on: H.R. 1319; H.R. 1603; H.R.
1904; H.R. 2639; H.R. 3234; H.R. 3471; H.R. 3549; draft
legislation, the Promoting Responsible Opioid Management and
Incorporating Scientific Expertise Act; and a VA legislative
proposal, the VA Purchased Health Care Streamlining and
Modernization Act.
The following witnesses testified:
The Honorable Beto O'Rourke of Texas; the Honorable Andy
Barr of Kentucky; the Honorable Matt Cartwright of
Pennsylvania; the Honorable Scott Peters of California; the
Honorable Martha Roby of Alabama; the Honorable Jackie Walorski
of Indiana; the Honorable John Kline of Minnesota; the
Honorable Gus Bilirakis of Florida; Adrian Atizado, the Deputy
National Legislative Director for the Disabled American
Veterans; LaRanda D. Holt, the Assistant Director for Women and
Minority Veterans Outreach for the National Veterans Affairs
and Rehabilitation Division of the American Legion; Carlos
Fuentes, the Senior Legislative Associate for the National
Legislative Service of the Veterans of Foreign Wars of the
United States; and Janet Murphy, Acting Deputy Under Secretary
for Health for Operations and Management for the Veterans
Health Administration of the U.S. Department of Veterans
Affairs, who was accompanied by Elias Hernandez, Chief Officer
for Workforce Management and Consulting for the Veterans Health
Administration, Harold Kudler, Chief Consultant for Mental
Health Services for the Veterans Health Administration, and
Susan Blauert, Deputy Assistant General Counsel for the
Veterans Health Administration.
Statements for the record were submitted by:
The American Counseling Association; the American Orthotic
and Prosthetic Association; AMVETS; the Kentucky Department of
Veterans Affairs; the National Mobility Equipment Dealers
Association; the Paralyzed Veterans of America; Heather
Simcakoski; and Martin Simcakoski.
Subcommittee Consideration
There were no Subcommittee markups involving H.R. 4063, as
amended.
Committee Consideration
On February 25, 2016, the Full Committee met in open markup
session, a quorum being present, and ordered H.R. 4063, as
amended, to be reported favorably to the House of
Representatives by voice vote.
During consideration of H.R. 4063, as amended, the
following amendments were considered and agreed to by voice
vote:
An amendment in the nature of a substitute offered by
Representative Gus Bilirakis of Florida;
An amendment to the amendment in the nature of a substitute
offered by Representative Jackie Walorski of Indiana;
A second amendment to the amendment in the nature of a
substitute offered by Representative Jackie Walorski of
Indiana.
Committee Votes
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, there were no recorded votes
taken on amendments or in connection with ordering H.R. 4063,
as amended, reported to the House. A motion by Ranking Member
Corrine Brown of Florida to report H.R. 4063, as amended,
favorably to the House of Representatives was agreed to by
voice vote.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
(2)(b)(1) of rule X of the Rules of the House of
Representatives, the Committee's oversight findings and
recommendations are reflected in the descriptive portions of
this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives of this legislation are to improve pain
care, patient advocacy, and the use of opioid therapy across
the VA health care system and to increase complementary and
integrative health techniques for veteran patients.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee adopts as its
own the estimate of new budget authority, entitlement
authority, or tax expenditures or revenues contained in the
cost estimate prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Earmarks and Tax and Tariff Benefits
H.R. 4063, as amended, does not contain any Congressional
earmarks, limited tax benefits, or limited tariff benefits as
defined in clause 9 of rule XXI of the Rules of the House of
Representatives.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
4063, as amended, prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
for H.R. 4063, as amended, provided by the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, May 4, 2016.
Hon. Jeff Miller,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 4063, the
Promoting Responsible Opioid Management and Incorporating
Scientific Expertise Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Ann E.
Futrell.
Sincerely,
Keith Hall.
Enclosure.
H.R. 4063--Promoting Responsible Opioid Management and Incorporating
Scientific Expertise Act
Summary: H.R. 4063 would require the Department of Veterans
Affairs (VA) to update safety measures for opioid therapy,
expand the use of alternative medicine, and conduct audits of
the VA health care system through a nongovernment entity. In
total, CBO estimates that implementing the bill would cost $138
million over the 2017-2021 period, subject to appropriation of
the necessary amounts.
Pay-as-you-go procedures do not apply because enacting the
legislation would not affect direct spending or revenues. CBO
estimates that enacting H.R. 4063 would not increase net direct
spending or on-budget deficits in any of the four consecutive
10-year periods beginning in 2027.
H.R. 4063 would impose an intergovernmental mandate by
requiring state medical boards to report to the VA information
about medical violations in the past 20 years committed by
licensed physicians whom the VA is considering for employment.
Information from state medical boards indicates that many
boards already provide information that is similar to what the
bill requires. Consequently, CBO estimates that the incremental
costs of the mandate would be small and would fall below the
annual threshold established in the Unfunded Mandates Reform
Act (UMRA) for intergovernmental mandates ($77 million,
adjusted annually for inflation).
This bill contains no private-sector mandates as defined in
UMRA.
Estimated Cost to the Federal Government: The estimated
budgetary effect of H.R. 4063 is shown in the table below. The
costs of this legislation fall within budget function 700
(veterans benefits and services).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars----
--------------------------------------------------
2017 2018 2019 2020 2021 2017-2021
----------------------------------------------------------------------------------------------------------------
SPENDING SUBJECT TO APPROPRIATION
Opioid Safety Measures
Estimated Authorization Level............................ 18 20 20 21 22 101
Estimated Outlays........................................ 16 20 20 21 22 99
Complementary and Integrative Health
Estimated Authorization Level............................ 0 0 6 7 7 20
Estimated Outlays........................................ 0 0 5 7 7 19
Audits
Estimated Authorization Level............................ 2 2 2 2 2 10
Estimated Outlays........................................ 1 2 2 2 2 9
Community Meetings
Estimated Authorization Level............................ * 1 1 1 1 4
Estimated Outlays........................................ * 1 1 1 1 4
Commission on Complementary Health
Estimated Authorization Level............................ 1 2 1 0 0 4
Estimated Outlays........................................ 1 2 1 * 0 4
Reports
Estimated Authorization Level............................ 1 1 * * * 3
Estimated Outlays........................................ 1 1 * * * 3
Total changes to Spending Subject to Appropriation
Estimated Authorization Level........................ 22 26 30 31 32 142
Estimated Outlays.................................... 19 26 29 31 32 138
----------------------------------------------------------------------------------------------------------------
Note:* = less than $500,000; details may not add to totals because of rounding.
