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106th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     106-863

======================================================================



 
    DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PERSONNEL ACT OF 2000

                                _______
                                

 September 18, 2000.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 5109]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 5109) to amend title 38, United States Code, to 
improve the personnel system of the Veterans Health 
Administration, and for other purposes, having considered the 
same, reports favorably thereon with an amendment and 
recommends that the bill as amended do pass.

  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 ``Department of 
Veterans Affairs Health Care Personnel Act of 2000''.
  (b) Table of Contents.--The table of contents of this Act is as 
follows:

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

                       TITLE I--PERSONNEL MATTERS

Sec. 101. Annual national pay comparability adjustment for nurses 
employed by Department of Veterans Affairs.
Sec. 102. Special pay for dentists.
Sec. 103. Exemption for pharmacists from ceiling on special salary 
rates.
Sec. 104. Physician assistant adviser to Under Secretary for Health.
Sec. 105. Temporary full-time appointments of certain medical 
personnel.
Sec. 106. Qualifications of social workers.
Sec. 107. Extension of voluntary separation incentive payments.

                  TITLE II--CONSTRUCTION AUTHORIZATION

Sec. 201. Authorization of major medical facility projects.
Sec. 202. Authorization of appropriations.

                   TITLE III--MILITARY SERVICE ISSUES

Sec. 301. Military service history.
Sec. 302. Study of post-traumatic stress disorder in Vietnam veterans.

                    TITLE IV--MEDICAL ADMINISTRATION

Sec. 401. Pilot program for coordination of hospital benefits.
Sec. 402. Benefits for persons disabled by participation in compensated 
work therapy program.
Sec. 403. Extension of authority to establish research and education 
corporations.
Sec. 404. Department of Veterans Affairs Fisher Houses.
Sec. 405. Extension of annual report of Committee on Mentally Ill 
Veterans.
Sec. 406. Exception to recapture rule.
Sec. 407. Change to enhanced use lease congressional notification 
period.
Sec. 408. Technical and conforming changes.
Sec. 409. Release of reversionary interest of the United States in 
certain real property previously conveyed to the State of Tennessee.

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

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

                       TITLE I--PERSONNEL MATTERS

SEC. 101. ANNUAL NATIONAL PAY COMPARABILITY ADJUSTMENT FOR NURSES 
                    EMPLOYED BY DEPARTMENT OF VETERANS AFFAIRS.

  (a) Revised Pay Adjustment Procedures.--Section 7451 is amended--
          (1) in subsection (d)--
                  (A) in paragraph (1)--
                          (i) by striking ``The rates'' and inserting 
                        ``Subject to subsection (e), the rates''; and
                          (ii) in subparagraph (A), by inserting ``and 
                        to be by the same percentage'' after ``to have 
                        the same effective date'';
                  (B) in paragraph (2), by striking ``Such'' in the 
                second sentence and inserting ``Except as provided in 
                paragraph (1)(A), such'';
                  (C) in paragraph (3)(B)--
                          (i) by inserting after the first sentence the 
                        following new sentence: ``To the extent 
                        practicable, the director shall use third-party 
                        industry wage surveys to meet the requirements 
                        of the preceding sentence.'';
                          (ii) by inserting before the penultimate 
                        sentence the following new sentence: ``To the 
                        extent practicable, all surveys conducted 
                        pursuant to this subparagraph or subparagraph 
                        (A) shall include the collection of salary 
                        midpoints, actual salaries, lowest and highest 
                        salaries, average salaries, bonuses, incentive 
                        pays, differential pays, actual beginning rates 
                        of pay and such other information needed to 
                        meet the purpose of this section.''; and
                          (iii) in the penultimate sentence, by 
                        inserting ``or published'' after ``completed'';
                  (D) by striking clause (iii) of paragraph (3)(C);
          (2) by striking subsection (e) and inserting the following:
  ``(e)(1) An adjustment in a rate of basic pay under subsection (d) 
may not reduce the rate of basic pay applicable to any grade of a 
covered position.
  ``(2) The director of a Department health-care facility, in 
determining whether to carry out a wage survey under subsection (d)(3) 
with respect to rates of basic pay for a grade of a covered position, 
may not consider as a factor in such determination the absence of a 
current recruitment or retention problem for personnel in that grade of 
that position. The director shall make such a determination based upon 
whether, in accordance with criteria established by the Secretary, 
there is a significant pay-related staffing problem at that facility in 
any grade for a position. If the director determines that there is such 
a problem, or that such a problem is likely to exist in the near 
future, the Director shall provide for a wage survey in accordance with 
paragraph (3) of subsection (d).
  ``(3) The Under Secretary for Health may, to the extent necessary to 
carry out the purposes of subsection (d), modify any determination made 
by the director of a Department health-care facility with respect to 
adjusting the rates of basic pay applicable to covered positions. Upon 
such action by the Under Secretary, any adjustment shall take effect on 
the first day of the first pay period beginning after such action. The 
Secretary shall ensure that the Under Secretary establishes a mechanism 
for the exercise of the authority in the preceding sentence.
  ``(4) Each director of a Department health-care facility shall 
provide to the Secretary, not later than July 31 each year, a report on 
staffing for covered positions at that facility. The report shall 
include the following:
          ``(A) Information on turnover rates and vacancy rates for 
        each grade in a covered position, including a comparison of 
        those rates with the rates for the preceding three years.
          ``(B) The director's findings concerning the review and 
        evaluation of the facility's staffing situation, including 
        whether there is, or is likely to be, in accordance with 
        criteria established by the Secretary, a significant pay-
        related staffing problem at that facility for any grade of a 
        covered position and, if so, whether a wage survey was 
        conducted, or will be conducted with respect to that grade.
          ``(C) In any case in which the director conducts such a wage 
        survey during the period covered by the report, information 
        describing the survey and any actions taken or not taken based 
        on the survey, and the reasons for taking (or not taking) such 
        actions.
          ``(D) In any case in which the director, after finding that 
        there is, or is likely to be, in accordance with criteria 
        established by the Secretary, a significant pay-related 
        staffing problem at that facility for any grade of a covered 
        position, determines not to conduct a wage survey with respect 
        to that position, a statement of the reasons why the director 
        did not conduct such a survey.
  ``(5) Not later than September 30 of each year, the Secretary shall 
submit to the Committees on Veterans' Affairs of the Senate and House 
of Representatives a report on staffing for covered positions at 
Department healthcare facilities. Each such report shall include the 
following:
          ``(A) A summary and analysis of the information contained in 
        the most recent reports submitted by facility directors under 
        paragraph (4).
          ``(B) The information for each such facility specified in 
        paragraph (4).'';
          (3) in subsection (f)--
                  (A) by striking ``February 1 of 1991, 1992, and 
                1993'' and inserting ``March 1 of each year''; and
                  (B) by striking ``subsection (d)(1)(A)'' and 
                inserting ``subsection (d)''; and
          (4) by striking subsection (g) and redesignating subsection 
        (h) as subsection (g).
  (b) Required Consultations With Nurses.--(1) Subchapter II of chapter 
73 is amended by adding at the end the following new section:

``Sec. 7323. Required consultations with nurses

  ``The Under Secretary for Health shall ensure that--
          ``(1) the director of a geographic service area, in 
        formulating policy relating to the provision of patient care, 
        shall consult regularly with a senior nurse executive or senior 
        nurse executives; and
          ``(2) the director of a medical center shall, to the extent 
        feasible, include a registered nurse as a member of any 
        committee used at that medical center to provide 
        recommendations or decisions on medical center operations or 
        policy affecting clinical services, clinical outcomes, budget, 
        or resources.''.
  (2) The table of sections at the beginning of such chapter is amended 
by inserting after the item relating to section 7322 the following new 
item:

``7323. Required consultations with nurses.''.

SEC. 102. SPECIAL PAY FOR DENTISTS.

  (a) Full-Time Status Pay.--Paragraph (1) of section 7435(b) is 
amended by striking ``$3,500'' and inserting ``$9,000''.
  (b) Special Pay for Post-Graduate Training.--Such section is amended 
by adding at the end the following new paragraph:
          ``(8) For a dentist who has successfully completed a post-
        graduate year of hospital-based training in a program 
        accredited by the American Dental Association, an annual rate 
        of $2,000 for each of the first two years of service after 
        successful completion of that training.''.
  (c) Tenure Pay.--The table in paragraph (2)(A) of that section is 
amended to read as follows:


------------------------------------------------------------------------
                                                          Rate
              ``Length of Service              -------------------------
                                                  Minimum      Maximum
------------------------------------------------------------------------
1 year but less than 2 years..................       $1,000       $2,000
2 years but less than 4 years.................        4,000        5,000
4 years but less than 8 years.................        5,000        8,000
8 years but less than 12 years................        8,000       12,000
12 years but less than 20 years...............       12,000       15,000
20 years or more..............................       15,000   18,000.''.
------------------------------------------------------------------------

  (d) Scarce Specialty Pay.--Paragraph (3)(A) of that section is 
amended by striking ``$20,000'' and inserting ``$30,000''.
  (e) Geographic Pay.--Paragraph (6) of that section is amended by 
striking ``$5,000'' and inserting ``$12,000''.
  (f) Responsibility Pay.--(1) The table in paragraph (4)(A) of that 
section is amended to read as follows:


------------------------------------------------------------------------
                                                          Rate
                  ``Position                   -------------------------
                                                  Minimum      Maximum
------------------------------------------------------------------------
Chief of Staff or in an Executive Grade.......      $14,500      $25,000
Director Grade................................            0       25,000
Service Chief (or in a comparable position as         4,500   15,000.''.
 determined by the Secretary).................
------------------------------------------------------------------------

  (2) The table in paragraph (4)(B) of that section is amended to read 
as follows:

------------------------------------------------------------------------
                         ``Position                              Rate
------------------------------------------------------------------------
Deputy Service Director....................................      $20,000
Service Director...........................................       25,000
Deputy Assistant Under Secretary for Health................       27,500
Assistant Under Secretary for Health (or in a comparable      30,000.''.
 position as determined by the Secretary)..................
------------------------------------------------------------------------

  (g) Crediting of Increased Tenure Pay for Civil Service Retirement.--
Section 7438(b) is amended--
          (1) by redesignating paragraph (5) as paragraph (6); and
          (2) by inserting after paragraph (4) the following new 
        paragraph:
  ``(5) Notwithstanding paragraphs (1) and (2), a dentist employed as a 
dentist in the Veterans Health Administration on the effective date of 
section 102 of the Department of Veterans Affairs Health Care Personnel 
Act of 2000 shall be entitled to have special pay paid to the dentist 
under section 7435(b)(2)(A) of this title (referred to as `tenure pay') 
considered basic pay for the purposes of chapter 83 or 84, as 
appropriate, of title 5 only as follows:
          ``(A) In an amount equal to the amount that would have been 
        so considered under such section on the day before such 
        effective date based on the rates of special pay the dentist 
        was entitled to receive under that section on the day before 
        such effective date.
          ``(B) With respect to any amount of special pay received 
        under that section in excess of the amount such dentist was 
        entitled to receive under such section on the day before such 
        effective date, in an amount equal to 25 percent of such excess 
        amount for each two years that the physician or dentist has 
        completed as a physician or dentist in the Veterans Health 
        Administration after such effective date.''.
  (h) Effective Date.--The amendments made by this section shall apply 
with respect to agreements entered into by dentists under subchapter 
III of chapter 74 of title 38, United States Code, on or after the 
later of--
          (1) the date of the enactment of this Act; and
          (2) October 1, 2000.
  (i) Transition.--(1) In the case of an agreement entered into by a 
dentist under subchapter III of chapter 74 of title 38, United States 
Code, before the date of the enactment of this Act that expires after 
the effective date specified in subsection (h), the Secretary of 
Veterans Affairs and the dentist concerned may agree to terminate that 
agreement as of that effective date in order to permit a new agreement 
in accordance with section 7435 of such title, as amended by this 
section, to take effect as of that effective date.
  (2) In the case of an agreement entered into under such subchapter 
before the date of the enactment of this Act that expires during the 
period beginning on the date of the enactment of this Act and ending on 
the effective date specified in subsection (h)(2), an extension or 
renewal of that agreement may not extend beyond that effective date.
  (3) In the case of a dentist who begins employment with the 
Department of Veterans Affairs during the period beginning on the date 
of the enactment of this Act and ending on the effective date specified 
in subsection (h)(2) who is eligible for an agreement under subchapter 
III of chapter 74 of title 38, United States Code, any such agreement 
may not extend beyond that effective date.

SEC. 103. EXEMPTION FOR PHARMACISTS FROM CEILING ON SPECIAL SALARY 
                    RATES.

  Section 7455(c)(1) is amended by inserting ``, pharmacists,'' after 
``anesthetists''.

SEC. 104. PHYSICIAN ASSISTANT ADVISER TO UNDER SECRETARY FOR HEALTH.

  Section 7306(f) is amended--
          (1) by striking ``and'' at the end of paragraph (1);
          (2) by striking the period at the end of paragraph (2) and 
        inserting ``; and''; and
          (3) by adding at the end the following new paragraph:
          ``(3) a physician assistant with appropriate experience (who 
        may have a permanent duty station at a Department medical care 
        facility in reasonable proximity to Washington, DC) advises the 
        Under Secretary on all matters relating to the utilization and 
        employment of physician assistants in the Administration.''.

SEC. 105. TEMPORARY FULL-TIME APPOINTMENTS OF CERTAIN MEDICAL 
                    PERSONNEL.

  (a) Physician Assistants Awaiting Certification or Licensure.--
Paragraph (2) of section 7405(c) is amended to read as follows:
  ``(2) A temporary full-time appointment may not be made for a period 
in excess of two years in the case of a person who--
          ``(A) has successfully completed--
                  ``(i) a full course of nursing in a recognized school 
                of nursing, approved by the Secretary; or
                  ``(ii) a full course of training for any category of 
                personnel described in paragraph (3) of section 7401 of 
                this title, or as a physician assistant, in a 
                recognized education or training institution approved 
                by the Secretary; and
          ``(B) is pending registration or licensure in a State or 
        certification by a national board recognized by the 
        Secretary.''.
  (b) Medical Support Personnel.--That section is further amended--
          (1) by redesignating paragraph (3) as paragraph (4); and
          (2) by inserting after paragraph (2) the following new 
        paragraph (3):
  ``(3)(A) Temporary full-time appointments of persons in positions 
referred to in subsection (a)(1)(D) shall not exceed three years.
  ``(B) Temporary full-time appointments under this paragraph may be 
renewed for one or more additional periods not in excess of three years 
each.''.

