The Committee bill would authorize the appropriation to the STRAF for the purposes of carrying out this pilot program, a total of $5 million for fiscal years 1990 through 1994. To the extent that less than $5 million is appropriated for this purpose, the Secretary would be authorized to transfer to the STRAF from unobligated amounts in the General Post Funds of the VA medical facilities which host CWT/TR programs such amounts as the Secretary determines would be necessary to carry out the pilot program.

Cost: CBO estimates that enactment of section 212 would entail estimated costs of $5 million in budget authority and $1 million in outlays in FY 1990 and total estimated costs of $5 million in budget authority and $5 million in outlays in FYs 1990-1994.

Pilot Program: Noninstitutional Care Alternatives to Nursing Home Care

Section 213 of the Committee bill, which is similar to the provisions of section 7 of S. 574, would amend subchapter II of chapter 17 of title 38 to add a new section 620C to require the Secretary, beginning on October 1, 1989, to conduct a 4-year pilot program to evaluate noninstitutional alternatives to institutional care.

Background

S. 574 was derived from section 306 of S. 9 as reported by the Committee and passed by the Senate on December 4, 1987, in H.R. 2616, section 204 of S. 2422 as reported by the Committee and passed by the Senate on September 30, 1986, in H.R. 5299, and S. 876 as reported by the Committee and passed by the Senate on July 30, 1985, in H.R. 505. Unfortunately, the House did not agree to these provisions and they were not included in the measures which were ultimately enacted.

Further background information regarding the approach proposed in this section of the Committee bill is provided in the Committee's reports on S. 9 (S. Rept. 100-215, pages 117-120), on S. 2422 (S. Rept. 99-444, pages 45-48), and on S. 876 (S. Rept. 99-101, pages 37-42).

Committee bill

The Committee is again acting on this provision because it remains convinced that, in light of current developments in healthcare services which enable more individuals to receive needed care without being institutionalized and of the rapid increase in the number of veterans age 65 and older who may be seeking care from VA in the years ahead, VA must take steps to develop new approaches to addressing the health-care needs of veteran patients. The kinds of new VA approaches this legislation envisions must include an emphasis on increased interaction with community entities that provide health and health-related services if VA is to get the maximum health-care benefits out of every dollar spent. There also must be a greater emphasis on reducing the need for institutional care for veterans.

Under the Committee bill, the Secretary would be required to conduct a four-year pilot program through which VA would provide certain veterans with medical, rehabilitative, and other health

services and, by contract with non-VA entities, with health-related services.

These health and health-related services would be provided under VA contracts in noninstitutional settings-such as the veteran's home or a personal-care or board-and-care home-with the goal of being able to avoid institutional care, such as in a hospital, nursing home, or domiciliary facility, for the participants in the program.

The bills previously passed by the Senate provided for broader categories of eligibility for this program. This year's bill would limit eligibility to those veterans eligible for and otherwise in need of nursing home care primarily for the treatment of a service-connected disability or veterans who have service-connected disabilities rated at 50 percent or more and are being treated for any disability.

Under the Committee bill, the Secretary would be required to appoint a VA employee to furnish case-management services (including screening, assessment of needs, referral, planning and monitoring) to each veteran participating in the pilot program. The Secretary would also be authorized to provide in-kind assistance to a facility or organization furnishing health-related services under this

program.

On the issue of increased VA-community interaction and cooperation, the Committee is convinced that VA must make greater use of community resources which help to maintain individuals in their homes-such as homemaker, personal-care, communal or athome nutrition, and transportation-assistance services-in order for the Department to respond in a reasonably adequate way to the growing demand for care that it is facing and will continue to face as the veteran population generally ages rapidly between now and the end of the century.

With reference to the cost of this pilot program, the bill would limit the cost to not more than 65 percent of the total cost that would otherwise have been incurred by VA if the veterans participating in the program had been furnished nursing home care instead of the noninstitutional services provided for under the new program. It is the Committee's intent that the pilot program be carried out through the use of funds that would otherwise be used for the provision of more costly intermediate care and that the funds saved by this pilot program be applied to care for more veterans than would otherwise be served.