Basis of estimate: For this estimate, CBO assumes that H.R.
4063 will be enacted near the start of fiscal year 2017, that
the estimated amounts will be appropriated each year, and that
outlays will follow historical spending patterns for affected
programs.
Opioid safety measures
Section 102 would require VA to expand its safety measures
by improving training on providing pain management and
prescribing opioids, establishing pain management teams at each
medical facility, and improving patient tracking through
electronic reports.
This provision would create pain management teams
throughout the VA health care system. According to VA, each
medical facility currently has its own methods to manage and
oversee pain therapy; however, they do not have designated pain
management teams. Under this provision, VA would be required to
implement a protocol for such teams. Based on information from
VA, we expect that establishing and implementing such protocols
at roughly 1,000 medical facilities would require very little
additional work and would have an annual cost of roughly $6,500
per facility. On that basis, CBO estimates that establishing
the pain management teams nationwide would cost $33 million
over the 2017-2021 period.
Section 102 also would require VA to expand the nationwide
availability of certain treatments such as Naloxone kits for
opioid overdose. According to VA, it currently has roughly
55,000 patients with opioid-use disorder and roughly 28,000
Naloxone kits in its inventory. CBO estimates that it would
cost roughly $14 million each year to ensure the availability
of kits (at a cost of about $400 per kit) for those 55,000
patients who have the greatest potential risk of overdose. On
that basis, CBO estimates it would cost $66 million over the
2017-2021 period to expand the availability of such treatments.
This section also would require VA to enhance the ability
of the electronic Opioid Therapy Risk Report (OTRR) to access
information on prescribed drugs through the Prescription Drug
Monitoring Programs. According to VA, such modifications to the
OTRR would require minimal analyst and programming support. CBO
estimates that implementing that requirement would cost less
than $500,000 over the 2017-2021 period.
In total, CBO estimates that implementing section 102 would
cost $99 million over the 2017-2021 period.
Complementary and integrative health
Section 302 would require VA to operate a three-year
program at 15 VA Medical Centers to assess the feasibility of
integrating complementary and alternative medicine with
traditional care. That program would begin after the commission
established under section 301 publishes their final report on
complementary health. CBO expects that report would be issued
near the end of fiscal year 2018 and that the three-year
program would begin near the beginning of fiscal year 2019. On
the basis of VA's implementation of other pilot programs of
similar scope (such as using meditation for veterans with Post
Traumatic Stress Disorder), CBO expects that developing and
operating the program would require two additional medical
practitioners at each of the 15 facilities to provide
nontraditional care, as well as two additional employees at
each facility to engage in research, training, and assessment
of the program.
The use of complementary and alternative medicine also
would partially displace the use of traditional care (emergency
care, primary care, and physical therapy) but would lead to
greater use of medical services on balance, than under current
law. Specifically, CBO estimates that the net cost to deliver
medical services, after adjusting for the expected reduction in
usage of traditional health care services would be roughly
$66,000 per medical provider, resulting in costs of roughly $2
million annually during the three-year pilot program.
On the basis of information from VA, CBO further estimates
that the annual cost per person for the research and training
personnel would be $127,000 in 2015. Thus, in total,
implementing section 302 would cost $19 million over the 2019-
2021 period, CBO estimates.
Audits
Section 501 would require VA to enter into a contract with
a private entity to conduct a series of audits of the VA health
care system. The audits would include a risk assessment for the
following five years and provide recommendations to improve the
delivery of health care and plans for subsequent audits. On the
basis of costs incurred for previous system-wide assessments of
the VA by contracted entities, CBO estimates that implementing
section 501 would cost about $2 million each year. After
factoring in the time to solicit and select a contractor, CBO
estimates total costs of $9 million over the 2017-2021 period.
Community meetings
Section 201 would require VA Medical Centers and Community
Based Outpatient Clinics to host community meetings on an
annual and quarterly basis, respectively. Those meetings would
be open to the public. VA currently hosts town hall meetings to
get feedback from veterans, their family members and other
community stakeholders. On the basis of information from VA,
CBO estimates that VA would need to hold an additional 500 such
meetings a year to meet the requirements of this provision.
Based on costs in the private sector, we estimate VA would
spend roughly $1,500 per meeting for audio visual equipment,
staff time, and supplies. In total, CBO estimates implementing
this provision would cost $4 million over the 2017-2021 period.
Commission on complementary health
Within 90 days of enactment, section 301 would establish
the Creating Options for Veterans' Expedited Recovery
Commission to:
Examine treatment of mental health at the VA
through evidence-based therapy;
Conduct a nationwide survey; and,
Determine the benefits of incorporating
alternative treatments at nonVA facilities.
The commission would have 10 members plus a paid staff and
would exist for about 18 months. The commission would be
required to submit interim reports and a final report within 18
months of the commission's first meeting. Within 90 days of the
final report, VA would be required to submit a plan to the
Congress on implementing the commission's recommendations.
Based on the costs of similar commissions, CBO estimates that
implementing section 301 would cost about $4 million over the
2017-2021 period.
Reports
The bill would require VA to produce about a dozen reports
on matters such as opioid therapy, patient advocacy, and
complementary medicine. Based on the costs of similar reports,
CBO estimates that meeting those requirements would cost a
total of $3 million over the 2017-2021 period.
Pay-As-You-Go considerations: None.
Increase in long-term direct spending and deficits: CBO
estimates that enacting H.R. 4063 would not increase net direct
spending or on-budget deficits in any of the four consecutive
10-year periods beginning in 2027.
Estimated impact on state, local, and tribal governments:
H.R. 4063 would impose an intergovernmental mandate by
requiring state medical boards to report to the VA information
about medical violations in the past 20 years committed by
licensed physicians whom the VA is considering for employment.
Information from state medical boards indicates that many
boards already provide information that is similar to what the
bill requires. Consequently, CBO estimates that the incremental
costs of the mandate would be small and would fall below the
annual threshold established in UMRA for intergovernmental
mandates ($77 million, adjusted annually for inflation).
Estimated impact on the private sector: This bill contains
no private-sector mandates as defined in UMRA.
Estimate prepared by: Federal Costs: Ann E. Futrell; Impact
on State, Local, and Tribal Governments: Jon Sperl; Impact on
the Private Sector: Paige Piper/Bach.
Estimate approved by: H. Samuel Papenfuss, Deputy Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 4063, as amended, prepared by the
Director of the Congressional Budget Office pursuant to section
423 of the Unfunded Mandates Reform Act.