SEC. 106. QUALIFICATIONS OF SOCIAL WORKERS.

  Section 7402(b)(9) is amended by striking ``a person must'' and all 
that follows and inserting ``a person must--
          ``(A) hold a master's degree in social work from a college or 
        university approved by the Secretary; and
          ``(B) be licensed or certified to independently practice 
        social work in a State, except that the Secretary may waive the 
        requirement of licensure or certification for an individual 
        social worker for a reasonable period of time recommended by 
        the Under Secretary for Health.''.

SEC. 107. EXTENSION OF VOLUNTARY SEPARATION INCENTIVE PAYMENTS.

  The Department of Veterans Affairs Employment Reduction Assistance 
Act of 1999 (title XI of Public Law 106-117; 5 U.S.C. 5597 note) is 
amended as follows:
          (1) Section 1102(c) is amended to read as follows:
  ``(c) Limitation.--The plan under subsection (a) shall be limited to 
8,110 positions within the Department.''.
          (2) Section 1105(a) is amended by striking ``26 percent'' and 
        inserting ``15 percent''.
          (3) Section 1109(a) is amended by striking ``December 31, 
        2000'' and inserting ``December 31, 2002''.

                  TITLE II--CONSTRUCTION AUTHORIZATION

SEC. 201. AUTHORIZATION OF MAJOR MEDICAL FACILITY PROJECTS.

  (a) Fiscal Year 2001 Projects.--The Secretary of Veterans Affairs may 
carry out the following major medical facility projects, with each 
project to be carried out in the amount specified for that project:
          (1) Construction of a psychogeriatric care building at the 
        Department of Veterans Affairs Medical Center, Palo Alto, 
        California, in an amount not to exceed $26,600,000.
          (2) Construction of a utility plant and electrical vault at 
        the Department of Veterans Affairs Medical Center, Miami, 
        Florida, in an amount not to exceed $23,600,000.
          (3) Seismic corrections, clinical consolidation, and other 
        improvements at the Department of Veterans Affairs Medical 
        Center, Long Beach, California, in an amount not to exceed 
        $51,700,000.
  (b) Additional Fiscal Year 2000 Project.--The Secretary is authorized 
to carry out a project for the renovation of psychiatric nursing units 
at the Department of Veterans Affairs Medical Center, Murfreesboro, 
Tennessee, in an amount not to exceed $14,000,000.

SEC. 202. AUTHORIZATION OF APPROPRIATIONS.

  (a) In General.--There are authorized to be appropriated to the 
Secretary of Veterans Affairs for fiscal years 2001 and 2002 for the 
Construction, Major Projects, account, $101,900,000 for the projects 
authorized in section 101(a).
  (b) Limitation.--The projects authorized in section 101(a) may only 
be carried out using--
          (1) funds appropriated for fiscal year 2001 or 2002 pursuant 
        to the authorization of appropriations in subsection (a);
          (2) funds appropriated for Construction, Major Projects for a 
        fiscal year before fiscal year 2001 that remain available for 
        obligation; and
          (3) funds appropriated for Construction, Major Projects for 
        fiscal year 2001 or 2002 for a category of activity not 
        specific to a project.

                   TITLE III--MILITARY SERVICE ISSUES

SEC. 301. MILITARY SERVICE HISTORY.

  (a) Military Histories.--The Secretary of Veterans Affairs, in 
carrying out the responsibilities of the Secretary under chapter 17 of 
title 38, United States Code, shall ensure that--
          (1) during at least one clinical evaluation of a patient in a 
        facility of the Department, a protocol is used to identify 
        pertinent military experiences and exposures of the patient 
        that may contribute to the health status of the patient; and
          (2) pertinent information relating to the military history of 
        the patient is included in the Department's medical records of 
        the patient.
  (b) Report.--Not later than nine months after the date of the 
enactment of this Act, the Secretary shall submit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives a report 
on the feasibility and desirability of using a computer-based system in 
conducting clinical evaluations referred to in subsection (a)(1).

SEC. 302. STUDY OF POST-TRAUMATIC STRESS DISORDER IN VIETNAM VETERANS.

  (a) Study on Post-Traumatic Stress Disorder.--Not later than 10 
months after the date of the enactment of this Act, the Secretary of 
Veterans Affairs shall enter into a contract with an appropriate entity 
to carry out a study on post-traumatic stress disorder.
  (b) Follow-Up Study.--The contract under subsection (a) shall provide 
for a follow-up study to the study conducted in accordance with section 
102 of the Veterans Health Care Amendments of 1983 (Public Law 98-160). 
Such follow-up study shall use the data base and sample of the previous 
study.
  (c) Information To Be Included.--The study conducted pursuant to this 
section shall be designed to yield information on--
          (1) the long-term course of post-traumatic stress disorder;
          (2) any long-term medical consequences of post-traumatic 
        stress disorder;
          (3) whether particular subgroups of veterans are at greater 
        risk of chronic or more severe problems with such disorder; and
          (4) the services used by veterans who have post-traumatic 
        stress disorder and the effect of those services on the course 
        of the disorder.
  (d) Report.--The Secretary shall submit to the Committees of 
Veterans' Affairs of the Senate and House of Representatives a report 
on the results of the study under this section. The report shall be 
submitted no later than October 1, 2004.

                    TITLE IV--MEDICAL ADMINISTRATION

SEC. 401. PILOT PROGRAM FOR COORDINATION OF HOSPITAL BENEFITS.

  (a) In General.--Chapter 17 is amended by inserting after section 
1725 the following new section:

``Sec. 1725A. Coordination of hospital benefits: pilot program

  ``(a) The Secretary may carry out a pilot program in not more than 
four geographic areas of the United States to improve access to, and 
coordination of, inpatient care of eligible veterans. Under the pilot 
program, the Secretary, subject to subsection (b), may pay certain 
costs described in subsection (b) for which an eligible veteran would 
otherwise be personally liable. The authority to carry out the pilot 
program shall expire on September 30, 2005.
  ``(b) In carrying out the program described in subsection (a), the 
Secretary may pay the costs authorized under this section for hospital 
care and medical services furnished on an inpatient basis in a non-
Department hospital to an eligible veteran participating in the 
program. Such payment may cover the costs for applicable plan 
deductibles and coinsurance and the reasonable costs of such inpatient 
care and medical services not covered by any applicable health-care 
plan of the veteran, but only to the extent such care and services are 
of the kind authorized under this chapter. The Secretary shall limit 
the care and services for which payment may be made under the program 
to general medical and surgical services and shall require that such 
services may be provided only upon preauthorization by the Secretary.
  ``(c)(1) A veteran described in paragraph (1) or (2) of section 
1710(a) of this title is eligible to participate in the pilot program 
if the veteran--
          ``(A) is enrolled to receive medical services from an 
        outpatient clinic operated by the Secretary which is (i) within 
        reasonable proximity to the principal residence of the veteran, 
        and (ii) located within the geographic area in which the 
        Secretary is carrying out the program described in subsection 
        (a);
          ``(B) has received care under this chapter within the 24-
        month period preceding the veteran's application for enrollment 
        in the pilot program;
          ``(C) as determined by the Secretary before the 
        hospitalization of the veteran (i) requires such hospital care 
        and services for a non-service-connected condition, and (ii) 
        could not receive such services from a clinic operated by the 
        Secretary; and
          ``(D) elects to receive such care under a health-care plan 
        (other than under this title) under which the veteran is 
        entitled to receive such care.
  ``(2) Nothing in this section shall be construed to reduce the 
authority of the Secretary to contract with non-Department facilities 
for care of a service-connected disability of a veteran.
  ``(3) Notwithstanding subparagraph (D) of paragraph (1), the 
Secretary shall ensure that not less than 15 percent of the veterans 
participating in the program are veterans who do not have a health-care 
plan.
  ``(d) As part of the program under this section, the Secretary shall, 
through provision of case-management, coordinate the care being 
furnished directly by the Secretary and care furnished under the 
program in non-Department hospitals to veterans participating in the 
program.
  ``(e)(1) In designating geographic areas in which to establish the 
program under subsection (a), the Secretary shall ensure that--
          ``(A) the areas designated are geographically dispersed;
          ``(B) at least 70 percent of the veterans who reside in a 
        designated area reside at least two hours driving distance from 
        the closest medical center operated by the Secretary which 
        provides medical and surgical hospital care; and
          ``(C) the establishment of the program in any such area would 
        not result in jeopardizing the critical mass of patients needed 
        to maintain a Department medical center that serves that area.
  ``(2) Notwithstanding paragraph (1)(B), the Secretary may designate 
for participation in the program at least one area which is in 
proximity to a Department medical center which, as a result of a change 
in mission of that center, does not provide hospital care.
  ``(f)(1) Not later than September 30, 2002, the Secretary shall 
submit to the Committees on Veterans' Affairs of the Senate and House 
of Representatives a report on the experience in implementing the pilot 
program under subsection (a).
  ``(2) Not later than September 30, 2004, the Secretary shall submit 
to those committees a report on the experience in operating the pilot 
program during the first two full fiscal years during which the pilot 
program is conducted. That report shall include--
          ``(A) a comparison of the costs incurred by the Secretary 
        under the program and the cost experience for the calendar year 
        preceding establishment of the program at each site at which 
        the program is operated;
          ``(B) an assessment of the satisfaction of the participants 
        in the program; and
          ``(C) an analysis of the effect of the program on access and 
        quality of care for veterans.
  ``(g) The total amount expended for the pilot program in any fiscal 
year (including amounts for administrative costs) may not exceed 
$50,000,000.
  ``(h) For purposes of this section, the term `health-care plan' has 
the meaning given that term in section 1725(f)(3) of this title.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is amended by inserting after the item relating to section 
1725 the following new item:

``1725A. Coordination of hospital benefits: pilot program.''.

SEC. 402. BENEFITS FOR PERSONS DISABLED BY PARTICIPATION IN COMPENSATED 
                    WORK THERAPY PROGRAM.

  Section 1151(a)(2) is amended--
          (1) by inserting ``(A)'' after ``proximately caused''; and
          (2) by inserting before the period at the end the following: 
        ``, or (B) by participation in a program (known as a 
        `compensated work therapy program') under section 1718 of this 
        title''.

SEC. 403. EXTENSION OF AUTHORITY TO ESTABLISH RESEARCH AND EDUCATION 
                    CORPORATIONS.

  Section 7368 is amended by striking ``December 31, 2000'' and 
inserting ``December 31, 2005''.

SEC. 404. DEPARTMENT OF VETERANS AFFAIRS FISHER HOUSES.

  (a) Authority.--Subchapter I of chapter 17 of title 38, United States 
Code, is amended by adding at the end the following new section:

``Sec. 1708. Temporary lodging

  ``(a) The Secretary may furnish persons described in subsection (b) 
with temporary lodging in a Fisher house or other appropriate facility 
in connection with the examination, treatment, or care of a veteran 
under this chapter or, as provided for under subsection (e)(5), in 
connection with benefits administered under this title.
  ``(b) Persons to whom the Secretary may provide lodging under 
subsection (a) are the following:
          ``(1) A veteran who must travel a significant distance to 
        receive care or services under this title.
          ``(2) A member of the family of a veteran and others who 
        accompany a veteran and provide the equivalent of familial 
        support for such veteran.
  ``(c) In this section, the term `Fisher house' means a housing 
facility that--
          ``(1) is located at, or in proximity to, a Department medical 
        facility;
          ``(2) is available for residential use on a temporary basis 
        by patients of that facility and others described in subsection 
        (b)(2); and
          ``(3) is constructed by, and donated to the Secretary by, the 
        Zachary and Elizabeth M. Fisher Armed Services Foundation.
  ``(d) The Secretary may establish charges for providing lodging under 
this section. The proceeds from such charges shall be credited to the 
medical care account and shall be available until expended for the 
purposes of providing such lodging.
  ``(e) The Secretary shall prescribe regulations to carry out this 
section. Such regulations shall include provisions--
          ``(1) limiting the duration of such lodging;
          ``(2) establishing standards and criteria under which medical 
        facilities may set charges for such lodging;
          ``(3) establishing criteria for persons considered to be 
        accompanying a veteran;
          ``(4) establishing criteria for the use of such premises; and
          ``(5) any other limitations, conditions, and priorities that 
        the Secretary considers appropriate with respect to temporary 
        lodging under this section.''.
  (b) Clerical Amendment.--The table of sections at the beginning of 
such chapter is amended by inserting after the item relating to section 
1707 the following new item:

``1708. Temporary lodging.''.

SEC. 405. EXTENSION OF ANNUAL REPORT OF COMMITTEE ON MENTALLY ILL 
                    VETERANS.

  Section 7321(d)(2) is amended by striking ``three'' and inserting 
``six''.

SEC. 406. EXCEPTION TO RECAPTURE RULE.

  Section 8136 is amended--
          (1) by inserting ``(a)'' at the beginning of the text of the 
        section; and
          (2) by adding at the end the following new subsection:
  ``(b) The establishment and operation by the Secretary of an 
outpatient clinic in facilities described in subsection (a) shall not 
constitute grounds entitling the United States to any recovery under 
that subsection.''.

SEC. 407. CHANGE TO ENHANCED USE LEASE CONGRESSIONAL NOTIFICATION 
                    PERIOD.

  Paragraph (2) of section 8163(c) is amended to read as follows:
  ``(2) The Secretary may not enter into an enhanced use lease until 
the end of the 90-day period beginning on the date of the submission of 
notice under paragraph (1).''.

SEC. 408. TECHNICAL AND CONFORMING CHANGES.

  (a) Requirement To Provide Care.--Section 1710A(a) is amended by 
inserting ``(subject to section 1710(a)(4) of this title)'' after 
``Secretary'' the first place it appears.
  (b) Conforming Amendment.--Section 1710(a)(4) is amended by striking 
``requirement in'' and inserting ``requirements in section 1710A(a) 
and''.

SEC. 409. RELEASE OF REVERSIONARY INTEREST OF THE UNITED STATES IN 
                    CERTAIN REAL PROPERTY PREVIOUSLY CONVEYED TO THE 
                    STATE OF TENNESSEE.