Finally, the Committee bill would require that the Secretary submit, by February 1, 1993, a report on the conduct of the pilot program during its first 3 fiscal years including an evaluation, findings, and conclusions about the program.

As introduced, this provision would have (1) limited eligibility for noninstitutional care to veterans eligible for nursing home care and receiving or needing that care for the treatment of service-connected disabilities, and (2) established the program as a permanent authority rather than a pilot. For the purpose of providing noninstitutional care, the Committee believes that veterans with serviceconnected disabilities rated at 50 percent or more and being treated for any disability should be afforded the same services as if they were being treated for a service-connected disability. Also, in order

to determine whether noninstitutional care alternatives serve the purpose for which they are designed, the Committee bill would require a pilot program until the results of a program evaluation are reviewed.

Cost: According to CBO, enactment of this provision would entail estimated costs of $4 million in both budget authority and outlays in FY 1990 and total estimated costs of $35 million in both budget authority and outlays in FYS 1990-1994.

Preventive Medicine

Section 214 of the Committee bill, which is substantively identical to S. 1306, would amend sections 663 and 664 of title 38 so as to (1) extend VA's pilot program of preventing health-care services through fiscal year 1994; (2) expand the categories of veterans to whom VA is required to furnish such services; (3) require that those veterans annually be offered a minimum of two preventive health-care services when they are otherwise receiving inpatient or outpatient care; (4) require that each VA health-care facility annually implement a major preventive health-care and health-promotion initiative for those veterans; (5) expressly provide that the scope of permissible preventive health-care services under the pilot program include certain specified services; (6) require the Secretary to submit reports on the experience under the pilot program; (7) limit expenditures under the pilot program; and (8) require that VA's Chief Medical Director (CMD) designate one official in the Veterans Health Services and Research Administration as the Director of Preventive Health and Health Promotion Programs. Background

VA preventive health-care services were first proposed to be authorized by the Senate in 1976 as part of S. 2098. In 1977, a preventive health-care provision, originally included in S. 1693, was included in the version of H.R. 5027 reported by the Committee and passed by the Senate. In 1979, the provision in S. 7 to authorize VA to establish a preventive health-care pilot program was enacted as section 105 of Public Law 96-22.

The preventive health-care pilot program established pursuant to that law was targeted to veterans with service-connected disabilities rated at 50 percent or greater and veterans receiving VA care for the treatment of service-connected disabilities. In 1983, provisions introduced in S. 11 and enacted as section 106 of Public Law 98-160 modified this preventive health-care program to (1) require VA to provide at least one preventive health-care service to veterans previously authorized to receive preventive care while otherwise receiving VA care, and (2) authorize VA to provide preventive health-care services to all veterans otherwise being furnished care under chapter 17 of title 38. Public Law 98-160 also added preventive health-care services to the definition of medical services in section 601(6)(A)(i) of title 38.

In implementing Public Law 98-160, VA developed a list of preventive-medicine services to be used as guidance for its facilities across the Nation. This list, which is altered and updated periodically-most recently in a July 25, 1989, VA circular (10-89-76)

now includes the following services or interventions (in priority order as determined by VA according to high benefit to cost ratios and significant numbers of veterans at risk): Hypertension screening; smoking cessation; cholesterol screening; influenza immunizations; cancer screening (colorectal, cervical, and breast); alcohol abuse counseling; nutrition/weight control counseling; physical fitness/exercise; and osteoporosis counseling. Every VA facility has a Preventive Medicine Coordinator who is responsible for monitoring the implementation of the program and who serves as the liaison for preventive medicine activities.