Advisory Committee Statement
Section 101 of H.R. 4063, as amended, would create an
advisory committee within the meaning of section 5(b) of the
Federal Advisory Committee Act.
Statement of Constitutional Authority
Pursuant to Article I, section 8 of the United States
Constitution, H.R. 4063, as amended, is authorized by Congress'
power to ``provide for the common Defense and general Welfare
of the United States.''
Applicability to Legislative Branch
The Committee finds that H.R. 4063, as amended, does not
relate to the terms and conditions of employment or access to
public services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Statement on Duplication of Federal Programs
Pursuant to section 3(g) of H. Res. 5, 114th Cong. (2015),
the Committee finds that no provision of H.R. 4063, as amended,
establishes or reauthorizes a program of the Federal Government
known to be duplicative of another Federal program, a program
that was included in any report from the Government
Accountability Office to Congress pursuant to section 21 of
Public Law 111-139, or a program related to a program
identified in the most recent Catalog of Federal Domestic
Assistance.
Disclosure of Directed Rulemaking
Pursuant to section 3(i) of H. Res. 5, 114th Cong. (2015),
the Committee estimates that H.R. 4063, as amended, contains no
directed rule making that would require the Secretary to
prescribe regulations.
Section-by-Section Analysis of the Legislation
TITLE I--OPIOID THERAPY AND PAIN MANAGEMENT
Section 1. Short title; Table of contents
Section 1(a) would provide the short title of H.R. 4063, as
amended, as the ``Promoting Responsible Opioid Management and
Incorporating Scientific Expertise Act'' or the ``Jason
Simcakoski PROMISE Act.''
Section 1(b) would provide a table of contents for the Act.
Section 101. Establishment of advisory committee to review guidelines
on management of opioid therapy by Department of Veterans
Affairs and Department of Defense
Section 101(a) would establish an advisory committee to:
(1) conduct a review of the VA/DOD Clinical Practice Guideline
for Management of Opioid Therapy for Chronic Pain; and (2) make
recommendations to the Secretaries for updating the Guideline.
Section 101(b) would require that the review under
subsection (a) include enhanced guidance in respect to: (1)
opioid and other drug prescription practices; (2) treatment of
patients with behaviors or comorbidities; (3) patient status
assessments for providers; (4) the use of the Opioid Therapy
Risk Report tool; (5) governance of the methodologies used by
VA and DOD providers to taper opioid therapy; (6) appropriate
case management for opioid patients transitioning from an
inpatient setting to an outpatient setting; (7) appropriate
case management for opioid patients transitioning from active
duty to post-military health care networks; (8) use of routine
and random urine drug tests to help prevent substance abuse;
(9) how providers should discuss with patients options for pain
management therapies before initiating opioid therapy; and (10)
evidence-based non-opioid treatments within VA and DOD.
Section 101(c) would require the advisory committee to
consult with the VA/DOD Management of Opioid Therapy for
Chronic Pain Working Group during the committee's review.
Section 101(d) would require the advisory committee to
submit the review and accompanying recommendations to the VA
and DOD Secretaries no later than one year after the enactment
of this act.
Section 101(e) would require that the provisions of the
Federal Advisory Committee Act (5 U.S.C. App.) apply to the
Advisory Committee.
Section 101(f) would define: (1) the term ``Advisory
Committee'' to mean the advisory committee established under
subsection (a); (2) the term ``Clinical Practice Guideline'' to
mean the VA/DOD Clinical Practice Guideline for Management of
Opioid Therapy for Chronic Pain; (3) the term ``controlled
substance'' to have the meaning given in section 102 of the
Controlled Substance Abuse Act (21 U.S.C. 802); and (4) the
term ``State'' to mean each of the several states, territories,
and possessions of the United States, the District of Columbia,
and the Commonwealth of Puerto Rico.
Section 102. Improvement of opioid safety measures by Department of
Veterans Affairs
Section 102(a) would require the Secretary to expand the
Opioid Safety Initiative to include all VA medical facilities
within 180 days of the enactment of this act.
Section 102(b)(1) would require that all VA employees who
prescribe opioids receive education and training on pain
management and safe opioid prescribing practices.
Section 102(b)(2) would require that this education and
training include the following: (A) the implementation and full
compliance with the VA/DOD Clinical Practice Guidelines for
Management of Opioid Therapy for Chronic Pain; (B) the use of
evidence-based pain management therapies for the treatment of
patients with chronic pain; (C) screening and identification of
patients with substance use disorder before prescribing opioids
and referral of patients to appropriate addiction treatment
professionals, if needed; (D) communication with patients on
the risks of opioid and other controlled substance use; and (E)
such other education and training as the Secretary considers
appropriate.
Section 102(b)(3) would require the Secretary to use the
Interdisciplinary Chronic Pain Management Training Team Program
(or success program) in providing this training and education.
Section 102(c)(1) would require that the director of each
medical facility designate a pain management team of health
care professionals responsible for coordinating and overseeing
pain management therapy at the facility to carry out the Opioid
Safety Initiative.
Section 102(c)(2) would require the Secretary to establish
protocols for designating pain management teams in consultation
with the VISN directors. Each protocol established under this
subsection must ensure that any provider without expertise in
prescribing analgesics or who has not completed the education
and training in subsection (b) does not prescribe opioids
except under specified circumstances.
Section 102(c)(3) would require the director of each
facility to submit a report within one year of the enactment of
this act to the Under Secretary for Health and the appropriate
VISN director identifying the members of the facility's pain
management team. Each report must include a certification as to
whether all members of the pain management team at the facility
have completed the education and training required under
subsection (b); a plan for the management and referral of
patients to such pain management team if providers without
expertise in analgesics prescribe opioid medications to treat
pain; a certification as to whether the medical facility fully
complies with the stepped-care model or other pain management
policies, and if not, whether the facility is carrying out a
corrective plan of action to ensure such full compliance.
Section 102(d)(1) would require that in carrying out the
Opioid Safety Initiative and the Opioid Therapy Risk Report
tool, the Secretary: (A) ensure that VA health care providers
have access to information on controlled substances prescribed
to veterans who receive care outside of VA through States'
prescription drug monitoring program through measures including
entering into memoranda of understanding with States to allow
shared access of such information; (B) include the information
in the Opioid Therapy Risk Report; and (C) require VA providers
to submit controlled substance prescription information to the
relevant State prescription drug monitoring program(s).