  (a) Release of Interest.--The Secretary of Veterans Affairs shall 
execute such legal instruments as necessary to release the reversionary 
interest of the United States described in subsection (b) in a certain 
parcel of real property conveyed to the State of Tennessee pursuant to 
the Act entitled ``An Act authorizing the transfer of certain property 
of the Veterans' Administration (in Johnson City, Tennessee) to the 
State of Tennessee'', approved June 6, 1953 (67 Stat. 54).
  (b) Specified Reversionary Interest.--Subsection (a) applies to the 
reversionary interest of the United States required under section 2 of 
the Act referred to in subsection (a), requiring use of the property 
conveyed pursuant to that Act to be primarily for training of the 
National Guard and for other military purposes.
  (c) Conforming Amendment.--Section 2 of such Act is repealed.

                              Introduction

    H.R. 5109 addresses a range of issues reviewed by the 
Committee in hearings, meetings, and through other oversight 
mechanisms over the course of this year.

    On February 17, 2000, the Committee on Veterans' Affairs 
held a hearing to receive information on the VA Medical Care 
budget request for FY 2001. Those testifying at the hearing 
included: the Honorable Togo D. West, Jr., Secretary of 
Veterans Affairs; representatives of the Independent Budget, 
Mr. Gordon H. Mansfield, Executive Director, Paralyzed Veterans 
of America; Mr. David Gorman, Executive Director, Disabled 
American Veterans; Mr. David E. Woodbury, National Executive 
Director, AMVETS; Mr. Dennis M. Cullinan, National Legislative 
Director, Veterans of Foreign Wars; Mr. Philip Wilkerson, 
Deputy Director, National Veterans Affairs and Rehabilitation 
Commission, The American Legion; Mr. Larry Rhea, Deputy 
Director of Legislative Affairs, Non Commissioned Officers 
Association; and Mr. Richard Weidman, Director of Government 
Relations, Vietnam Veterans of America, on behalf of the 
National Military Veterans Alliance.

    On April 5, 2000, the Subcommittee on Health received 
testimony on the issue of Veterans Health Administration 
capital asset planning. Among those testifying at that hearing 
were the Honorable Dave Weldon, Member of Congress from the 
State of Florida; Mr. Stephen P. Backhus, Director, Veterans' 
Affairs and Military Health Care Issues, Health, Education, and 
Human Services Division, General Accounting Office, accompanied 
by Mr. Paul Reynolds, Assistant Director, Veterans' Affairs and 
Military Health Care Issues, Health, Education, and Human 
Services Division, General Accounting Office; and Mr. Walter 
Gembacz, Assistant Director, Veterans Affairs and Military 
Health Care Issues, Health Education, and Human Services 
Division, General Accounting Office; Dr. Frances M. Murphy, 
Acting Deputy Under Secretary for Policy and Management, 
Department of Veterans Affairs; accompanied by Dr. Terrence S. 
Batliner, Director, VISN 19; Mr. Dennis Smith, Director, VA 
Maryland Health Care System; Charles V. Yarbrough, Chief 
Facilities Management Officer, Department of Veterans Affairs; 
Mr. Gordon H. Mansfield, Executive Director, Paralyzed Veterans 
of America; Mr. Dennis M. Cullinan, Director, National 
Legislative Service, Veterans of Foreign Wars; and Mrs. 
Jacqueline Garrick, Deputy Director, National Veterans Affairs 
and Rehabilitation Commission, The American Legion.

    On April 12, 2000, the Subcommittee on Health received 
testimony on the issue of recruitment, retention, and 
compensation of the VA health care workforce. Those testifying 
at this hearing included: Mr. Kenneth J. Clark, Chief Network 
Officer, Department of Veterans Affairs; accompanied by Mr. 
Walter A. Hall, Assistant General Counsel, Mr. Thomas J. Hogan, 
Director Management Support, Ms. Mari A. Horak, Management 
Support; Ms. Margaret Kruckemeyer, President, Nursing 
Organization for Veterans' Affairs (NOVA); Mr. Bobby Harnage, 
National President, American Federation of Government 
Employees; Dr. John F. Burton, National Association of VA 
Physicians and Dentists, and Dr. Robert M. Anderton, American 
Dental Association.

    On May 17, 2000, the Subcommittee on Health received 
testimony on the issue of Health Care Sharing programs of the 
Departments of Veterans Affairs (VA) and Defense (DoD). Among 
those testifying at this hearing included: Mr. Anthony J. 
Principi, Chairman, Congressional Commission on Servicemembers 
and Veterans Transition Assistance, Mr. Stephen P. Backhus, 
Director, Veterans Affairs and Military Health Care Issues, 
Health, Education, and Human Services Division, General 
Accounting Office; the Honorable Thomas L. Garthwaite, Deputy 
Under Secretary for Health, Department of Veterans Affairs; 
Gwendolyn Brown, Deputy Assistant Secretary of Defense, Health 
Budgets and Financial Policy, Department of Defense; and 
Lieutenant General Paul K. Carlton, Jr., Surgeon General, 
United States Air Force.

    On the basis of its hearings and oversight on these 
matters, the Subcommittee on Health met on September 7, 2000, 
to mark up H.R. 5109, the Department of Veterans Affairs Health 
Care Personnel Act of 2000. The bill was endorsed unanimously 
by the Subcommittee and reported to the full Committee on 
Veterans' Affairs. The full Committee met on September 13, 
2000, and ordered the bill reported, as amended, favorably to 
the House.

                      Summary of the Reported Bill

    H.R. 5109 would:

                       TITLE I-PERSONNEL MATTERS

    1.  LAuthorize annual ``national'' comparability pay raise 
for VA nurses on par with that of other federal employees.
    2.  LMake optional annual locality survey process for VA 
nurse pay. Define ``triggers'' that indicate the need for 
Directors to perform locality pay surveys for nurses such as 
turnover, lag time, looming nurse shortage, to be defined in 
criteria of Secretary; require communication to peer and senior 
Veterans Health Administration (VHA) management of intent to 
survey; report to Congress on decision to survey.
    3.  LEliminate the sole discretion vested in facility 
directors to make pay decisions; clarify that the absence of a 
nurse recruitment or retention problem not be a basis for 
failure to provide a pay increase; prohibit ``negative pay 
adjustments''; authorize the use of independent survey results; 
and provide, to the extent practicable, for pay surveys to 
collect actual salary and benefits data.
    4.  LProvide for nurse participation in policy and 
decision-making at the network and medical center levels.
    5.  LRevise and increase the rates of special pay (in 
addition to base pay) which is provided to dentists employed by 
the Veterans Health Administration.
    6.  LAdd pharmacists to the occupations that are exempt 
from a statutory cap on special salary rates that may be paid 
to meet documented staffing problems.
    7.  LRequire that the Under Secretary for Health: (a) 
designate a physician assistant (PA) to serve as a consultant 
to the Under Secretary and (b) seek the advice of a PA 
consultant on all matters relating to the employment and 
utilization of PAs in the Veterans Health Administration.
    8.  LAuthorize temporary appointments of up to two years 
for PAs who have successfully completed the full course of 
training for that profession and are pending certification.

    9. LAuthorize temporary extensions of term appointments for 
medical support personnel in VA-funded research projects.
    10. LAuthorize the Secretary to waive state licensure 
requirements for VA social workers while they are completing 
training.
    11. LExtend and modify employee ``buyout'' legislation 
through December 31, 2002.

                  TITLE II-CONSTRUCTION AUTHORIZATION

    1.  LAuthorize the Secretary to construct and authorize the 
appropriation of $102 million in fiscal year 2001 or 2002 for 
major construction projects (a psychogeriatric care building at 
the Palo Alto, CA VA Medical Center; a utility plant at the 
Miami, FL VA Medical Center; and seismic improvements at the 
Long Beach, CA VA Medical Center).
    2.  LAuthorize previously appropriated but not authorized, 
long-term care psychiatric facility at the Murfreesboro, TN VA 
Medical Center.

                   TITLE III-MILITARY SERVICE ISSUES

    1.  LRequire that, in conducting an initial clinical 
evaluation of a veteran, VA identify and document pertinent 
military experiences and exposures, which may contribute to the 
health status of the patient.
    2.  LRequire that VA enter into a contract with an 
appropriate entity to carry out a study on post-traumatic 
stress disorder in follow-up to the study on that disorder 
conducted under section 102 of Public Law 98-160.

                    TITLE IV-MEDICAL ADMINISTRATION

    1.  LAuthorize VA to conduct a four site pilot program 
involving coordination of VA and non-VA health care benefits; 
(a) limit program to $50M/year total expenditure; (b) authorize 
VA to include veterans without other health care benefits; (c) 
set a delimiting date of September 30, 2005, for the 
demonstration; (d) limit the ``scope of services'' to basic 
medical-surgical care; and (e) require reports to the Veterans' 
Affairs Committees.
    2.  LProvide compensation under section 1151 of title 38, 
United States Code, (with consequent health care coverage under 
chapter 17) to a veteran who is injured as a result of 
participation in a VA compensated work therapy program.
    3.  LExtend through 2005, VA's authority to establish 
nonprofit foundations to foster research, education, or both, 
in VA medical centers.
    4.  LAuthorize VA to furnish veterans and others 
accompanying veterans with temporary lodging (Fisher Houses) in 
connection with treatment or other provision of services.
    5.  LExtend the requirement that VA maintain a special 
committee relating to the care of the seriously chronically 
mentally ill.
    6.  LFacilitate VA establishment of VA outpatient clinics 
in State veterans' homes.
    7.  LModify the congressional reporting requirement for a 
proposed enhanced use lease that requires VA to wait ``60 
legislative days'' to ``90 calendar days.''
    8.  LRelease a reversionary interest of the United States 
in certain property previously conveyed to the State of 
Tennessee for use by the Army National Guard.

                       Background and Discussion

                               Nurse Pay

    Congress in 1990 enacted a law (the Department of Veterans 
Affairs Nurse Pay Act of 1990, Public Law 101-366) which 
completely restructured the VA pay system for nurses to remedy 
a serious recruitment and retention problem documented at that 
time. The legislation was sparked by a nationwide shortage of 
nurses which, under the constraints of then-applicable law, 
left VA at a marked competitive disadvantage in hiring and 
retaining registered nurses.

    The 1990 nurse pay act established a flexible authority for 
VA medical center directors to set pay rates for nurses, based 
on the local labor market. (Pay adjustments were to be based on 
data from the Bureau of Labor Statistics, or if unavailable, on 
data from locally administered surveys). The act replaced a 
system in which basic pay could only increase within a 
specified pay range (for each of then eight nurse-pay grade 
levels), and in accordance with annual government pay 
increases. ``Special salary rates'' could be set to respond to 
recruitment/retention problems but only through a cumbersome 
headquarters-administered process. The new system allowed for 
substantial pay increases tied to starting salaries for nurses 
in the local community. The law also limited the extent of 
locality pay adjustments to preclude VA from becoming a 
community pay-leader (specifying that the minimum rate of basic 
pay for any grade would not exceed the beginning rate of pay 
for corresponding positions at non-VA facilities) and divorced 
nurse pay from the pay system governing other VA employees. 
Nurses' organizations supported this legislation, though it had 
both positive and negative aspects. By linking pay to 
compensation in the local private sector, the system offered 
the potential for substantial pay increases. By severing that 
system from the pay mechanisms of the General Schedule pay 
system under which other medical care personnel are paid, 
however, it left nurses without the assurance of annual pay 
increases other employees received.

    As an early result of this pay act, nurses in many 
locations received very substantial pay increases which were 
not given other health care personnel. In 1991, for example, 
when the General Schedule increase was 4.1 percent, the minimum 
pay rates for entry and intermediate level nurses at the 
Washington, DC VA Medical Center jumped more than 59 and 35 
percent, respectively. With the passage of years, however, 
nurses in certain grades and in certain areas of the country 
experienced substantially smaller pay increases than other VA 
employees under the General Schedule system. In some instances, 
nurses received no locality pay increases for two or more 
years.

    Overall, VA reports that nurse salaries have generally 
tracked U.S. nurse salaries at large. But those salaries 
reflect marked variability across the country. Current salaries 
for beginning VA nurses at ``grade 1, step 1'' range from a 
high of approximately $49,000 in San Francisco to salaries from 
$25,000 to $30,000 in many locations; in many other major 
metropolitan areas those salaries range from $35,000 to 
$45,000. Those in the first step of ``grade 2'' range from 
approximately $57,000 in northern California to salaries from 
$35,000 to $40,000 in many locations. At the ``grade 3'' level, 
VA nurse salaries begin above $60,000 in several locations (to 
a high of about $63,000). The last three years have seen a 
steady increase nationally in the percentage increase in 
adjustments to nurse pay, with a national average increase of 
2.2 percent, 3 percent, and 4.3 percent, in January of 1998, 
1999, and 2000, respectively. The average increases for the 
preceding two years were 1.2 percent and 1.3 percent, 
respectively. General Schedule increases for these years, 
however, outpaced nurses' average increases.

    In light of concerns about administration of the locality-
pay system, in June 1998, VA entered into a contract for a 
study to identify how well the locality pay system (LPS) is 
working, and what could be done to improve the system. 
Anticipating that study, Congress in November 1998, in Public 
Law 105-368, directed VA to furnish its findings regarding the 
locality pay system and provide recommendations to Congress by 
February 1999 for administrative and legislative action. The 
Secretary of Veterans Affairs ultimately submitted a report to 
Congress in December 1999. That report, however, did not make 
legislative recommendations. While acknowledging problems with 
the manner in which the locality pay system had operated, in 
testifying before the Subcommittee on Health, VA offered 
neither a legislative nor an administrative remedy, nor any 
timetable for presenting or implementing the contractor's 
recommendations.

    VA has generally agreed with the findings reported by its 
contractor, that when first implemented, LPS helped VA efforts 
to recruit and retain nurses. In subsequent years, however, a 
reduction in nurse staffing in the non-Federal sector has 
markedly changed the labor market. The contractor reported that 
recruitment for nurses did not appear to be a major problem for 
VA medical centers, and retention of VA nurses appeared to be 
even less of a problem. The design, operation, and 
administration of the LPS system were seen to represent 
challenges, however. The report identified several problems 
associated with conducting locality-pay surveys. For example, 
approximately two-thirds of VA medical centers reportedly 
experienced significant problems in obtaining pertinent salary 
information from non-VA hospitals. The contractor identified as 
a ``fundamental problem'' the fact that the LPS process focuses 
on beginning rates of pay, which may not give a full or 
completely accurate view of appropriate compensation levels. 
Industry practice reportedly is to begin with midpoints for a 
range and set the boundaries of the range at 20 percent or more 
above and below the midpoints; thus, non-VA facilities may 
never actually pay at the ``beginning'' rate of the range.

