(c) REPORTS.-Not later than February 1 of each of 1995, 1996, and 1997, the Secretary of Veterans Affairs shall submit to the Committees on Veterans' Affairs of the Senate and House of Representatives a report on the status and activities during the previous fiscal year of the mental illness, research, education, and clinical centers established pursuant to section 7319 of title 38, United States Code (as added by subsection (a)). Each such report shall contain the following: (1) A description of— (A) the activities carried out at each center and the funding provided for such activities; (B) the advances made at each center in research, education and training, and clinical activities relating to mental illness in veterans; and (C) the actions taken by the Under Secretary for Health pursuant to subsection (d) of such section (as so added) to disseminate useful information derived from such activities throughout the Veterans Health Administration. (2) The Secretary's evaluations of the effectiveness of the centers in fulfilling the purposes of the centers. (d) TECHNICAL AMENDMENT.-Section 7314(d)(1) of such title is amended by striking out "the Chief Medical Director" and inserting in lieu thereof “the Under Secretary for Health". INTRODUCTION On September 30, 1993, the Committee's Chairman, Senator John D. Rockefeller IV, introduced S. 1512, the proposed "VA Mental Health Care Improvement Act of 1993", with the cosponsorship of Committee members Daniel K. Akaka and Ben Nighthorse Campbell. Joining later as a cosponsor was Senator Paul Wellstone. As introduced, S. 1512 would have established up to five centers of mental illness research, education, and clinical activities (MIRECCs) at existing Department of Veterans Affairs (VA) health care facilities. On August 3, 1993, the Committee held a hearing focusing on legislation relating to veterans' mental health, including S. 1512. Witnesses included Department of Veterans Affairs Deputy Secretary, Hershel Gober; National Schizophrenia Biological Research Center Chief, Dennis Charney, M.D.; National Center for Post Traumatic Stress Disorder (PTSD) Executive Director, Matthew Friedman, M.D.; National Alliance for the Mentally Ill Research Advocate, Richard Greer; American Psychiatric Association Representative, John O. Lipkin, M.D.; Philadelphia VA Medical Center Psychiatry Services Chief, Charles O'Brien, M.D.; New Orleans VA Medical Center PTSD Clinical Team Chief Psychologist, Patricia Sutker, Ph.D; and representatives of The American Legion, Disabled American Veterans, Paralyzed Veterans of America, and Veterans of Foreign Wars. Testimony was also submitted for the hearing record by United States Congresswoman Marcy Kaptur and representatives of AMVETS and Vietnam Veterans of America. COMMITTEE MEETING After carefully reviewing the testimony from the foregoing hearing, the Committee met in open session on November 3, 1993, and voted unanimously to report S. 1512 with an amendment in the nature of a substitute derived from the bill, as introduced, with minor revisions. SUMMARY OF S. 1512 AS REPORTED S. 1512 as reported (hereinafter referred to as the "Committee Bill") contains provisions that would (a) require the Secretary to designate not more than five VA health care facilities as the locations for centers of mental illness research, education, and clinical activities, with at least one to be designated by January 1, 1994; (b) provide that, to qualify for designation, a facility must demonstrate that it can (1) maintain arrangements with an accredited medical school which provides training in psychiatry and with a graduate school of psychology under which residents and students receive training and education through regular rotation at the VA facility, (2) maintain an arrangement under which nursing, social work, or other allied health personnel receive training and education in mental health at the VA facility, (3) attract the participation of scientists with ingenuity and creativity in mental illness research and treatment, (4) maintain a policymaking advisory committee composed of VA mental health staff and research representatives from the affiliated schools, and (5) effectively conduct evaluations of the activities of the center; (c) provide that a peer review panel is to be used to determine the location of such centers so as to ensure that any such center meets the highest competitive standards of scientific and clinical merit prior to selection by the Secretary; (d) require the Secretary to ensure that the sites selected are located in various geographic areas; (e) require that at least three of the five centers emphasize the development of community-based alternatives to institutional treatment; and (f) authorize the appropriation of $3.125 million for fiscal year 1994 and $6.25 million for each of fiscal years 1995, 1996, and 1997 for MIRECCS. DISCUSSION BACKGROUND The October 20, 1985, Report of the Special Purpose Committee