Section 102(d)(2) would require that, no later than 18
months after the enactment of this act, the Secretary submit to
the Committees on Veterans' Affairs of the House and the Senate
a report on the feasibility and advisability of improving the
VA Opioid Therapy Risk Report tool to allow for a more advanced
real-time tracking of and access to data on: (A) the key
clinical indicators with respect to the totality of opioid use
by veterans; (B) concurrent prescribing by VA health care
providers of opioids in different health care settings; and (C)
mail-order prescriptions of opioids prescribed to veterans
under laws administered by the Secretary.
Section 102(e)(1) would require the Secretary to maximize
the availability of FDA approved opioid receptor antagonists to
veterans. In doing so, not later than 90 days after the
enactment of this act, the Secretary must equip each VA
pharmacy with opioid receptor antagonists to be given to
outpatients as needed, and expand the VA Overdose Education and
Naloxone Distribution program to ensure that veterans at risk
of opioid overdose have access to and training on opioid
receptor antagonists.
Section 102(e)(2) would require that, no later than 120
days after the enactment of this act, the Secretary submit a
report regarding VA's implementation of this subsection to the
Committees on Veterans' Affairs of the House and of the Senate.
Section 102(f) would require the Secretary to include in
the VA Opioid Therapy Risk Report tool: (1) information on when
the tool was last accessed by a VA provider regarding each
veteran and the results of each veteran's most recent urine
drug test; and (2) the ability to determine whether a VA
provider prescribed opioids to a veteran without checking the
information in the tool with respect to that veteran.
Section 102(g) would require the Secretary to modify the VA
computerized patient record system to ensure that any health
care provider who accesses a veteran's record is notified
immediately whether that veteran is: (1) receiving opioid
therapy and has a history of substance abuse or has previously
overdosed; (2) has a history of opioid abuse; or (3) is at risk
for opioid abuse.
Section 102(h) would define the term ``controlled
substance'' as having the meaning given to that term in section
102 of the Controlled Substances Act (21 U.S.C. 802) and the
term ``State'' to mean each of the several States, territories,
and possessions of the United States, the District of Columbia,
and the Commonwealth of Puerto Rico.
Section 103. Strengthening of Joint Working Group on Pain Management of
the Department of Veterans Affairs and the Department of
Defense
Sec 103(a) would require that, within 90 days after the
enactment of this act, the Secretaries of VA and DOD ensure
that the Pain Management Working Group of the Health Executive
Committee of VA-DOD Joint Executive Committee focuses on: (1)
opioid prescribing practices of health care providers of each
Department; (2) the ability of each Department to manage pain
of each Department's patients (including employee training on
pain management); (3) the use of each Department of
complementary and integrative health and complementary
alternative medicines in treating those patients; (4) the
concurrent use by each Department's providers of opioids and
prescription drugs to treat mental health disorders; (5) the
practice by each Department's providers of prescribing opioids
to treat mental health disorders; (6) the coordination in
coverage of and access to medications as patients transition
from DOD to VA care; and (7) the ability of each Department to
identify and treat substance abuse disorders among patients.
Sec 103(b) would require the Secretaries of VA and DOD to
ensure that the working group described in subsection (a): (1)
coordinates its activities with other relevant working groups;
(2) consults with other relevant Federal agencies with respect
to its activities; (3) and consults with VA and DOD with
respect to any proposed updates to the VA/DOD Clinical Practice
Guideline for Management of Opioid Therapy for Chronic Pain.
Section 103(c) would require the Secretaries of VA and DOD
to ensure that the working group described in subsection (a) is
able to meaningfully consult regarding updates to the Guideline
for Management of Opioid Therapy no later than one year after
the enactment of this act.
Section 104. Review, investigation, and report on use of opioids in
treatment by Department of Veterans Affairs
Section 104(a)(1) would require the Comptroller General
within two years after the enactment of this act to submit to
the Committees on Veterans' Affairs of the House and of the
Senate a report on the VA Opioid Safety Initiative and the
opioid prescribing practices of VA providers.
Section 104(a)(2) would require that the report include:
(A) recommendations on improvements to the Opioid Safety
Initiative; (B) information regarding VA-prescribed opioid-
related deaths, overall opioid prescription rates to treat non-
cancer, non-palliative, and non-hospice care patients,
concomitant opioid and benzodiazepine prescription rates, the
prescription of opioids to patients without any pain, and the
effectiveness of opioid therapy; (C) an evaluation of VA's
oversight processes regarding veterans' opioid use; and (D) an
assessment of the Secretary's implementation of the VA/DOD
Guideline for Management of Opioid Therapy.
Section 104(b) would require that, within two years of the
enactment of this act, and no later than 30 days after the end
of each quarter thereafter, the Secretary submit to the
Committees on Veterans' Affairs of the House and of the Senate
a progress report on VA's implementation of GAO's
recommendations under subsection (a).
Section 104(c) would require that, within one year of the
enactment of this act, and at least once a year for the
following five years, the Secretary submit to the Committees on
Veterans' Affairs of the House and of the Senate a report
regarding information about VA providers' prescription of
opioids with respect to each VA facility to treat non-cancer,
non-palliative, and non-hospice care patients, including the
following pertaining to the one-year period preceding the
submission of the report: (1) the number of patients and
percentage of VA's patient population concurrently prescribed
opioids; (2) the number of patients and the percentage of VA's
patient population; (3) the number of patients and the
percentage of VA's patient population treated with opioids by a
VA provider on an in-patient basis who also received
prescription opioids through VA's Consolidated Mail Order
Pharmacy; (4) the number of patients and the percentage of VA's
patient population who were prescribed opioids concurrently by
a VA provider and a non-VA provider; (5) with respect to each
VA facility, the concurrent and the aggregate opioid
prescription rate for all providers; the rate at which each
facility provider prescribed opioids by mail to patients who
were being treated with opioids on an in-patient basis, and the
aggregate of such rate; the number of times a facility
pharmacist overrode a critical drug interaction warning before
dispensing opioids to a veteran.
Section 104(d) would require the Secretary to immediately
notify the Committees on Veterans' Affairs of the House and of
the Senate and conduct an investigation through the Office of
the Medical Inspector if the Secretary determines that an
identified prescription rate is inconsistent with the standards
of appropriate and safe care.
Section 104(e) would define the term ``prescription rate''
to mean, with respect to a VA provider or facility, each of the
following: (1) the number of patients treated with opioids by a
provider or at a facility, divided by the total number of
pharmacy users of that provider or facility; (2) the average
number of morphine equivalents per day prescribed by the
provider or at the facility to patients being treated with
opioids; (3) the average number of prescriptions per patient of
the patients being treated with opioids.