    The report also addressed the question of how well the 
compensation system was working, and found only one of five 
indicators to be problematic, involving ``internal equity.'' It 
identified several factors contributing to morale problems. 
First, nurses may or may not receive an increase in a given 
year, depending on the results of LPS and the judgments of VA 
medical center directors, while their General Schedule-paid co-
workers receive annual pay increases and private sector nurses 
generally receive cost-of-living or similar increases every 
year. Second, many believe that budget constraints have a 
direct and negative affect on pay increases. Because hospital 
directors have exercised their discretion to provide pay raises 
so variably across the system, nurses perceive their pay system 
to be ``unfair.''

    The study recommended that the LPS survey administration 
reflect private industry practice. For example, the study 
recommended use of independent, third-party surveys; acquiring 
data on averages and ranges, as opposed to beginning pay only; 
surveying hospitals on actual pay rather than published 
minimums; and doing job analysis and detailed job matching on a 
less than annual basis, using standard industry terms and 
definitions.

    In light of finding wide variability in VA medical center 
directors' interpretations and implementations of the LPS law, 
the study recommended that VA establish more checkpoints for 
the validity, reasonableness, and fairness of the pay 
adjustment decisionmaking process. It further recommended that 
VA Headquarters communicate these checkpoints frequently to 
directors. The study also made a ``longer-term'' recommendation 
for the pay-setting process--to establish two separate 
components for annual pay adjustment, a general across-the-
board pay adjustment for all VA nurses and a locality based 
differential that reflects local market conditions or cost-of-
living differences. Insofar as the latter element is 
characterized in the study as ``retain[ing] the key feature of 
the current VA LPS that permits nurse pay at VA facilities to 
be competitive with pay at local non-VA health care 
facilities,'' the Committee believes that the recommendation is 
worthy as an alternative to the current LPS.

    For the past three years, at the urging of Congress, VA's 
Under Secretary for Health has strongly encouraged facility 
directors to grant pay increases to prevent pay-related 
staffing problems. Even under that invigorated policy, however, 
nurses' average pay increases over the past five years still 
have lagged behind the General Schedule increases. In addition, 
the VA has yet to make other administrative changes recommended 
by the contractor.

    To respond to these continuing problems, the Honorable 
Steven C. LaTourette introduced H.R. 1216, the ``Department of 
Veterans Affairs Nurses Appreciation Act of 1999.'' This bill 
would require that VA provide the same General Schedule pay 
raises for nurses and certain other health-care professionals 
employed by the Department of Veterans Affairs as it provides 
to other federal employees, and would revise the authority of 
the Secretary of Veterans Affairs to make further locality pay 
adjustments for those employees. Mr. LaTourette's advocacy in 
the VA nurse pay issue, and particularly the introduction of 
H.R. 1216, encouraged the Committee to require an annual 
``national'' comparability pay increase for VA nurses. Also, 
the Committee bill rescinds the mandatory annual locality 
survey process governing VA nurse pay.

    Instead of a mandated survey process, the bill requires 
each VA health care facility to complete an annual report with 
information on turnover and vacancy rates in nurse staffing, 
including a comparison of these rates with those of the 
preceding three years. If a director of a VA health-care 
facility using objective criteria established by the Secretary 
determines that no current recruitment or retention problems 
exist, he or she may decide not to survey that year. This 
decision, however, must be explained to the Under Secretary and 
reported to Congress. The VA Under Secretary for Health, 
however, may also question and override the decision of the 
local director. Alternatively, if a director determines that 
there is a current or pending problem with recruitment and 
retention of VA nurses, the director may, after informing local 
and regional directors, activate the wage survey process. The 
VA Secretary will also report to Congress on these matters. The 
Committee believes that providing a guaranteed annual 
comparability pay increase and a means of providing competitive 
wages in tight local labor markets for nurses, as well as 
required oversight and reporting, will solve this longstanding 
problem raised by VA nurses.

    The reported bill requires VA network officials and VA 
medical center directors to consult with VA nurses in matters 
of allocation of resources, quality and other aspects of health 
policy. It requires VA directors to appoint registered nurses 
to local policy committees to ensure that the nursing 
perspective is considered in formulating recommendations 
affecting the delivery of health care in VA facilities.

                               Dental Pay

    Section 7439 of title 38, United States Code, ensures that 
Congress establish levels of total pay for physicians and 
dentists of the Veterans Health Administration that are 
reasonably comparable to levels of total pay for other federal 
and non-federal physicians and dentists. That policy is 
intended to ensure that VA recruits and retains a well-
qualified work force of physicians and dentists. To that end, 
the law requires the Secretary of Veterans Affairs to report to 
the President on a quadrennial basis on recruitment, retention, 
and compensation of VA physicians and dentists, and to 
recommend appropriate rates of special pay adjustments when 
appropriate or necessary. The President is to include such 
recommendations on rates of special pay changes in the budget.

    The last substantial changes to physician and dental 
special pay authorities were enacted in 1991 in the Department 
of Veterans Affairs Physician and Dentist Recruitment and 
Retention Act of 1991, Public Law 102-40. With that law, 
Congress modified provisions established in 1975 when it first 
provided for supplementing the pay of certain VA physicians and 
dentists with ``special pay'' and ``incentive pay'' to improve 
the hiring and retention of these clinicians. A rapid rise in 
pay during the 1980s created new problems for VA in recruiting 
and retaining certain physicians and dentists, particularly 
specialists in these fields, and led to adoption of the 1991 
Act.

    The 1991 act authorized VA to pay physicians and dentists 
supplementary amounts of pay (above base pay rates) in exchange 
for their agreements to work for specified terms of years. 
``Special'' pay could be paid (within specified pay ranges) for 
any of the following: full-time status, tenure, supervisory or 
executive responsibilities, exceptional qualifications, scarce 
specialty status, and geographic location. This special pay 
authority was intended to give the agency flexibility to 
respond to local labor market conditions. At the time, 
recruitment and retention of dentists did not pose as 
significant a problem for VA as physicians did and, 
accordingly, the Act provided lesser amounts of special pay in 
most categories for VA dentists.

    In its most recent (1999) quadrennial report to the 
President, VA reported that pay for physicians is comparable to 
physicians in other federal agencies and is reasonably 
comparable to that of physicians in the uniformed services. In 
light of the reported effectiveness of decentralized authority 
on pay decisions, the ability to offer competitive compensation 
packages, and ongoing restructuring of its professional work 
force, VA found no need to propose changes in VA physician pay. 
However, while concluding that ``the existing pay system is 
working for physicians,'' the report acknowledged a dentist pay 
problem.

          VHA is starting to experience difficulty in 
        recruiting and retaining dentists. Most of this 
        difficulty is focused on VHA's inability to offer 
        adequate financial incentives due to the limitations of 
        dental special pay. During the five-year period 
        starting in 1995, VHA experienced a decline in full-
        time dentists from 830 to about 677 while the annual 
        turnover rate has been running in excess of 11 percent. 
        There are also fewer ``highly qualified'' applicants to 
        fill vacant positions and most vacancies take several 
        months to fill. During this same period, income levels 
        for dentists in the private sector have increased to an 
        average of $130,000 per year, versus an average base 
        pay of $95,000 per year for VA dentists. In addition, 
        Congress recently passed legislation that provided 
        accession bonuses of $30,000 for newly appointed 
        military dentists while at the same time increasing 
        tenure pay to an amount up to $18,000 per annum.''

    In that report, VA recommended an increase in ``full-time 
pay'' for dentists (from $3,500 to $9,000) as ``a modest 
response to a developing problem,'' and also proposed to 
increase the pay ranges for dental executives to those of their 
physician counterparts. As the report noted, lack of a 
significant pay increase for dental executives ``has been a 
financial disincentive to dentists assuming positions of added 
responsibility, has hindered recruitment for these positions, 
and has been cited as the reason for the resignation of several 
dental service chiefs.''

    There are relatively limited data to document the extent of 
dentist recruitment and retention problems because many VA 
medical center directors apparently have not attempted to fill 
position vacancies. Nevertheless, in testifying before the 
Subcommittee on Health on April 12, 2000, VA acknowledged that 
almost seven in ten VA dentists will be eligible to retire by 
2003. With VA dental specialists' salaries averaging $104,959 
per year (as of September 30, 1999), including incentives, and 
with pay of VA dentists in general practice averaging $102,063, 
including incentives, the Committee concluded that VA dentist 
pay is significantly below that of the uniformed services and 
far below community levels. In capsule, VA's dentist pay 
problem was summarized at the April 12 hearing as follows:

          Mr. SIMPSON: ``. . . if 70 percent of the dentists in 
        the VA system are going to retire within the next three 
        years, or eligible for retirement within the next three 
        years, we're going to have serious problems in trying 
        to recruit dentists, even though you suggest that we 
        might not have that problem now. Over the next two 
        years, it is going to become a real problem, especially 
        when the rate of dental school graduates is decreasing, 
        and the environment in the private sector is so much 
        more advantageous for those people to enter into 
        private practice.

    Although VA, in its report to the President, recommended 
changes in two components of special pay, it is questionable 
whether those changes alone would adequately address either the 
recruitment or retention problems identified at the hearing. 
Neither, for example, addresses the concern that VA no longer 
attracts dentists with sufficient experience to work 
effectively with VA's unique patient population. The reported 
bill, accordingly, would provide special pay targeted to the 
first two years of employment of dentists who have successfully 
completed post-graduate hospital-based training. The reported 
bill would also provide greater amounts of special pay in 
recognition of the greater experience acquired over years of 
service. VA policy as set under current law limits a dentist in 
(what some might view as) the prime of his or her career to 
tenure pay of only $3,500 and a maximum after 19 years service 
of $4,000. The reported bill would significantly increase these 
levels, as well as other key components of dental special pay, 
to ensure that VA can meet its recruitment and retention goals.

                            Pharmacists' Pay

    Under section 7455 of title 38, United States Code, VA has 
authority to increase rates of basic pay--either nationally, 
locally or on another geographic basis--when deemed necessary 
for recruitment and retention of certain health care personnel. 
The grant of special rates is based on documented staffing 
problems, to include turnover, resignations based on pay, and 
inability to fill vacancies.

    With limited exceptions, the law limits such ``special 
salary rates'' to a maximum, expressed as twice the difference 
between the high and low basic pay levels for the particular 
grade. (That maximum is the equivalent of the 28th pay step for 
the particular grade.) It is noteworthy, however, that Congress 
has exempted two categories of health care personnel from that 
statutory ceiling: nurse anesthetists and physical therapists.

    The Subcommittee on Health, in a recent survey and site 
visits, has considered reports of severe difficulties in 
recruitment and retention of pharmacists. The Committee 
understands that significant competition to hire and retain 
pharmacists is hampering VA's efforts to staff its pharmacies 
adequately. Competition from retail pharmacies has already 
prompted VA to increase salaries. As of April 30, 2000, VA 
reported that 176 special salary authorizations for pharmacists 
had been granted covering 3,762 individuals. Accordingly, 86 
percent of the 4,384 pharmacists employed by VA as of that date 
were being paid special salary rates. In the first four months 
of this year alone, VA implemented 48 new or increased 
pharmacist special rate authorizations. The number of special 
rate authorizations at or within six percent of the step-28 
limit increased by 12 in just over one month--from 73 as of 
March 28, 2000 to 85 as of May 3, 2000.

    Anticipating that, absent relief, these trends will 
continue to plague VA's retention and recruitment of 
pharmacists, the Committee has included language in this bill 
that will add VA pharmacists to the two existing categories of 
VA personnel exempted from statutory pay ceilings.

                     Physician Assistant Consultant

    Physician assistants (PAs) have been employed in the VA 
health care system since 1970. Physician assistants are 
utilized in both inpatient and outpatient settings working in 
virtually all medical specialties. VA is the largest American 
employer of PAs with nearly 1,200 PAs employed throughout the 
system. PAs are being utilized extensively as physician 
extenders, and VA has acknowledged its need to employ still 
more PAs to staff the growing number of VA outpatient clinics.

    VHA is administered by an Under Secretary for Health who, 
with chief consultants leading various strategic healthcare 
groups, formulates VA health care policy. The VA Committee 
envisions that a PA consultant would participate in these 
policy discussions regarding personnel issues, recruitment and 
staff development, education, clinical practice issues, and 
health care strategic planning. Most recently, in December 
1999, the VA Committee Chairman and Ranking Member wrote the 
Deputy Under Secretary for Health urging VA to establish such a 
position. VA's response in February 2000 stated that physician 
assistants in VA are currently represented by the Chief 
Consultant of Primary and Ambulatory Care, who coordinates with 
a physician assistant field advisory group.

    Despite employing PAs for nearly 30 years, the VA does not 
employ a representative of the PA practice within VHA to advise 
the administration on the optimal utilization of PAs. Without 
this expertise, VHA has placed restrictions on the ability of 
VA physicians to effectively use PAs. The Committee has 
concluded that VHA is not fully utilizing a valuable resource 
for providing cost-effective health care, especially primary 
care as practiced in so many of the VA community-based 
outpatient clinics.

    The reported bill would create a PA consultant position 
held by a VHA physician assistant who would serve as a 
consultant to the Under Secretary for Health. The Committee 
expects the Under Secretary to use this authority to address 
many problems reported by VA PAs that would improve the 
delivery of health care.

            Temporary Appointments for Physician Assistants

    Under current law (section 7405(c)(2) of title 38, United 
States Code), VA has authority to provide temporary 
appointments of up to two years to individuals in certain 
professions (nursing, pharmacy, and respiratory, physical, and 
occupational therapy) who have successfully completed a full 
course of study and who are pending registration, licensure, or 
certification. Upon obtaining the required credentials, these 
professionals are converted to career appointments. The initial 
temporary ``graduate technician'' experience can be credited 
toward meeting grade level requirements for promotion within an 
occupation. The temporary appointment authority provides VA a 
means of recruiting health professionals while they are meeting 
the technical qualification standards.