to Evaluate the Mental Health and Behavioral Sciences Research Program of the VA, which was chaired by Dr. Seymour Kety (hereinafter referred to as the "Kety Committee"), concluded that research on mental illness and training for mental health specialists at VA facilities were totally inadequate. The report noted that approximately 40 percent of all VA beds are occupied by veterans who suffer from mental disorders, whereas less than 10 percent of VA's research resources are directed toward mental illness. These percentages have remained at similar levels in subsequent years. In order to improve and expand the capability of VA health care facilities to respond to the needs of veterans with mental illnesses, the Kety Committee recommended that VA centers of excellence be established to develop first-rate psychiatric research programs within VA. Such centers would provide state-of-the-art treatment, increase innovative basic and clinical research opportunities, and enhance and encourage continuing education and training in the treatment of mental illness. Based on the recommendations of the Kety Committee, the Senate Committee on Veterans' Affairs began efforts five years ago to encourage more research into mental illnesses and to establish centers of excellence. First, legislation enacted on May 20, 1988, Public Law 100-322, included a provision to add a specific reference to mental illness research in the statutory description of VA's medical research mission, now set forth in section 7303(a)(2) of title 38. This reference in the law is intended to express the importance of research to mental health care and thereby to help counteract the historical trend of underfunding mental illness research. Second, the Committee report accompanying that legislation (S. Rept. No. 100-215, p. 138) urged VA to establish three centers of excellence, or MIRECCs, as proposed by the Kety Committee. The VA has yet to take any action to do so. Testimony received at this Committee's August 3, 1993, hearing was very supportive of this provision. For example, the witnesses representing both the National Association of VA Chiefs of Psychiatry and the National Association of VA Chiefs of Psychology emphasized that the establishment of MIRECCs would improve VA's ability to attract topnotch psychiatrists and psychologists and thus enhance the Department's ability to provide high quality mental health services to veterans. Dr. John O. Lipkin, the Chief of Staff of the Perry Point VA Medical Center, who represented the American Psychiatric Association before the Committee, testified: Funding for psychiatric research in the VA has remained vastly disproportionate to the utilization of psychiatric services. While psychiatric problems account for about 40 percent of inpatient days in VA medical centers, funding for behavioral research has never matched that percentage of the total medical research budget. Research is vital to our understanding of the causes and treatment of mental illnesses * * The establishment of MIRECCS with a strong clinical base will draw valuable participation from affiliated institutions and benefit veterans for decades to come. * The Committee also notes that the January 1991 final report of the VA Advisory Committee for Health Research Policy, a blue ribbon committee established by the Secretary of Veterans Affairs, recommended that VA establish MIRECCs as a means of increasing opportunities in psychiatric research and encouraging the formulation of new research initiatives in mental health care, as well as maintaining the intellectual environment so important to quality health care. The report stated that "[these] centers could provide a way to deal with the emerging priorities in the VA and the Nation at large." COMMITTEE BILL The Committee bill would require VA to establish MIRECCS at not more than five VA facilities which are geographically dispersed and which meet certain specified criteria. The purpose of the MIRECCS would be (1) to facilitate the improvement of health care services for eligible veterans suffering from mental illness, especially from conditions which are service connected, through research, the education and training of health personnel, and the de velopment of improved models of clinical services; and (2) to develop improved models for the furnishing of clinical services. The proposed MIRECCS would be modeled after the successful Geriatric Research, Education, and Clinical Centers (GRECCs) which were authorized in 1980 in section 302 of Public Law 96-330 and are currently located in 18 VA medical centers. The MIRECCs would be designed to (1) attract clinicians and investigators with a clear and focused clinical research mission, such as PTSD, schizophrenia, or drug and alcohol abuse; (2) provide training and educational opportunities for students and residents in psychiatry, psychology, nursing, social work, and other professions which treat individuals with mental