Section 105. Mandatory disclosure of certain veteran information to
state controlled substance monitoring programs
Section 105 would amend Section 5701(l) of title 38, United
States Code, by striking ``may'' and inserting ``shall.''
TITLE II--PATIENT ADVOCACY
Section 201. Community meetings on improving care furnished by
Department of Veterans Affairs
Section 201(a) would require that: (1) within 90 days of
the enactment of this act, and at least once every 90 days
thereafter, the Secretary ensure that each VA medical facility
hosts a public community meeting on improving VA health care;
and (2) within one year of the enactment of this act, and at
least annually thereafter, the Secretary will ensure that each
community-based outpatient clinic (CBOC) hosts such a community
meeting.
Section 201(b) would require that each community meeting
hosted by a facility or CBOC under subsection (a) be attended
by the VISN director in which the facility or CBOC is located.
The director may delegate the requirement of attendance to an
employee of the director, provided the VISN director attends at
least one community meeting each year.
Section 201(c) would require that the Secretary notify the
Committees on Veterans' Affairs of the House and of the Senate
and the Members of Congress who represent the area in which the
facility is located of any community meetings under subsection
(a) at least ten days in advance.
Section 202. Improvement of awareness of Patient Advocacy Program and
patient bill of rights of Department of Veterans Affairs
Section 202 would require that, within 90 days of the
enactment of this act, the Secretary display in as many
prominent locations as the Secretary determines appropriate to
be seen by the largest percentage of patients at each VA
medical facility: (1) the purposes of the VA Patient Advocacy
Program and the contact information for the patient advocate at
each medical facility; and (2) the rights and responsibilities
of patients and family members and, with respect to community
living centers and other VA residential facilities, residents
and family members.
Section 203. Comptroller General report on Patient Advocacy Program of
Department of Veterans Affairs
Section 203(a) would require that, within two years of the
enactment of this act, the Comptroller General submit a report
on the VA Patient Advocacy Program to the Committees on
Veterans' Affairs of the House and of the Senate.
Section 203(b) would require that the report include: (1) a
description of the Program, including the Program's purpose,
activities, and sufficiency in achieving its purpose; (2) an
assessment of the sufficiency of the Program's staffing; (3) an
assessment of the Program's employee training; (4) an
assessment of veterans' and family members' awareness of and
utilization of the Program; (5) recommendations for improving
the Program; and (6) any other information the Comptroller
General considers appropriate.
TITLE III--COMPLEMENTARY AND INTEGRATIVE HEALTH
Section 301. Expansion of research and education on and delivery of
complementary and integrative health to veterans
Section 301(a) would establish a commission known as the
``Creating Options for Veterans' Expedited Recovery'' or the
``COVER Commission,'' which would be required to examine the
evidence-based therapy treatment model used by VA for treating
mental health conditions of veterans and the potential benefits
of incorporating complementary alternative treatments available
in non-VA facilities.
Section 301(b) would require that the Commission's duties
are to: (1) examine the efficacy of the evidence-based therapy
model used by VA to treat mental health illnesses and identify
areas of improvement; (2) conduct a patient-centered survey
within each VISN to examine: (A) the experiences of veterans
with VA facilities regarding mental health care, (B) the
experiences of veterans with non-VA facilities regarding mental
health care, (C) the preferences of veterans regarding
available treatment for mental health issues and which methods
the veterans believe to be most effective, (D) the experience,
if any, of veterans with respect to the complementary
alternative treatment therapies described in subsection (b)(3),
(E) the prevalence of prescribing medication to veterans
seeking treatment for mental health disorders through VA, and
(F) the outreach efforts of VA regarding the availability of
benefits and treatments for veterans for addressing mental
health issues; (3) examine available research on complementary
alternative treatment therapies for mental health disorders in
areas of therapy including: music therapy, equine therapy,
training and caring for service dogs, yoga therapy, acupuncture
therapy, meditation therapy, outdoor sports therapy, hyperbaric
oxygen therapy, accelerated resolution therapy, art therapy,
magnetic resonance therapy, and others; (4) study the
sufficiency of VA resources to deliver quality mental health
care; and (5) study the current treatments and resources
available within VA and assess: (A) the effectiveness of such
treatments and resources in decreasing the number of suicides
per day by veterans, (B) the number of veterans who have been
diagnosed with mental health issues, (C) the number of veterans
who have been diagnosed with mental health issues, (D) the
percentage of veterans who have completed VA counseling
sessions, and (E) the efforts of VA to expand complementary
alternative treatments viable to the recovery of veterans with
mental health issues as determined by the Secretary to improve
the effectiveness of treatments offered by VA.
Section 301(c)(1) would require that the Commission consist
of 10 members, with at least one of each of the following pairs
being a veteran: (A) two appointed by the Speaker of the House;
(B) two appointed by the House Minority Leader; (C) two
appointed by the Senate Majority Leader; (D) two appointed by
the Senate Minority Leader; and (E) two appointed by the
President.
Section 301(c)(2) would require that members of the
Commission be: (A) individuals who have standing and
distinction within the field of mental health care: (B)
individuals with experience working with military and former
military populations; and (C) individuals who have no financial
interest in any complementary alternative treatments to be
reviewed by the Commission.
Section 301(c)(3) would require that the President choose
the chairman.
Section 301(c)(4) would require that members be appointed
for the life of the Commission.
Section 301(c)(5) would require that any vacancy be filled
in the same manner as the original appointment.
Section 301(c)(6) would require that appointments be made
within 90 days of the enactment of this act.
Section 301(d)(1) would require that the Commission hold
its first meeting no later than thirty days after a majority of
members are appointed and that the Commission meet regularly at
the chairman's discretion.
Section 301(d)(2) would allow the Commission to hold
hearings that it deems advisable to carry out its
responsibilities.
Section 301(d)(3) would allow the Commission to secure any
information it considers necessary to carry out its duties, and
it may do so directly from any department or Federal agency.
Section 301(d)(4) would allow the Commission to seek
guidance through consultation with foundations, veteran service
organizations, nonprofit groups, faith-based organizations,
private and public institutions of higher education, and other
non-governmental organizations as the Commission determines
appropriate.
Section 301(d)(5) would require the Commission to keep a
record of its action and meetings, which would be required to
be made available to the public for inspection and to the
Comptroller General for audit.
Section 301(d)(6) would require the Commission to keep a
record regarding personnel, which would be required to be made
available to the public for inspection and to the Comptroller
General for audit.