    VA plans to double the number of PAs it employs within the 
next several years. Nevertheless, VA has far less flexibility 
in hiring physician assistants in training than it does nurses. 
The only basis for employment of a physician assistant who is 
waiting to take the certification examination is a one-year, 
nonrenewable appointment. A one-year appointment limits VA's 
efforts to recruit candidates. Moreover, since the physician 
assistant national certification examination is only given 
twice yearly, an individual often has only one opportunity to 
take the examination during the course of his or her one-year 
term appointment. Even highly qualified individuals are 
reluctant to accept a VA position under these circumstances.

    The reported bill would amend section 7405(c)(2) to enable 
VA to provide temporary graduate technician appointments to 
physician assistants who have completed approved training 
programs on the same basis as for VA nurses and other 
professionals. Graduate physician assistants would have up to 
two years to seek and obtain professional certification. This 
change should help VA's recruitment efforts for this important 
occupation.

                        Social Worker Licensure

    Public Law 102-86 requires a VA social worker to be 
licensed, certified, or registered in the State in which he or 
she works in a VA facility, within three years of initial 
appointment in this capacity by VA. Certain states such as 
California require challenging prerequisites to the licensure 
examination that routinely require more than three years for 
individuals to complete. Many states do not work reciprocally, 
and thus will not grant a license unless a social worker takes 
the state licensing examination. At present, VA social workers 
are the only VA health care practitioners who cannot use their 
state licenses to gain credentials in other states' VA medical 
centers. As a consequence, in the State of California, for 
example, 68 VA social workers face termination of employment or 
significant position downgrades because of failure to meet this 
three-year licensing requirement. VA social workers in 
Louisiana are concerned as well, and this problem may occur in 
additional states as yet unidentified. The Committee believes, 
notwithstanding the fact that VA first proposed the three-year 
licensure requirement, that VA should have additional 
flexibility in managing its social workers. Therefore, the 
reported bill would provide for the VA Secretary's waiver of 
the licensure requirement to enable social workers to complete 
their training preparatory to state licensure examinations.

          Extension of Voluntary Separation Incentive Payments

    The Veterans' Millennium Health Care and Benefits Act, 
Public Law 106-117, authorized the Secretary of Veterans 
Affairs to offer employees voluntary separation incentives 
``buyouts'' of up to $25,000 each, in order to restructure 
operations and functions identified in a plan designed to 
improve operating efficiency and quality of care. The bill 
continues to require a one-for-one exchange--in other words, VA 
must hire one employee for every employee offered a buyout. VA 
has sought replacement employees for 94 percent of the 
positions for which it offered buyouts under its current 
authority, which expires on December 31, 2000. VA made an 
informal request late in this Congress for a three-year 
extension of this authority.

    In considering VA's request, the Committee notes that VA 
stands alone among agencies in being required to make to the 
federal civil service retirement fund a contribution of 26 
percent of an employee's average highest three-year salary as a 
type of premium paid to the fund to cover its added costs 
incurred from these particular retirements. However, a 
Committee inquiry to the Office of Personnel Management yielded 
information leading the Committee to conclude that this rate 
represents an overpayment by VA. The OPM actuarial forecast 
that was used previously to derive the 26 percent payment was 
based on an ``early out'' analysis, not a buyout basis. The 
Committee observes and VA has documented that most VA employees 
who have participated in the voluntary separation program to 
date were either already eligible for voluntary retirement on 
the basis of length of service, or shortly would have been so 
eligible. Other agencies participating in the buyout program 
contribute at the 15 percent level for the ``high-three'' 
average salary years. Based on all the efforts of Congress in 
the 1998-99 period to restore VA medical care funding, and 
given that most of the buyouts to date emanated from the 
Veterans Health Administration, the Committee believes that 
there is no basis for requiring VA to make a higher payment 
than other agencies to the retirement fund.

    The reported bill would provide an extension of VA's buyout 
authority until December 31, 2002, a two-year extension rather 
than the three years requested informally by VA. The Committee 
will closely monitor VA's use of buyout authority to ensure 
that the qualitative base for delivering health care to 
veterans is not eroded by VA's use of this authority.

                        Military Service History

    The Committee recognizes and applauds the leadership of the 
Veterans Health Administration for initiating efforts to 
incorporate a military history into the scope of a 
comprehensive medical examination. Left unidentified and 
untreated, conditions which have their origins in military 
service not only portend severe consequences for a patient's 
health, but represent the very essence of what a veterans' 
health care system was intended to detect and rehabilitate. 
Ascertaining that a veteran was a prisoner of war, participated 
in combat, or was exposed to sustained subfreezing conditions, 
toxic substances, or environmental hazards or nuclear ionizing 
radiation, for example, are of critical diagnostic and 
treatment relevance. The Committee views the taking of a 
thorough history, to include a military medical history, to be 
so central to VA's mission that it has included this 
requirement in the reported bill. While VA has stated its 
support of this effort, progress in implementing it has been 
slow. This Committee has historically respected, and repeatedly 
declined invitations to direct, clinicians' practice of their 
professions. Yet there is both value and importance in 
recognizing and affirming the wisdom of ensuring that a 
military medical history be a mandatory component of every 
veteran's VA care. The reported bill would provide assurance 
that such a policy becomes a matter not only of administrative 
policy but also everyday clinical practice in VA.

                  Post-Traumatic Stress Disorder Study

    In 1984, the VA began a large-scale survey on the 
prevalence and incidence of post-traumatic stress disorder and 
other psychological problems among Vietnam veterans. That 
study, directed by Congress in Public Law 98-160, involved a 
representative sample of all Vietnam theater and era veterans 
who served between August 1964 and May 1975. The study found 
that at the time some 15 percent of male and 8.5 percent of 
female Vietnam theater veterans suffered from post-traumatic 
stress disorder (PTSD). Among those exposed to high levels of 
war zone stress the rates were dramatically higher--fourfold 
for men (a rate of almost 35.8 percent) and sevenfold for women 
(a rate of 17.5 percent)--than rates for those with low to 
moderate stress exposure. Some 31 percent of males and 27 
percent of female Vietnam theater veterans were found to have 
suffered from PTSD at some point after their military service.

    The VA study was recognized as a landmark investigation 
that provided definitive and unique information on the 
prevalence and etiology of PTSD. The study results led VA to 
develop specialized programs to treat those veterans suffering 
from this condition. Because of the high rates of PTSD and 
strong evidence of its persistence, experts have cited the 
importance of initiating a follow-up study involving those who 
participated in the original work.

    Recent studies have documented that PTSD is an important 
determinant of continued disability and need for care. PTSD has 
been shown to be strongly associated with a range of other 
mental health diagnoses, social and adjustment problems, 
including substance use disorders, and with high consumption of 
VA health care resources. Given its chronicity and association 
with long-term disability, the proportion of VA resources 
required to meet the needs of veterans with PTSD may increase 
over the coming years. To help VA prepare to meet such a need, 
it must have a better understanding of whether PTSD is a risk 
factor for later health problems which may yet emerge in this 
still comparatively young population. A follow-up study of the 
National Vietnam Veterans Readjustment Study would provide a 
valuable, cost-efficient mechanism to answer important 
questions such as:

    (1) LWhat is the impact of PTSD on subsequent medical 
morbidity? There is suspicion, for example, that PTSD could be 
a risk factor for cardiovascular disease. A follow-up of 
findings from the original study coupled with physical 
examinations and more extensive data collection on physical 
health problems would permit VA to collect valuable information 
that could help plan for veterans' future needs for medical 
services.
    (2) LWhat is the long-range course of PTSD? Follow-up 
interviews would allow an estimate of remission and relapse 
rates, and identification of risk factors that affect the 
course of the syndrome.
    (3) LWhat are the psychological and psychiatric 
consequences of PTSD?
    (4) LWhat subgroups of veterans are least likely to recover 
from PTSD and most likely to suffer effects of PTSD in other 
aspects of their health and functioning?
    (5) LWhat VA health care services do veterans with PTSD use 
and what impact has such use had on the course of the disorder?

    Scientists who have conceived such a follow-up study 
envision that it would involve re-interviewing the 
approximately 2,350 theater and era veterans who participated 
in the original study, and that a portion of the study 
population would undergo a standardized physical examination, 
psychiatric assessment, as well as a review of their medical 
and treatment records. It is anticipated that the cost of this 
study would be a fraction of the original, longer $10 million 
study. The Committee believes that VA, with the close 
involvement of its National Center for Post-Traumatic Stress 
Disorder, should design this project. Based on the earlier 
understanding that the study's subjects not be identifiable by 
the government, the study should be conducted by an independent 
contractor.

                       Enhanced Use Lease Program

    Congress, in the Veterans' Millennium Health Care Act, 
Public Law 106-117, eased limits in law on leasing underused VA 
property based on a finding that long-term leasing could be 
used more extensively to enhance health care delivery to 
veterans. In an April 5, 2000, hearing before the Subcommittee 
on Health on VA capital asset planning and management, the 
General Accounting Office reiterated its earlier-expressed view 
that VA could improve veterans' health care if it reduced the 
level of resources spent on underused, inefficient, or obsolete 
buildings and reinvested those savings in providing health care 
more efficiently in modern facilities at existing or new 
locations closer to where veterans live. A survey of VA 
facilities conducted by the Subcommittee earlier this year 
revealed that many facilities have unneeded buildings or land 
with potential for long-term leasing and commercial 
development. The years-long approval process was frequently 
cited as a significant disincentive for potential private 
sector lessees.

    The Committee has written to the Secretary of Veterans 
Affairs to encourage the Department to streamline its approval 
process. The Secretary has as yet failed to act on the 
Committee's initiative. Statutory requirements, however, to 
include a requirement for public hearing and Congressional 
notice also delay development and execution of such leases. The 
Committee's review of those statutory requirements suggests 
that, with the maturing and demonstrated success of this 
program, it is appropriate to consider relaxing safeguards 
which were imposed at its inception, but which now may no 
longer be necessary. Therefore, in this bill, the Committee has 
included language reducing the waiting period after VA notifies 
Congress of the intent to execute an enhanced use lease from 60 
``legislative days'' to 90 ``days.''

             Temporary Lodging at VA Health Care Facilities

    Fundamental changes in VA health care delivery over the 
past 20 years have dramatically increased the number of medical 
procedures being performed on an outpatient basis at VA medical 
centers. Because of the lengthy travel required to undergo 
needed tests and procedures, VA's patients occasionally need 
overnight lodging. For example, patients, who may live hours 
from a VA medical center, often must be at that center early in 
the morning to undergo a procedure and to be sent home later 
the same day. Transportation problems may require a patient, 
often accompanied by a family member, to arrive the night 
before a procedure. It is also common for a patient to require 
a series of outpatient visits over a short period of time, none 
necessitating a hospital admission. Thus, for example, a 
patient might have surgery on an outpatient basis and be 
required to return to the clinic for follow-up care the next 
day. Such situations can present great difficulties for often 
elderly patients with limited financial means who must travel 
long distances to obtain outpatient care, but who lack the 
means to procure local accommodations. While VA's establishment 
of hundreds of new community-based outpatient clinics has 
helped ameliorate the problem, many patients must still travel 
significant distances for diagnostic testing, specialty care, 
or surgery. In an effort to meet patients' needs, VA medical 
centers have for some years made efforts to assist patients and 
family members accompanying them in finding overnight 
accommodations. Similar efforts are made by many non-VA medical 
facilities that serve a geographically-dispersed patient 
population.

    The Committee is aware that VA has tried to meet the needs 
of veterans for accommodations in various ways. One alternative 
has been the establishment of facilities known as ``Fisher 
Houses,'' built with funds donated by the Zachary and Elizabeth 
M. Fisher Foundation. Four such facilities are now being 
operated in conjunction with VA medical centers. The Committee 
is also aware that many VA medical centers over the years have 
converted unused wards and other available space to establish 
temporary lodging facilities for use by patients. In fact, VA 
has encouraged medical centers to establish such facilities as 
an alternative to hospitalizing patients when outpatient 
treatment is more appropriate. In 1996, the Under Secretary for 
Health issued VHA Information Letter 10-96-028 to provide 
guidance on the requirements for operating these facilities, 
which the Under Secretary named as ``hoptels.'' The guidance 
provided that VA facilities could provide lodging without 
charge to outpatients and family members accompanying the 
veteran when medically necessary. The guidance also sanctioned 
the use of a revocable license for family members under which 
the individual would be required to pay VA a fee equal to the 
fair market value of the services being furnished.

    It is the Committee's understanding that most VA medical 
centers now offer patients in need help with some form of 
hoptel or lodging facility. Indeed, VA has informally advised 
the Committee that more than 115 facilities offer lodging of 
some kind on VA grounds, and that services are available in 
non-VA facilities at a number of other locations. It is not at 
all clear, however, that these facilities are operated in 
strict compliance with the guidance provided in the 1996 
Information Letter.

    The reported bill would provide clear authority for VA to 
provide such temporary overnight accommodations in Fisher 
Houses and other similar facilities located at or near a VA 
facility, when it is appropriate to do so. These accommodations 
would be available to veterans who have business at a VA 
medical facility and must travel a significant distance to 
receive Department services, and to other individuals 
accompanying veterans. The bill would also give VA clear 
authority to charge for overnight accommodations and apply the 
fees collected to help support these services. The bill 
contemplates that VA will promulgate regulations to address 
such matters such as the appropriate limitations on the use of 
the facilities and the length of time individuals may stay in 
the facilities.

               Pilot Program on Coordination of Benefits

    The VA health care system has undergone a profound 
transformation in recent years. Among the changes in VA health 
care is a marked improvement in veterans' access to care. In 
contrast to the hospital-centered system of years ago, many 
veterans no longer rely exclusively on VA hospitals for routine 
health care delivery, but increasingly have access to VA 
community-based clinics that provide primary care and sometimes 
additional services within reasonable distances of their homes. 
The proliferation of such clinics, however, has not necessarily 
eased access to hospital care when hospitalization is required.

    The remarkable success of a pilot program in east central 
Florida has sparked development of a model which could improve 
veterans' access to needed inpatient care. In appropriating 
funds for VA medical care for fiscal year 1998, Congress 
earmarked $5 million for this pilot program. (The earmarking 
followed Congressional rejection of a VA proposal to construct 
a new VA hospital in that area, and appropriation of funds 
instead to construct a community-based VA clinic.) The pilot 
program was designed to explore the cost effectiveness of 
meeting veterans' needs for hospital care in their own 
communities. It also provides an alternative to veterans 
traveling considerable distances to receive VA hospital care.