Each year the Preventive Medicine Field Advisory Group, a group of between 5 and 9 VA physicians who serve as a liaison between VA health-care facilities and VA Central Office, while encouraging all these preventive health-care services and interventions, recommends one preventive service to receive special systemwide emphasis. This practice of emphasizing one special preventive service per year augments the health services being provided to veterans and provides education to and increases awareness on the part of professionals and patients as well. VA expects that through these highlighted interventions there will be a greater awareness of the importance of preventive medicine in the veteran population. Beginning mid-way through fiscal year 1985 and continuing through fiscal year 1986, the special initiative was influenza immunization; in fiscal year 1987, it was colorectal cancer screening; in fiscal year 1988, it was smoking cessation; and, currently, in fiscal year 1989, it is cholesterol screening.

On August 12, 1988, VA released a final report on preventive health-care services under Public Law 98-160. According to this report, 84 facilities provided services other than those on the recommended list, and over 50 different activities were reported throughout the system. These included glaucoma screening, preventive foot care, stress management, hearing conservation, and a variety of counseling and other health-education activities. The most widespread preventive health-care measure in 1987 was hypertension screening, with over 3 million tests performed in that year. In addition, colorectal cancer screening and influenza immunization both showed increases from 1985 to 1987. Finally, the 1988 report noted increases in the number of preventive health-care services for women veterans, with over 2,000 mammograms and pap smears provided in 1987.

Although the preventive health-care services pilot program in subchapter VII of chapter 17 of title 38 expired on September 30, 1988, VA has continued to provide preventive health-care and health-promotion services pursuant to the 1983 amendment to its general health-care authority under chapter 17.

In statements submitted after the Committee's May 18 hearing, S. 1306 received general support, except from VA. VA noted the "desirability of providing veterans with preventive health-care services" but stated that it did not believe "that enactment of a statutorily prescribed preventive health-care program warranted."

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Committee bill

Section 214 of the Committee bill, in addition to reestablishing the pilot program to run through fiscal year 1994, expands the category of veterans who are entitled to preventive health care to include, in addition to those with service-connected disabilities rated 50 percent or more and those receiving care for a service-connected disability, all other veterans receiving care or treatment to which they are entitled. In the case of those receiving hospital or nursinghome care, this includes all category A patients—primarily veterans who have any service-connected disability, who are ex-POWs or World War I veterans, who have disabilities that may be related to their exposure to radiation from a nuclear detonation or to an herbicide in Vietnam, or who have incomes below the category A maximum (currently $16,466 per year for a veteran with no dependents). In the case of those receiving outpatient treatment, this includes primarily those being treated for service-connected disabilities, those with service-connected disabilities rated at 50 percent or more being treated for any disability and, when receiving treatment necessary to prepare for or obviate hospitalization or to follow up on institutional care, veterans who have service-connected disabilities rated at 30 or 40 percent, and veterans with incomes not exceeding the applicable maximum rate of VA need-based pension for those needing aid and attendance (currently $10,338 for a veteran with no dependents).

In this time of serious budget constraints for VA health care and all Federal spending, the Committee believes that the foresight to see and think beyond immediate budgetary limitations must be encouraged. It is interesting that the institution from which veterans have come, the military, has long recognized the importance of preventive health-care and health-promotion services as a means to help keep our military personnel at the highest state of good health. This emphasis should be continued after their service.

The Committee is convinced of the value and cost-effectiveness of preventive health-care and health-promotion services and is concerned that funds for these services have been and will continue to be difficult to obtain. The Committee believes that if preventive health-care services are not mandated, the current budget crunch will very likely lead to cutbacks on that front which will, in the long run, cost more money, not less. Preventive health care is an investment that saves money in the long run. The Committee wants to ensure that this program continues and that it is enhanced rather than contracted.

Implementation of this measure should not become an additional burden to VA health-care practitioners. When a veteran receives VA health care for any health problem, there is very often some preventive health care involved as well, and it is standard practice for health-care professionals to ask about a patient's medical history and personal habits and to check a patient's blood pressure and other vital signs. By expanding the preventive health-care mandate, the Committee seeks to make sure all veterans who are entitled to the inpatient or outpatient care they are receiving are also furnished preventive care.