Section 301(d)(7) would require that members serve without
pay, but allows members to be compensated for travel expenses
to perform Commission duties at rates authorized under
subchapter I of chapter 57 of title 5, U.S.C.
Section 301(d)(8) would allow the Commission to employ a
staff director and other personnel as needed to perform the
Commission's function without regard to the provisions of title
5, U.S.C., governing appointments in the competitive service,
without regard to the provision of chapter 51 and subchapter
III of chapter 53 of such title relating to classification and
General Schedule pay rates, except that no rate of pay fixed
under this paragraph may exceed the equivalent of that payable
for a position at a level IV of the Executive Schedule under
section 5316 of title 5, U.S.C.
Section 301(d)(9) would require that such personnel be
employees under section 2105 of title 5, U.S.C., for purposes
of chapters 63, 81, 83, 84, 85, 87, 89, and 90 of such title.
This does not apply to the members of the Commission.
Section 301(d)(10) would allow the Commission to enter into
contracts to enable it to discharge its duties.
Section 301(d)(11) would allow the Commission to utilize
experts and consultants in accordance with section 3109 of
title 5, U.S.C., at rates not to exceed the daily rate paid to
a person occupying a position at level IV of the Executive
Schedule under section 3109 of title 5, U.S.C.
Section 301(d)(12) would allow the Commission to use the
postal service in the same manner as other Federal agencies and
departments.
Section 301(d)(13) would allow the Commission to be
provided, on a reimbursable basis, physical facilities,
equipment, and administrative support services necessary to
carry out its duties.
Section 301(e)(1) would require that, within 60 days of the
Commission's first meeting and every 30 days thereafter until
the Commission submits its final report under subsection
(e)(2), the Commission submit to the Committees on Veterans'
Affairs of the House and the Senate and the President a report
describing the level of cooperation of the Secretary and the
heads of other Federal agencies or departments. The Commission
must also submit an interim report regarding its findings to
the Committees on Veterans' Affairs of the House and the Senate
and any other appropriate entities at times it deems
appropriate.
Section 301(e)(2) would require that the Commission, within
18 months of its first meeting, submit to the Committees on
Veterans' Affairs of the House and the Senate, the President,
and the Secretary its final report. The final report would be
required to include: (A) recommendations on improving the areas
for which it was tasked with exploring; (B) analysis of the
evidence-based therapy model used by VA for treating mental
illness; (C) findings of the survey conducted within each VISN
pursuant to subsection (b)(2); and (D) an examination of
complementary alternative treatments described in subsection
(b)(3) and their potential benefits.
Section 301(e)(3) would require that, within 90 days of the
submission of the Commission's final report, the Secretary
submit a report to the Committees on Veterans' Affairs of the
House and of the Senate containing: (A) an action plan for
implementing the Commission's recommendations; (B) a feasible
timeframe for implementation; and (C) justifications for any
recommendations the Secretary believes are not feasible
complete with alternative solutions.
Section 301(f) would require that the Commission be
terminated within 30 days after the Commission submits its
final report.
Section 302. Pilot program on integration of complementary alternative
medicines and related issues for veterans and family members of
veterans
Section 302(a)(1) would require that, within 180 days after
the Secretary receives the Commission's final report under
Section 301(e), the Secretary commence a pilot program to
assess the feasibility and advisability of using wellness-based
programs to complement pain management and related health care
services.
Section 302(a)(2) would require that, in carrying out the
pilot program, the Secretary assess: (A) means of improving
pain management care coordination between Federal, State, and
community providers; (B) means of enhancing outreach by and
among such providers; (C) means of using wellness-based
programs as complements to pain management services by and
among such providers; and (D) the effectiveness of wellness-
based programs.
Section 302(b) would require that the pilot program last
for three years.
Section 302(c)(1) would require that the pilot program be
carried out at no fewer than 15 VA facilities providing pain
management, two of which must be polytrauma centers.
Section 302(c)(2) would require that the Secretary
prioritize medical centers at which there is a prescription
rate that is inconsistent with the standards of appropriate
care when selecting medical centers under subsection(c)(1).
Section 302(d) would require the Secretary to provide
covered veterans covered services by integrating complementary
and alternative medicine under the pilot program those
treatments into other services provided by VA.
Section 302(e) would define the term ``covered veteran'' to
mean a veteran who: (1) has a mental health condition diagnosed
by a VA provider; (2) experiences chronic pain; (3) has a
chronic condition being treated by a VA provider; or (4) is not
described in paragraph (1), (2), or (3) and requests to
participate in the pilot program or is referred by a VA
provider treating that veteran.
Section 302(f)(1) would define the term ``covered
services'' to mean services consisting of complementary and
integrative health services as selected by the Secretary.
Section 302(f)(2) would require that covered services under
the pilot program be: (A) administered by VA professionals or
other instructors with appropriate training and expertise; (B)
included as part of the Patient Aligned Care Teams initiative
in coordination with the Offices of Patient Centered Care and
Cultural Transformation; (C) made available to covered veterans
who have and have not received conventional treatments from VA
for the conditions for which the veteran seeks complementary
and integrative health services.
Section 302(g)(1) would require that, within 30 months of
the start of the pilot program, the Secretary submit to the
Committees on Veterans' Affairs of the House and of the Senate
a report on the pilot program.
Section 302(g)(2) would require that the report include:
(A) the Secretary's findings and conclusions regarding the use
and efficacy of complementary and alternative health services
established under the pilot program, the outreach conducted by
VA about the pilot, and an assessment of the benefit of the
pilot program to covered veterans; (B) the identification of
any unresolved barriers to VA's use of complementary and
integrative medicine; and (C) recommendations for the
continuation or expansion of the pilot program as the Secretary
considers appropriate.
Section 302(h) would define the term ``complementary and
integrative health'' to have the meaning given to that term by
the National Institutes of Health.
TITLE IV--FITNESS OF HEALTH CARE PROVIDERS
Section 401. Additional requirements for hiring of health care
providers by Department of Veterans Affairs
Section 401 would require that, as part of the hiring
process for all heath care providers considered for a position
after the date of the enactment of this act, the Secretary
require from the medical board of the State in which the
applicant is licensed: (1) information on any violations of the
requirements of medical license over the previous 20 years; and
(2) information on whether the provider has entered into any
settlement agreements for disciplinary charges related to the
practice of medicine.
Section 402. Provision of information on health care providers of
Department of Veterans Affairs to state medical boards
Section 402 would require that VA provide to the medical
board of each State in which the provider is licensed
information regarding violations, regardless of whether the
board has requested such information.