    In June 1997, an interim primary care clinic was opened in 
Palm Bay (Brevard County), FL, pending completion of the new 
Brevard County clinic in Viera, FL, which opened in July 1999. 
The east central Florida pilot program outlined above (ECF 
pilot) was initiated in June 1998. Under the pilot, veterans 
residing in Brevard County who were enrolled and referred for 
services in the Palm Bay clinic and who did not have specialty 
needs were given a choice of receiving any needed hospital care 
at VA expense at the Tampa or Palm Beach VA medical centers or 
in a private sector hospital. The pilot program operated from 
July 1, 1998 to June 30, 1999.

    An independent study of the pilot program, discussed at the 
Subcommittee's hearing on April 5, 2000, found that the 
veterans who participated in the ECF pilot were generally 
comparable in age and illness experience to Brevard County and 
non-Brevard County veterans who were not eligible for the pilot 
and were hospitalized at VA facilities in Tampa and Palm Beach. 
These patients were enrolled in a primary care clinic which 
indicated that they did not have conditions that required 
ongoing treatment by specialists. This eliminated many veterans 
with chronic disabilities and ensured that most of the care 
these veterans received was for acute conditions. Patient 
satisfaction among participants was generally high. Pilot 
participants who were hospitalized in contract facilities had a 
much shorter length of stay than that of veterans hospitalized 
in VA facilities. The study indicates that overall inpatient 
costs for the ECF pilot were about 28 percent less than the VA 
hospitalized groups. According to the report, ``[t]here is 
reason to believe that private sector contracting might be the 
most cost-effective approach to veteran care in areas where 
there is no VA hospital presence and many underutilized private 
sector hospitals.'' The report estimated that the cost of 
extending the pilot program for an additional five years would 
increase from $5 million to more than $35 million annually.

    While the ECF pilot has demonstrated success, further 
extending or expanding a contract program is not the only way 
to apply ``lessons learned'' from this experience. The 
Committee takes note, for example, that many veterans who 
obtain care from VA have other health plan coverage. The ECF 
pilot demonstrates that in areas of the country in which VA 
does not operate a hospital, a VA clinic can coordinate 
veterans' care. There is no precedent, however, for VA's 
coordinating payments among external plans and payers.

    The reported bill would authorize a pilot program involving 
coordination of hospital benefits which could operate in up to 
four locations. Under such a program, veterans with Medicare or 
other health plan coverage who rely on a nearby VA clinic for 
care but reside far from the nearest VA medical facility could 
make a choice when VA finds that they need hospital care. 
Veterans who are reluctant to travel hundreds of miles to a VA 
facility could elect to receive care at a community hospital as 
a Medicare or other health plan beneficiary. The VA clinic 
would still coordinate the care. To ensure that the patient 
does not incur additional out-of-pocket costs, the reported 
bill provides that VA would cover copayments required by an 
individual veteran's health plan. The experience of the Florida 
pilot program strongly suggests that veterans would welcome 
such an option. It would represent a step beyond simply 
contracting for care and instead provide for coordination of 
health care benefits. The anticipated result would be that 
veterans who now often must choose between two or more health 
plans would get better, VA-coordinated, and less costly care.

    VA's Deputy Under Secretary for Health cited the importance 
of developing mechanisms for coordinating benefits at the 
Subcommittee's May 17 hearing:

          Providing incentives in health care is a difficult 
        proposition. Having said that, I think we can make 
        significant progress in clarifying benefits for 
        military veterans and retirees. Many are eligible for 
        VA benefits and retiree benefits and many are eligible 
        for Medicare, and there is a significant amount of 
        shopping of benefits between the systems that results 
        in wasting of resources and it results in poor 
        coordination of care.

    The reported bill offers a limited model for testing 
coordination of hospital benefits in a manner that promises to 
improve access and veteran satisfaction without diminishing the 
quality of patient care.

    In providing for siting the program in up to four 
geographic areas, the intent is that such geographic areas 
would be relatively circumscribed and would not encompass the 
area of an entire ``VISN'' (one of the 22 veterans' integrated 
service networks). The Committee anticipates, for example, that 
the catchment area of the Brevard, FL outpatient clinic in east 
central Florida would be one of the areas designated for this 
program. The Committee intends further that VA, in considering 
potential areas for siting this program, avoid any situation 
where the establishment of such a program would have the likely 
effect of so diminishing the number of veterans receiving care 
at a VA medical center so as to reduce the patient base to the 
point at which that facility would have to consider eliminating 
services.

    The Committee also seeks to avoid a situation in which 
either program costs markedly exceed initial projections or the 
impact on a VA medical center is more profound than 
anticipated, with the result that continued expansion of the 
program would likely impair the efficient operation of that 
facility. In addition, the program is specifically designed to 
address a coordinated benefit. This means that VA must pre-
approve any care-intentionally limited to acute medical and 
general services-that program enrollees receive in community 
hospitals. This will allow VA to remain responsible for 
delivering the specialized care it delivers best, including its 
special emphasis programs, mental health programs, and 
inpatient long-term care services. In order to ensure that VA 
not erode its current services, the Committee has introduced a 
$50 million annual limitation on expenditures, including 
administrative expenses, that the program would allow. This 
limit does not apply to expenditures for emergency care which 
VA is now authorized to pay in limited circumstances under 
authority granted in Public Law 106-117. The Committee has also 
addressed concerns that the program serves only ``wealthier'' 
veterans. This proposal strongly recommends that VA sites 
enroll up to 15 percent of its participants who lack any 
insurance. VA will sponsor the full costs of these individuals' 
care in the community.

    The Committee envisions that VA will select sites that best 
meet the criteria outlined in the bill. Once sites are 
selected, VA directors should request proposals from providers 
within the designated project area and select providers based 
upon such factors as reimbursement rates, accreditation by 
appropriate agencies (such as the Joint Commission on 
Accreditation of Healthcare Organizations), other indicators of 
quality, the availability of services, and the provider's 
ability and willingness to ensure adequate exchange of patient 
information with VA to enhance veterans' continuity of care and 
provide for effective utilization review. VA may select as many 
local providers as meet these criteria to ensure adequate 
coverage for the pilot program area. In addition, the Committee 
intends that patients who volunteer to participate in this 
pilot program be limited to those who, in general, require 
short duration, general medical and surgical inpatient care as 
those terms are defined in title 38, United States Code. The 
Committee imposed this limitation out of concern that VA's 
specialized medical programs--unique national VA resources for 
the care of severely disabled veterans--not be eroded or 
otherwise affected negatively by this pilot program. To 
reiterate, it is the Committee's intent that this pilot program 
be directed to promote veterans' access to care and convenience 
in communities where a VA community based clinic operates 
distant from its host VA medical center, and in instances in 
which patients under its care need short periods of general 
hospital care that can be obtained from community hospitals.

                    Compensated Work Therapy Program

    The Compensated Work Therapy Program (CWT) is a therapeutic 
program authorized by section 1718 of title 38, United States 
Code, which VA employs in the rehabilitation of veteran-
patients. Veterans are paid for work performed on contracts 
with governmental and industrial entities. This work-based 
model helps veterans re-enter the work force while enabling 
them to increase self confidence and improve their ability to 
adjust appropriately to the work setting. VA data indicate that 
some 85 percent admitted to the program have substance abuse 
problems; 66 percent are homeless; and 44 percent have been 
diagnosed with major mental health disorders. The program has 
enjoyed success in assisting these often-challenging patients 
in making the transition from medical settings into the 
community by developing the capacity for work and increasing 
their self-worth.

    Nearly 15,000 veterans were treated in 101 different CWT 
programs throughout the country in fiscal year 1999. These 
veterans earned over $43.8 million for work performed on more 
than 3,600 contracts. The traditional CWT setting was in the 
nature of a sheltered workshop environment at the VA medical 
center. Work might range from simple collating tasks to 
fabrication of elaborate electromechanical subassemblies or 
machine shop operations using technologically sophisticated 
equipment. VA also employs a second model, in the nature of a 
``transitional work experience,'' in which participants work at 
industry sites (including VA medical centers and other Federal 
agency settings). The latter mode, broadly supported in the 
field of rehabilitation, has proven effective in helping 
veterans transition to full employment. The rate of placement 
into employment from CWT is 43 percent, with another seven 
percent of participating veterans entering various training 
programs.

    The Committee has become aware that as the ``transitional 
work experience'' component of the program has grown, more 
program participants are placed at risk of work-related injury 
for which they can receive no compensation. The risk of injury 
is real with transitional therapeutic work opportunities being 
provided at sites such as manufacturing settings and 
construction sites. In the event of work-related injury while 
participating in a CWT program, participants are not entitled 
to any worker compensation benefits. Veterans are not 
considered ``employees'' of either the United States, or of the 
private entity where they may work. Rather, their status is as 
patients, and the work they perform is undertaken in the 
context of medical rehabilitative treatment, prescribed by a VA 
physician and monitored by VA clinical staff.

    In the past, CWT jobs have been relatively safe, with few 
adverse consequences, and the Committee understands that in 
instances when CWT participants have incurred injuries in the 
course of such participation, VA has typically awarded the 
veteran benefits under section 1151 of title 38, United States 
Code. In that instance, VA has considered a work-related injury 
as if it were service-incurred. With amendments to section 1151 
in section 422 of Public Law 104-204 (adding a requirement that 
the injury or death have been due to negligence or fault, or 
have been unforeseeable), the VA Office of General Counsel has 
advised CWT program staff that in a routine case a veteran now 
has little actual recourse under section 1151. The situation 
raises concern about the viability of continuing the 
transitional work experience model. To ensure that these 
participants in the work therapy program are protected 
financially in the event of work-related injury, the reported 
bill would make them eligible for compensation benefits under 
section 1151 without regard to whether the injury was the 
result of negligence.

    In proposing to provide CWT participants with such 
financial protection in the event of injury, the Committee is 
proposing the same remedy Congress employed three years ago in 
an analogous situation. In that instance, it provided such 
protection to participants in VA's vocational rehabilitation 
program. Under that program, as under the CWT program, 
participants work in community settings where they are at risk 
for injury. In 1996, Congress provided that veterans injured 
while working in the vocational rehabilitation program could 
receive compensation benefits under section 1151 without regard 
to whether the injury was the result of negligence. The 
reported bill would provide the same coverage to CWT program 
participants.

                           Oversight Findings

    No oversight findings have been submitted to the committee 
by the Committee on Government Reform.

                          Administration Views

    At the Subcommittee on Health Hearing on VA Capital Asset 
Planning, April 5, 2000, Frances Murphy, M.D., Acting Deputy 
Under Secretary for Policy and Management, gave the following 
written testimony concerning changes in VA health care:

        VA was a hospital-based, disease-oriented, impersonal 
        organization of medical centers. The ``New VA'' is an 
        integrated health system that provides a continuum of 
        accessible, coordinated, patient-centered care. We have 
        seen demonstrable improvements in our capacity to 
        achieve consistently reliable, accessible, satisfying, 
        high-quality care. We continue to face challenges of 
        reducing medical errors in our health care; of meeting 
        the needs of an aging population; of incorporating the 
        rapid growth of scientific knowledge into daily 
        practice; of incorporating expensive new medical and 
        information technologies; and of realigning our 
        infrastructure to more effectively support current 
        health care needs.

           *         *         *         *         *

          The transformation that is occurring in how health 
        care is provided has outpaced our ability to make 
        infrastructure changes. VA's infrastructure was built 
        largely at a time when bed based care was the standard 
        mode of providing health care. As described above, over 
        the past 5 years VA has significantly shifted care from 
        inpatient to ambulatory care delivery. We have also 
        significantly moved care closer to the patient by 
        establishing Community Based Clinics and home care. We 
        currently face the challenge of realigning our 
        infrastructure to optimally support how health care is 
        being delivered today and will be delivered in the 
        future.

    At the April 12, 2000, Subcommittee on Health hearing on 
Status of Recruitment, Retention, and Compensation of the VA 
Health Care Work Force, Kenneth J. Clark, Chief Network 
Officer, VHA, submitted testimony on VA professional personnel 
to include the following:

        At the present time, health care staffing in the VA 
        health care system is relatively stable and we are not 
        currently experiencing any widespread or critical 
        staffing shortage for our health care occupations.

          However, there are some specific problem areas--
        individual locations that are experiencing some 
        difficulties for some occupations and non-VA pay trends 
        for dentists and pharmacists are beginning to create 
        difficulties.

           *         *         *         *         *

          We believe that the Department needs the flexibility 
        to consider salary information beyond and in addition 
        to the BLS results if we are to retain the ability to 
        adjust pay rates when justified and necessary to 
        maintain a competitive stance with the community, 
        whether it be to set rates for remote locations, for 
        specialized groups of nurses, or for pay comparability, 
        should the BLS survey data not be adequate to VA's 
        staffing needs. Thus, VA favors retention of its 
        current authority to conduct local surveys where BLS 
        data are inadequate, not yet validated, for too large 
        an area, or offer insufficient detail on specialties.

           *         *         *         *         *

          When the amounts of special pay for dentists were 
        established in P.L. 102-40, the Department was not 
        experiencing significant turnover or retention 
        difficulties for dentists. For that reason, special pay 
        increases at the level of those for physicians were not 
        put in place.

          Although VA does not currently have a widespread 
        recruitment and retention problem for dentists, there 
        are some areas where problems exist. Almost 70 percent 
        of VA full-time dentists will be eligible for regular 
        or early retirement in the next three years. Therefore, 
        we are concerned that as VA dentists retire, it will be 
        difficult to attract the best qualified dentists to 
        work in the VA, given the gap that exists between VA 
        and non-VA compensation packages. VA is currently 
        reviewing legislative options that would mitigate these 
        potential problems.

           *         *         *         *         *

          One occupation for which VA is currently experiencing 
        increased recruitment and retention difficulties is 
        pharmacist. Currently, VA pharmacists are not leaving 
        their jobs to pursue private sector opportunities (most 
        losses are due to retirements); rather VA is 
        experiencing some increased difficulty recruiting new 
        pharmacists.

          There is a significant increase in the number of 
        special salary rate authorizations for pharmacists. The 
        Department is receiving requests for new or increased 
        special rates on almost a daily basis. VA will continue 
        to monitor the ceiling on special rates contained in 38 
        U.S.C. 7455(c) to ensure that restrictions in salary 
        adjustments do not become problematic.