illness; and (3) develop new models of effective care and treatment for veterans with mental illnesses, especially those which are service connected. The Committee believes that the establishment of MIRECCs would also encourage research into outcomes of various types of treatment for mental illnesses, an aspect of mental illness research which, to date, has not been fully pursued either by VA or other researchers in the field. In order to designate a facility as the site for a MIRECC, the Secretary, upon the recommendation of the Chief Medical Director, would have to determine that the facility has, or may reasonably be expected to develop (1) arrangements with an affiliated medical school and an affiliated graduate school of psychology for the regular rotation of their residents and students through the center; (2) an arrangement under which nursing or other allied health personnel receive education and training in mental health care through regular rotation through the facility; (3) the ability to attract superior mental illness researchers; (4) a policymaking advisory committee composed of health care and research representatives of the VA facility and the schools involved; and (5) the capability to evaluate effectively the activities of a MIRECC. The Committee bill would require that a peer review panel be used to determine the location of such centers so as to ensure that, in addition to being geographically diverse, any such center meets the highest competitive standards of scientific and clinical merit prior to selection by the Secretary. Also, at least three of the five centers should emphasize the development of community-based alternatives to institutional treatment. The Committee bill would promote research at the MIRECCS by requiring that, in the awarding of research funds for mental illness projects, MIRECC applications be given a priority. Centers would include an emphasis on the psychosocial dimension of mental illness and on developing models for furnishing care and treatment of mental illness. Further, the Committee bill would promote the dissemination of information regarding all aspects of MIRECC activities throughout VHA by requiring the Chief Medical Director to develop continuing education programs provided at Regional Medical Education Centers. Finally, beginning February 1, 1995, the Secretary would be required to submit three annual reports to the House and Senate Committees on Veterans' Affairs on the research, educational, and clinical care activities at each MIRECC and on efforts to dissemi nate the information throughout the VA health care system. The administration of the program would be assigned to the VA Central Office official responsible for mental health and behavioral sciences, which is currently the Director of Mental Health and Behavioral Sciences Service. The Committee also urges VA-as it has in the past-to create a Mental Illness Research Service, similar to research services that exist for each of the other categories of research expressly mentioned in the statutory provision, section 7303(a)(2), which establishes VA's research mission. Section 135 of Public Law 100-322, which originated in this Committee, added specific mention of mental illness to this description of VA's research mission in this section in order to emphasize the importance of such research and the establishment of such a service. The Committee is firmly convinced that the creation of a separate service with its own budgetary allocation would help VA to pursue more creatively cost-effective and innovative treatment for veterans suffering from mental illness. COST ESTIMATE In compliance with paragraph 11(a) of rule XXVI of the Standing Rules of the Senate, the Committee, based on information supplied by the Congressional Budget Office (CBO), estimates that the costs resulting from the enactment of the Committee bill (as compared to costs under current law), as scored against the current CBO baseline, would entail costs of $3 million in budget authority and $1 million in outlays in FY 1994, and total costs of $18 million in budget authority and $20 million in outlays in FYS 1995-1998. The cost estimate provided by CBO follows: Hon. JOHN D. ROCKEFELLER IV, DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for S. 1512, as ordered reported by the Senate Committee on Veterans' Affairs, November 3, 1993. Enactment of S. 1226 would not affect direct spending or receipts. Therefore, pay-as-you-go procedures would not apply to the bill. If you wish further details on this estimate, we will be pleased to provide them. Sincerely, ROBERT D. REISCHAUER, Director. CONGRESSIONAL BUDGET OFFICE COST ESTIMATE 1. Bill number: S. 1512. 2. Bill title: None. 3. Bill status: As ordered reported by the Senate Committee on Veterans' Affairs, November 3, 1993. 4. Bill purpose: To authorize the Department of Veterans Affairs (VA) to establish up to five centers for mental illness research and |