Section 403. Report on compliance by Department of Veterans Affairs
with reviews of health care providers leaving the Department or
transferring to other facilities
Section 403 would require that, within 180 days of the
enactment of this act, the Secretary submit to the Committees
on Veterans' Affairs of the House and of the Senate a report on
VA's compliance with VA policy to conduct a review of each
provider who transfers from another VA medical facility,
retires, or is terminated and to take appropriate actions with
respect to any concerns, complaints, or allegations against the
provider.
TITLE V--OTHER VETERANS MATTERS
Section 501. Audit of Veterans Health Administration programs of
Department of Veterans Affairs
Section 501(a) would require that the Secretary seek to
enter into a contract with a nongovernmental entity under which
the entity will conduct audits of VHA programs to identify ways
to improve the administration of benefits and health care to
veterans and their families.
Section 501(b) would require that the entity perform the
following with regard to each such audit: (1) five-year risk
assessments to identify the functions, staff organizations, and
staff offices of the VHA that would lead to the greatest
improvement in health care and benefits provided; (2)
development of plans that are informed by those risk
assessments to conduct audits of the functions, staff
organizations, and staff offices; (3) conduct audits in
accordance with the developed plans.
Section 501(c) would require that, within 90 days of the
completion of each audit under subsection (a), the Secretary
submit to the Committees on Veterans' Affairs of the House and
of the Senate a report including: (1) a summary of the audit;
(2) the entity's findings; and (3) recommendations as the
Secretary determines appropriate.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the 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):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
TITLE 38, UNITED STATES CODE
* * * * * * *
PART IV--GENERAL ADMINISTRATIVE PROVISIONS
* * * * * * *
CHAPTER 57--RECORDS AND INVESTIGATIONS
* * * * * * *
SUBCHAPTER I--RECORDS
Sec. 5701. Confidential nature of claims
(a) All files, records, reports, and other papers and
documents pertaining to any claim under any of the laws
administered by the Secretary and the names and addresses of
present or former members of the Armed Forces, and their
dependents, in the possession of the Department shall be
confidential and privileged, and no disclosure thereof shall be
made except as provided in this section.
(b) The Secretary shall make disclosure of such files,
records, reports, and other papers and documents as are
described in subsection (a) of this section as follows:
(1) To a claimant or duly authorized agent or
representative of a claimant as to matters concerning
the claimant alone when, in the judgment of the
Secretary, such disclosure would not be injurious to
the physical or mental health of the claimant and to an
independent medical expert or experts for an advisory
opinion pursuant to section 5109 or 7109 of this title.
(2) When required by process of a United States court
to be produced in any suit or proceeding therein
pending.
(3) When required by any department or other agency
of the United States Government.
(4) In all proceedings in the nature of an inquest
into the mental competency of a claimant.
(5) In any suit or other judicial proceeding when in
the judgment of the Secretary such disclosure is deemed
necessary and proper.
(6) In connection with any proceeding for the
collection of an amount owed to the United States by
virtue of a person's participation in any benefit
program administered by the Secretary when in the
judgment of the Secretary such disclosure is deemed
necessary and proper.
(c)(1) The amount of any payment made by the Secretary to any
person receiving benefits under a program administered by the
Secretary shall be made known to any person who applies for
such information.
(2) Any appraisal report or certificate of reasonable value
submitted to or prepared by the Secretary in connection with
any loan guaranteed, insured, or made under chapter 37 of this
title shall be made available to any person who applies for
such report or certificate.
(3) Subject to the approval of the President, the Secretary
may publish at any time and in any manner any or all
information of record pertaining to any claim filed with the
Secretary if the Secretary determines that the public interest
warrants or requires such publication.
(d) The Secretary as a matter of discretion may authorize an
inspection of Department records by duly authorized
representatives of recognized organizations.
(e) Except as otherwise specifically provided in this section
with respect to certain information, the Secretary may release
information, statistics, or reports to individuals or
organizations when in the Secretary's judgment such release
would serve a useful purpose.
(f) The Secretary may, pursuant to regulations the Secretary
shall prescribe, release the name or address, or both, of any
present or former member of the Armed Forces, or a dependent of
a present or former member of the Armed Forces, (1) to any
nonprofit organization if the release is directly connected
with the conduct of programs and the utilization of benefits
under this title, or (2) to any criminal or civil law
enforcement governmental agency or instrumentality charged
under applicable law with the protection of the public health
or safety if a qualified representative of such agency or
instrumentality has made a written request that such name or
address be provided for a purpose authorized by law. Any
organization or member thereof or other person who, knowing
that the use of any name or address released by the Secretary
pursuant to the preceding sentence is limited to the purpose
specified in such sentence, willfully uses such name or address
for a purpose other than those so specified, shall be guilty of
a misdemeanor and be fined not more than $5,000 in the case of
a first offense and not more than $20,000 in the case of any
subsequent offense.
(g)(1) Subject to the provisions of this subsection, and
under regulations which the Secretary shall prescribe, the
Secretary may release the name or address, or both, of any
person who is a present or former member of the Armed Forces,
or who is a dependent of a present or former member of the
Armed Forces, to a consumer reporting agency if the release of
such information is necessary for a purpose described in
paragraph (2) of this subsection.
(2) A release of information under paragraph (1) of this
subsection concerning a person described in such paragraph may
be made for the purpose of--
(A) locating such a person--
(i) who has been administratively determined
to be indebted to the United States by virtue
of the person's participation in a benefits
program administered by the Secretary; or
(ii) if the Secretary has determined under
such regulations that (I) it is necessary to
locate such person in order to conduct a study
pursuant to section 527 of this title or a
study required by any other provision of law,
and (II) all reasonable steps have been taken
to assure that the release of such information
to such reporting agency will not have an
adverse effect on such person; or
(B) Obtaining a consumer report in order to assess
the ability of a person described in subparagraph
(A)(i) of this paragraph to repay the indebtedness of
such person to the United States, but the Secretary may
release the name or address of such person for the
purpose stated in this clause only if the Secretary
determines under such regulations that such person has
failed to respond appropriately to administrative
efforts to collect such indebtedness.
(3) The Secretary may also release to a consumer reporting
agency, for the purposes specified in subparagraph (A) or (B)
of paragraph (2) of this subsection, such other information as
the Secretary determines under such regulations is reasonably
necessary to identify a person described in such paragraph,
except that the Secretary may not release to a consumer
reporting agency any information which indicates any
indebtedness on the part of such person to the United States or
any information which reflects adversely on such person. Before
releasing any information under this paragraph, the Secretary
shall, under such regulations, take reasonable steps to provide
for the protection of the personal privacy of persons about
whom information is proposed to be released under this
paragraph.