               Congressional Budget Office Cost Estimate

    At the time of filing this report, the Congressional Budget 
Office had not provided the Committee with a cost estimate.

                  Applicability to Legislative Branch

    The reported bill would not be applicable to the 
legislative branch under the Congressional Accountability Act, 
Public Law 104-1, because the bill would only affect certain 
Department of Veterans Affairs programs and benefits 
recipients.

                     Statement of Federal Mandates

    The reported bill would not establish a federal mandate 
under the Unfunded Mandates Reform Act, Public Law 104-4.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, the reported bill is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
of the United States.''

         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 italics, existing law in which no change 
is proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE



           *       *       *       *       *       *       *
                       PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


             SUBCHAPTER VI--GENERAL COMPENSATION PROVISIONS

Sec. 1151. Benefits for persons disabled by treatment or vocational 
                    rehabilitation

  (a) Compensation under this chapter and dependency and 
indemnity compensation under chapter 13 of this title shall be 
awarded for a qualifying additional disability or a qualifying 
death of a veteran in the same manner as if such additional 
disability or death were service-connected. For purposes of 
this section, a disability or death is a qualifying additional 
disability or qualifying death if the disability or death was 
not the result of the veteran's willful misconduct and--
          (1) * * *
          (2) the disability or death was proximately caused 
        (A) by the provision of training and rehabilitation 
        services by the Secretary (including by a service-
        provider used by the Secretary for such purpose under 
        section 3115 of this title) as part of an approved 
        rehabilitation program under chapter 31 of this title, 
        or (B) by participation in a program (known as a 
        ``compensated work therapy program'') under section 
        1718 of this title.

           *       *       *       *       *       *       *


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

                          subchapter i--general

Sec.
1701.    Definitions.
     * * * * * * *
1708.    Temporary lodging.
     * * * * * * *

   subchapter iii--miscellaneous provisions relating to hospital and 
           nursing home care and medical treatment of veterans

1721.    Power to make rules and regulations.
     * * * * * * *
1725A.   Coordination of hospital benefits: pilot program.

           *       *       *       *       *       *       *


                        SUBCHAPTER I--GENERAL

           *       *       *       *       *       *       *


Sec. 1708. Temporary lodging

  (a) The Secretary may furnish persons described in subsection 
(b) with temporary lodging in a Fisher house or other 
appropriate facility in connection with the examination, 
treatment, or care of a veteran under this chapter or, as 
provided for under subsection (e)(5), in connection with 
benefits administered under this title.
  (b) Person to whom the Secretary may provide lodging under 
subsection (a) are the following:
          (1) A veteran who must travel a significant distance 
        to receive care or services under this title.
          (2) A member of the family of a veteran and others 
        who accompany a veteran and provide the equivalent of 
        familial support for such veteran.
  (c) In this section, the term ``Fisher house'' means a 
housing facility that--
          (1) is located at, or in proximity to, a Department 
        medical facility;
          (2) is available for residential use on a temporary 
        basis by patients of that facility and others described 
        in subsection (b)(2); and
          (3) is constructed by, and donated to the Secretary 
        by, the Zachary and Elizabeth M. Fisher Armed Services 
        Foundation.
  (d) The Secretary may establish charges for providing lodging 
under this section. The proceeds from such charges shall be 
credited to the medical care account and shall be available 
until expended for the purposes of providing such lodging.
  (e) The Secretary shall prescribe regulations to carry out 
this section. Such regulations shall include provisions--
          (1) limiting the duration of such lodging;
          (2) establishing standards and criteria under which 
        medical facilities may set charges for such lodging;
          (3) establishing criteria for persons considered to 
        be accompanying a veteran;
          (4) establishing criteria for the use of such 
        premises; and
          (5) any other limitations, conditions, and priorities 
        that the Secretary considers appropriate with respect 
        to temporary lodging under this section.

 SUBCHAPTER II--HOSPITAL, NURSING HOME OR DOMICILIARY CARE AND MEDICAL 
                               TREATMENT

Sec. 1710. Eligibility for hospital, nursing home, and domiciliary care

  (a)(1) * * *

           *       *       *       *       *       *       *

  (4) The requirement in paragraphs (1) and (2) that the 
Secretary furnish hospital care and medical services, and the 
[requirement in] requirements in section 1710A(a) and section 
1710B of this title that the Secretary provide a program of 
extended care services, shall be effective in any fiscal year 
only to the extent and in the amount provided in advance in 
appropriations Acts for such purposes.

           *       *       *       *       *       *       *


Sec. 1710A. Required nursing home care

  (a) The Secretary (subject to section 1710(a)(4) of this 
title) shall provide nursing home care which the Secretary 
determines is needed (1) to any veteran in need of such care 
for a service-connected disability, and (2) to any veteran who 
is in need of such care and who has a service-connected 
disability rated at 70 percent or more.

           *       *       *       *       *       *       *


   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
         NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

           *       *       *       *       *       *       *


Sec. 1725A. Coordination of hospital benefits: pilot program

  (a) The Secretary may carry out a pilot program in not more 
than four geographic areas of the United States to improve 
access to, and coordination of, inpatient care of eligible 
veterans. Under the pilot program, the Secretary, subject to 
subsection (b), may pay certain costs described in subsection 
(b) for which an eligible veteran would otherwise be personally 
liable. The authority to carry out the pilot program shall 
expire on September 30, 2005.
  (b) In carrying out the program described in subsection (a), 
the Secretary may pay the costs authorized under this section 
for hospital care and medical services furnished on an 
inpatient basis in a non-Department hospital to an eligible 
veteran participating in the program. Such payment may cover 
the costs for applicable plan deductibles and coinsurance and 
the reasonable costs of such inpatient care and medical 
services not covered by any applicable health-care plan of the 
veteran, but only to the extent such care and services are of 
the kind authorized under this chapter. The Secretary shall 
limit the care and services for which payment may be made under 
the program to general medical and surgical services and shall 
require that such services may be provided only upon 
preauthorization by the Secretary.
  (c)(1) A veteran described in paragraph (1) or (2) of section 
1710(a) of this title is eligible to participate in the pilot 
program if the veteran--
          (A) is enrolled to receive medical services from an 
        outpatient clinic operated by the Secretary which is 
        (i) within reasonable proximity to the principal 
        residence of the veteran, and (ii) located within the 
        geographic area in which the Secretary is carrying out 
        the program described in subsection (a);
          (B) has received care under this chapter within the 
        24-month period preceding the veteran's application for 
        enrollment in the pilot program;
          (C) as determined by the Secretary before the 
        hospitalization of the veteran (i) requires such 
        hospital care and services for a non-service-connected 
        condition, and (ii) could not receive such services 
        from a clinic operated by the Secretary; and
          (D) elects to receive such care under a health-care 
        plan (other than under this title) under which the 
        veteran is entitled to receive such care.
  (2) Nothing in this section shall be construed to reduce the 
authority of the Secretary to contract with non-Department 
facilities for care of a service-connected disability of a 
veteran.
  (3) Notwithstanding subparagraph (D) of paragraph (1), the 
Secretary shall ensure that not less than 15 percent of the 
veterans participating in the program are veterans who do not 
have a health-care plan.
  (d) As part of the program under this section, the Secretary 
shall, through provision of case-management, coordinate the 
care being furnished directly by the Secretary and care 
furnished under the program in non-Department hospitals to 
veterans participating in the program.
  (e)(1) In designating geographic areas in which to establish 
the program under subsection (a), the Secretary shall ensure 
that--
          (A) the areas designated are geographically 
        dispersed;
          (B) at least 70 percent of the veterans who reside in 
        a designated area reside at least two hours driving 
        distance from the closest medical center operated by 
        the Secretary which provides medical and surgical 
        hospital care; and
          (C) the establishment of the program in any such area 
        would not result in jeopardizing the critical mass of 
        patients needed to maintain a Department medical center 
        that serves that area.
  (2) Notwithstanding paragraph (1)(B), the Secretary may 
designate for participation in the program at least one area 
which is in proximity to a Department medical center which, as 
a result of a change in mission of that center, does not 
provide hospital care.
  (f)(1) Not later than September 30, 2002, the Secretary shall 
submit to the Committees on Veterans' Affairs of the Senate and 
House of Representatives a report on the experience in 
implementing the pilot program under subsection (a).
  (2) Not later than September 30, 2004, the Secretary shall 
submit to those committees a report on the experience in 
operating the pilot program during the first two full fiscal 
years during which the pilot program is conducted. That report 
shall include--
          (A) a comparison of the costs incurred by the 
        Secretary under the program and the cost experience for 
        the calendar year preceding establishment of the 
        program at each site at which the program is operated;
          (B) an assessment of the satisfaction of the 
        participants in the program; and
          (C) an analysis of the effect of the program on 
        access and quality of care for veterans.
  (g) The total amount expended for the pilot program in any 
fiscal year (including amounts for administrative costs) may 
not exceed $50,000,000.
  (h) For purposes of this section, the term ``health-care 
plan'' has the meaning given that term in section 1725(f)(3) of 
this title.

           *       *       *       *       *       *       *


             PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


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

                       subchapter i--organization

Sec.
7301.    Functions of Veterans Health Administration: in general.
     * * * * * * *

           subchapter ii--general authority and administration

7311.    Quality assurance.
     * * * * * * *
7323.    Required consultations with nurses.

           *       *       *       *       *       *       *


                      SUBCHAPTER I--ORGANIZATION

           *       *       *       *       *       *       *


Sec. 7306. Office of the Under Secretary for Health

  (a) * * *

           *       *       *       *       *       *       *

  (f) In organizing the Office and appointing persons to 
positions in the Office, the Under Secretary shall ensure 
that--
          (1) the Office is staffed so as to provide the Under 
        Secretary, through a designated clinician in the 
        appropriate discipline in each instance, with expertise 
        and direct policy guidance on--
                  (A) * * *
                  (B) the programs established under section 
                1712A of this title; [and]
          (2) with respect to the programs established under 
        section 1712A of this title, a clinician with 
        appropriate expertise in those programs is responsible 
        to the Under Secretary for the management of those 
        programs[.]; and
          (3) a physician assistant with appropriate experience 
        (who may have a permanent duty station at a Department 
        medical care facility in reasonable proximity to 
        Washington, DC) advises the Under Secretary on all 
        matters relating to the utilization and employment of 
        physician assistants in the Administration.

           *       *       *       *       *       *       *


          SUBCHAPTER II--GENERAL AUTHORITY AND ADMINISTRATION

Sec. 7321. Committee on Care of Severely Chronically Mentally Ill 
                    Veterans

  (a) * * *

           *       *       *       *       *       *       *

  (d)(1) * * *
  (2) Not later than February 1, 1998, and February 1 of each 
of the [three] six following years, the Secretary shall submit 
to the Committees on Veterans' Affairs of the Senate and House 
of Representatives a report containing information updating the 
reports submitted under this subsection before the submission 
of such report.

           *       *       *       *       *       *       *


Sec. 7323. Required consultations with nurses

  The Under Secretary for Health shall ensure that--
          (1) the director of a geographic service area, in 
        formulating policy relating to the provision of patient 
        care, shall consult regularly with a senior nurse 
        executive or senior nurse executives; and
          (2) the director of a medical center shall, to the 
        extent feasible, include a registered nurse as a member 
        of any committee used at that medical center to provide 
        recommendations or decisions on medical center 
        operations or policy affecting clinical services, 
        clinical outcomes, budget, or resources.

           *       *       *       *       *       *       *


                 SUBCHAPTER IV--RESEARCH CORPORATIONS

           *       *       *       *       *       *       *


Sec. 7368. Expiration of authority

  No corporation may be established under this subchapter after 
December 31, [2000] 2005.

           *       *       *       *       *       *       *


              CHAPTER 74--VETERANS HEALTH ADMINISTRATION--
                               PERSONNEL

           *       *       *       *       *       *       *


                       SUBCHAPTER I--APPOINTMENTS

           *       *       *       *       *       *       *


Sec. 7402. Qualifications of appointees

  (a) * * *
  (b)(1) * * *

           *       *       *       *       *       *       *

  (9) Social Worker.--To be eligible to be appointed to a 
social worker position, [a person must hold a master's degree 
in social work from a college or university approved by the 
Secretary and satisfy the social worker licensure, 
certification, or registration requirements, if any, of the 
State in which the social worker is to be employed, except that 
the Secretary may waive the licensure, certification, or 
registration requirement of this paragraph for an individual 
social worker for a reasonable period, not to exceed 3 years, 
in order for the social worker to take any actions necessary to 
satisfy the licensure, certification, or registration 
requirements of such State.] a person must--
          (A) hold a master's degree in social work from a 
        college or university approved by the Secretary; and
          (B) be licensed or certified to independently 
        practice social work in a State, except that the 
        Secretary may waive the requirement of licensure or 
        certification for an individual social worker for a 
        reasonable period of time recommended by the Under 
        Secretary for Health.

           *       *       *       *       *       *       *


Sec. 7405. Temporary full-time appointments, part-time appointments, 
                    and without-compensation appointments

  (a) * * *

           *       *       *       *       *       *       *

  (c)(1) * * *
  [(2) Temporary full-time appointments of persons who have 
successfully completed a full course of nursing in a recognized 
school of nursing, approved by the Secretary, or who have 
successfully completed a full course of training for any 
category of personnel described in paragraph (3) of section 
7401 of this title in a recognized education or training 
institution approved by the Secretary, and who are pending 
registration or licensure in a State, or certification by a 
national board recognized by the Secretary, shall not exceed 
two years.]
  (2) A temporary full-time appointment may not be made for a 
period in excess of two years in the case of a person who--
          (A) has successfully completed--
                  (i) a full course of nursing in a recognized 
                school of nursing, approved by the Secretary; 
                or
                  (ii) a full course of training for any 
                category of personnel described in paragraph 
                (3) of section 7401 of this title, or as a 
                physician assistant, in a recognized education 
                or training institution approved by the 
                Secretary; and
          (B) is pending registration or licensure in a State 
        or certification by a national board recognized by the 
        Secretary.
  (3)(A) Temporary full-time appointments of persons in 
positions referred to in subsection (a)(1)(D) shall not exceed 
three years.
  (B) Temporary full-time appointments under this paragraph may 
be renewed for one or more additional periods not in excess of 
three years each.
  [(3)] (4) Temporary full-time appointments of other personnel 
may not be for a period in excess of one year except as 
authorized in subsection (f).