(4)(A) If the Secretary determines, under regulations which
the Secretary shall prescribe, that a person described in
paragraph (1) of this subsection has failed to respond
appropriately to reasonable administrative efforts to collect
an indebtedness of such person described in paragraph (2)(A)(i)
of this subsection, the Secretary may release information
concerning the indebtedness, including the name and address of
such person, to a consumer reporting agency for the purpose of
making such information available for inclusion in consumer
reports regarding such person and, if necessary, for the
purpose of locating such person, if--
(i) the Secretary has (I) made reasonable efforts to
notify such person of such person's right to dispute
through prescribed administrative processes the
existence or amount of such indebtedness and of such
person's right to request a waiver of such indebtedness
under section 5302 of this title, (II) afforded such
person a reasonable opportunity to exercise such
rights, and (III) made a determination with respect to
any such dispute or request; and
(ii) thirty calendar days have elapsed after the day
on which the Secretary has made a determination that
reasonable efforts have been made to notify such person
(I) that the Secretary intends to release such
information for such purpose or purposes, and (II)
that, upon the request of such person, the Secretary
shall inform such person of whether such information
has been so released and of the name and address of
each consumer reporting agency to which such
information was released by the Secretary and of the
specific information so released.
(B) After release of any information under subparagraph (A)
of this paragraph concerning the indebtedness of any person,
the Secretary shall promptly notify--
(i) each consumer reporting agency to which such
information has been released by the Secretary; and
(ii) each consumer reporting agency described in
subsection (i)(3)(B)(i) of this section to which such
information has been transmitted by the Secretary
through a consumer reporting agency described in
subsection (i)(3)(B)(ii)(I) of this section,
of any substantial change in the status or amount of such
indebtedness and, upon the request of any such consumer
reporting agency for verification of any or all information so
released, promptly verify or correct, as appropriate, such
information. The Secretary shall also, after the release of
such information, inform such person, upon the request of such
person, of the name and address of each consumer reporting
agency described in clause (i) or (ii) of this subparagraph to
which such information was released or transmitted by the
Secretary and of the specific information so released or
transmitted.
(h)(1) Under regulations which the Secretary shall prescribe,
the Secretary may release the name or address, or both, of any
person who is a present or former member of the Armed Forces,
or who is a dependent of a present or former member of the
Armed Forces (and other information relating to the identity of
such person), to any person in a category of persons described
in such regulations and specified in such regulations as a
category of persons to whom such information may be released,
if the release of such information is necessary for a purpose
described in paragraph (2) of this subsection.
(2) A release of information under paragraph (1) of this
subsection may be made for the purpose of--
(A) determining the creditworthiness, credit
capacity, income, or financial resources of a person
who has (i) applied for any benefit under chapter 37 of
this title, or (ii) submitted an offer to the Secretary
for the purchase of property acquired by the Secretary
under section 3720(a)(5) of this title;
(B) verifying, either before or after the Secretary
has approved a person's application for assistance in
the form of a loan guaranty or loan insurance under
chapter 37 of this title, information submitted by a
lender to the Secretary regarding the creditworthiness,
credit capacity, income, or financial resources of such
person;
(C) offering for sale or other disposition by the
Secretary, pursuant to section 3720 of this title, any
loan or installment sale contract owned or held by the
Secretary; or
(D) providing assistance to any applicant for
benefits under chapter 37 of this title or
administering such benefits if the Secretary promptly
records the fact of such release in appropriate records
pertaining to the person concerning whom such release
was made.
(i)(1) No contract entered into for any of the purposes of
subsection (g) or (h) of this section, and no action taken
pursuant to any such contract or either such subsection, shall
result in the application of section 552a of title 5 to any
consumer reporting agency or any employee of a consumer
reporting agency.
(2) The Secretary shall take reasonable steps to provide for
the protection of the personal privacy of persons about whom
information is disclosed under subsection (g) or (h) of this
section.
(3) For the purposes of this subsection and of subsection (g)
of this section--
(A) The term ``consumer report'' has the meaning
provided such term in subsection (d) of section 603 of
the Fair Credit Reporting Act (15 U.S.C. 1681a(d)).
(B) The term ``consumer reporting agency'' means--
(i) a consumer reporting agency as such term
is defined in subsection (f) of section 603 of
the Fair Credit Reporting Act (15 U.S.C.
1681a(f)), or
(ii) any person who, for monetary fees, dues,
or on a cooperative nonprofit basis, regularly
engages in whole or in part in the practice of
(I) obtaining credit or other information on
consumers for the purpose of furnishing such
information to consumer reporting agencies (as
defined in clause (i) of this paragraph), or
(II) serving as a marketing agent under
arrangements enabling third parties to obtain
such information from such reporting agencies.
(j) Except as provided in subsection (i)(1) of this section,
any disclosure made pursuant to this section shall be made in
accordance with the provisions of section 552a of title 5.
(k)(1)(A) Under regulations that the Secretary shall
prescribe, the Secretary may disclose the name and address of
any individual described in subparagraph (C) to an entity
described in subparagraph (B) in order to facilitate the
determination by such entity whether the individual is, or
after death will be, a suitable organ, tissue, or eye donor
if--
(i) the individual is near death (as determined by
the Secretary) or is deceased; and
(ii) the disclosure is permitted under regulations
promulgated pursuant to section 264 of the Health
Insurance Portability and Accountability Act of 1996
(42 U.S.C. 1320d-2 note).
(B) An entity described in this subparagraph is--
(i) an organ procurement organization, including eye
and tissue banks; or
(ii) an entity that the Secretary has determined--
(I) is substantially similar in function,
professionalism, and reliability to an organ
procurement organization; and
(II) should be treated for purposes of this
subsection in the same manner as an organ
procurement organization.
(C) An individual described in this subparagraph is--
(i) a veteran; or
(ii) a dependent of veteran.
(2) In this subsection, the term ``organ procurement
organization'' has the meaning given the term ``qualified organ
procurement organization'' in section 371(b) of the Public
Health Service Act (42 U.S.C. 273(b)).
(l) Under regulations the Secretary shall prescribe, the
Secretary [may] shall disclose information about a veteran or
the dependent of a veteran to a State controlled substance
monitoring program, including a program approved by the
Secretary of Health and Human Services under section 399O of
the Public Health Service Act (42 U.S.C. 280g-3), to the extent
necessary to prevent misuse and diversion of prescription
medicines.
* * * * * * *
[all]