           *       *       *       *       *       *       *


        SUBCHAPTER III--SPECIAL PAY FOR PHYSICIANS AND DENTISTS

           *       *       *       *       *       *       *


Sec. 7435. Special pay: full-time dentists

  (a) * * *
  (b) The special pay factors, and the annual rates, applicable 
to full-time dentists are as follows:
          (1) For full-time status, [$3,500] $9,000.
          (2)(A) For length of service as a dentist within the 
        Veterans Health Administration--

------------------------------------------------------------------------
                                                            Rate
                [Length of Service                 ---------------------
                                                     Minimum    Maximum
------------------------------------------------------------------------
  2 years but less than 4 years...................     $1,000     $2,000
  4 years but less than 8 years...................      2,000      3,000
  8 years but less than 12 years..................      3,000      3,500
  12 years or more................................      3,000     4,000]
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                          Rate
               Length of Service               -------------------------
                                                  Minimum      Maximum
------------------------------------------------------------------------
1 year but less than 2 years..................       $1,000       $2,000
2 years but less than 4 years.................        4,000        5,000
4 years but less than 8 years.................        5,000        8,000
8 years but less than 12 years................        8,000       12,000
12 years but less than 20 years...............       12,000       15,000
20 years or more..............................       15,000      18,000.
------------------------------------------------------------------------

          (3)(A) For service in a dental specialty with respect 
        to which there are extraordinary difficulties (on a 
        nationwide basis or on the basis of the needs of a 
        specific medical facility) in the recruitment or 
        retention of qualified dentists, an annual rate of not 
        more than [$20,000] $30,000.

           *       *       *       *       *       *       *

          (4)(A) For service in any of the following executive 
        positions, an annual rate not to exceed the rate 
        applicable to that position as follows:

------------------------------------------------------------------------
                                                            Rate
                     [Position                     ---------------------
                                                     Minimum    Maximum
------------------------------------------------------------------------
  Service Director................................     $1,000     $9,000
  Deputy Service Director.........................      1,000      8,000
  Chief of Staff or in an Executive Grade.........      1,000      8,000
  Director Grade..................................          0      8,000
  Service Chief (or in a comparable position as         1,000     5,000]
   determined by the Secretary)...................
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                          Rate
                   Position                    -------------------------
                                                  Minimum      Maximum
------------------------------------------------------------------------
Chief of Staff or in an Executive Grade.......      $14,500      $25,000
Director Grade................................            0       25,000
Service Chief (or in a comparable position as         4,500      15,000.
 determined by the Secretary).................
------------------------------------------------------------------------

          (B) For service in any of the following executive 
        positions, the annual rate applicable to that position 
        as follows:

      [Position                                                     Rate
    Assistant Under Secretary for Health (or in a comparable 
      position as determined by the Secretary)................   $10,000
    Deputy Assistant Under Secretary for Health...............   10,000]

------------------------------------------------------------------------
                          Position                               Rate
------------------------------------------------------------------------
Deputy Service Director....................................      $20,000
Service Director...........................................       25,000
Deputy Assistant Under Secretary for Health................       27,500
Assistant Under Secretary for Health (or in a comparable         30,000.
 position as determined by the Secretary)..................
------------------------------------------------------------------------


                                                             

           *       *       *       *       *       *       *
          (6) For service in a specific geographic location 
        with respect to which there are extraordinary 
        difficulties in the recruitment or retention of 
        qualified dentists in a specific category of dentists, 
        an annual rate not more than [$5,000] $12,000.

           *       *       *       *       *       *       *

          (8) For a dentist who has successfully completed a 
        post-graduate year of hospital-based training in a 
        program accredited by the American Dental Association, 
        an annual rate of $2,000 for each of the first two 
        years of service after successful completion of that 
        training.

Sec. 7438. Special pay: coordination with other benefits laws

  (a) * * *
  (b)(1) * * *

           *       *       *       *       *       *       *

  (5) Notwithstanding paragraphs (1) and (2), a dentist 
employed as a dentist in the Veterans Health Administration on 
the effective date of section 102 of the Department of Veterans 
Affairs Health Care Personnel Act of 2000 shall be entitled to 
have special pay paid to the dentist under section 
7435(b)(2)(A) of this title (referred to as ``tenure pay'') 
considered basic pay for the purposes of chapter 83 or 84, as 
appropriate, of title 5 only as follows:
          (A) In an amount equal to the amount that would have 
        been so considered under such section on the day before 
        such effective date based on the rates of special pay 
        the dentist was entitled to receive under that section 
        on the day before such effective date.
          (B) With respect to any amount of special pay 
        received under that section in excess of the amount 
        such dentist was entitled to receive under such section 
        on the day before such effective date, in an amount 
        equal to 25 percent of such excess amount for each two 
        years that the physician or dentist has completed as a 
        physician or dentist in the Veterans Health 
        Administration after such effective date.
  [(5)] (6) For purposes of this subsection:
          (A) * * *

           *       *       *       *       *       *       *


     SUBCHAPTER IV--PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL

Sec. 7451. Nurses and other health-care personnel: competitive pay

  (a) * * *

           *       *       *       *       *       *       *

  (d)(1) [The rates] Subject to subsection (e), the rates of 
basic pay for each grade in a covered position shall be 
adjusted periodically in accordance with this subsection in 
order to achieve the purposes of this section. Such adjustments 
shall be made--
          (A) whenever there is an adjustment under section 
        5305 of title 5 in the rates of pay under the General 
        Schedule, with the adjustment under this subsection to 
        have the same effective date and to be by the same 
        percentage as the adjustment in the rates of basic pay 
        under the General Schedule; and
  (2) An adjustment in rates of basic pay under this subsection 
for a grade shall be carried out by adjusting the amount of 
minimum rate of basic pay for that grade in accordance with 
paragraph (3) and then adjusting the other rates for that grade 
to conform to the requirements of subsection (c). [Such] Except 
as provided in paragraph (1)(A), such an adjustment in the 
minimum rate of basic pay for a grade shall be made by the 
director of a Department health-care facility so as to achieve 
consistency with the beginning rate of compensation for 
corresponding health-care professionals in the Bureau of Labor 
Statistics (BLS) labor-market area of that facility.
  (3)(A) * * *
  (B) In the case of a Department health-care facility located 
in an area for which the Bureau of Labor Statistic does not 
have current information on beginning rates of compensation for 
corresponding health-care professional for the labor-market 
area of that facility for any covered position, the director of 
that facility shall conduct a survey in accordance with this 
subparagraph and shall adjust the amount of the minimum rate of 
basic pay for grades in that covered position at that facility 
based upon that survey. To the extent practicable, the director 
shall use third-party industry wage surveys to meet the 
requirements of the preceding sentence. Any such survey shall 
be conducted in accordance with regulations prescribed by the 
Secretary. Those regulations shall be developed in consultation 
with the Secretary of Labor in order to ensure that the 
director of a facility collects information that is valid and 
reliable and is consistent with standards of the Bureau. The 
survey should be conducted using methodology comparable to that 
used by the Bureau in making industry-wage surveys except to 
the extent determined infeasible by the Secretary. To the 
extent practicable, all surveys conducted pursuant to this 
subparagraph or subparagraph (A) shall include the collection 
of salary midpoints, actual salaries, lowest and highest 
salaries, average salaries, bonuses, incentive pays, 
differential pays, actual beginning rates of pay and such other 
information needed to meet the purpose of this section. Upon 
conducting a survey under this subparagraph the director 
concerned shall determine, not later than 30 days after the 
date on which the collection of information through the survey 
is completed or published, whether an adjustment in rates of 
pay for employees at that facility for any covered position is 
necessary in order to meet the purposes of this section. If the 
director determines that such an adjustment is necessary, the 
adjustment, based upon the information determined in the 
survey, shall take effect on the first day of the first pay 
period beginning after that determination.
  (C)(i) * * *

           *       *       *       *       *       *       *

  [(iii) The authority of the director to use such additional 
data under this subparagraph with respect to certified 
registered nurse anesthetists expires on January 1, 1998.]

           *       *       *       *       *       *       *

  [(e) Adjustments in rates of basic pay under subsection (d) 
may increase or reduce the rates of basic pay applicable to any 
grade of a covered position. In the case of such an adjustment 
that reduces the rates of pay for a grade, an employee serving 
at a Department health-care facility on the day before the 
effective date of that adjustment in a position affected by the 
adjustment may not (by reason of that adjustment) incur a 
reduction in the rate of basic pay applicable to that employee 
so long as the employee continues to serve in that covered 
position at that facility. If such an employee is subsequently 
promoted to a higher grade, or advanced to a higher step within 
the employee's grade, for which the rate of pay as so adjusted 
is lower than the employee's rate of basic pay on the day 
before the effective date of the promotion, the employee shall 
continue to be paid at a rate of basic pay not less than the 
rate of basic pay applicable to the employee before the 
promotion so long as the employee continues to serve in that 
covered position at that facility.]
  (e)(1) An adjustment in a rate of basic pay under subsection 
(d) may not reduce the rate of basic pay applicable to any 
grade of a covered position.
  (2) The director of a Department health-care facility, in 
determining whether to carry out a wage survey under subsection 
(d)(3) with respect to rates of basic pay for a grade of a 
covered position, may not consider as a factor in such 
determination the absence of a current recruitment or retention 
problem for personnel in that grade of that position. The 
director shall make such a determination based upon whether, in 
accordance with criteria established by the Secretary, there is 
a significant pay-related staffing problem at that facility in 
any grade for a position. If the director determines that there 
is such a problem, or that such a problem is likely to exist in 
the near future, the Director shall provide for a wage survey 
in accordance with paragraph (3) of subsection (d).
  (3) The Under Secretary for Health may, to the extent 
necessary to carry out the purposes of subsection (d), modify 
any determination made by the director of a Department health-
care facility with respect to adjusting the rates of basic pay 
applicable to covered positions. Upon such action by the Under 
Secretary, any adjustment shall take effect on the first day of 
the first pay period beginning after such action. The Secretary 
shall ensure that the Under Secretary establishes a mechanism 
for the exercise of the authority in the preceding sentence.
  (4) Each director of a Department health-care facility shall 
provide to the Secretary, not later than July 31 each year, a 
report on staffing for covered positions at that facility. The 
report shall include the following:
          (A) Information on turnover rates and vacancy rates 
        for each grade in a covered position, including a 
        comparison of those rates with the rates for the 
        preceding three years.
          (B) The director's findings concerning the review and 
        evaluation of the facility's staffing situation, 
        including whether there is, or is likely to be, in 
        accordance with criteria established by the Secretary, 
        a significant pay-related staffing problem at that 
        facility for any grade of a covered position and, if 
        so, whether a wage survey was conducted, or will be 
        conducted with respect to that grade.
          (C) In any case in which the director conducts such a 
        wage survey during the period covered by the report, 
        information describing the survey and any actions taken 
        or not taken based on the survey, and the reasons for 
        taking (or not taking) such actions.
          (D) In any case in which the director, after finding 
        that there is, or is likely to be, in accordance with 
        criteria established by the Secretary, a significant 
        pay-related staffing problem at that facility for any 
        grade of a covered position, determines not to conduct 
        a wage survey with respect to that position, a 
        statement of the reasons why the director did not 
        conduct such a survey.
  (5) Not later than September 30 of each year, the Secretary 
shall submit to the Committees on Veterans' Affairs of the 
Senate and House of Representatives a report on staffing for 
covered positions at Department healthcare facilities. Each 
such report shall include the following:
          (A) A summary and analysis of the information 
        contained in the most recent reports submitted by 
        facility directors under paragraph (4).
          (B) The information for each such facility specified 
        in paragraph (4).
  (f) Not later than [February 1 of 1991, 1992, and 1993] March 
1 of each year, the Secretary shall submit to the Committees on 
Veterans' Affairs of the Senate and House of Representatives a 
report regarding any pay adjustments under the authority of 
subsection [(d)(1)(A)] (d) effective during the 12 months 
preceding the submission of the report. Each such report shall 
set forth, by health-care facility, the percentage of such 
increases and, in any case in which no increase was made, the 
basis for not providing an increase.
  [(g) Not later than December 1 of 1991, 1992, and 1993, the 
Secretary shall submit to the Committees on Veterans' Affairs 
of the Senate and House of Representatives a report regarding 
the exercise of the authorities provided in this section for 
the preceding fiscal year. Each such report shall include the 
following:
          [(1) A review of the use of the authorities provided 
        in this section (including the Secretary's and Under 
        Secretary for Health's actions, findings, 
        recommendations, and other activities under this 
        section) during the preceding fiscal year, including an 
        assessment of the effects of the exercise of such 
        authorities on the ability of the Department to recruit 
        and retain qualified health-care professionals for 
        covered positions.
          [(2) The plans for the use of the authorities 
        provided in this subchapter for the next fiscal year.
          [(3) A description of the rates of basic pay in 
        effect during the preceding fiscal year, with a 
        comparison to the rates in effect during the previous 
        fiscal year, shown by facility and by covered position.
          [(4) The numbers of employees in covered positions 
        (shown separately for registered nurses and for each 
        other covered positions who during the preceding fiscal 
        year (A) left employment with the Department, (B) left 
        employment at one Department medical facility for 
        employment at another Department medical facility, or 
        (C) changed from full-time status to part-time status 
        (and from part-time status to full-time status), and a 
        summary of the reasons therefor.
          [(5) The number of vacancies in covered positions in 
        the Administration and a summary of the reasons that 
        those positions are vacant.
          [(6) The number of employees who during the preceding 
        fiscal year left employment at a health-care facility 
        in one Bureau of Labor Statistics labor-market area for 
        employment at a health-care facility in another such 
        labor-market area, without changing residence.
          [(7) Justification for setting the maximum rate of 
        basic pay for any grade at a rate in excess of 133 
        percent of the minimum rate of basic pay for that 
        grade.
          [(8) The discussion required by section 7452(b)(2) of 
        this title.
          [(9) The justification required by section 7452(e) of 
        this title.
          [(10) The number of nurses, shown by facility and by 
        grade, who are on pay retention or in the top step of 
        any grade and, with respect to those employees, 
        comprehensive information (by facility) as to whether 
        an extension of the pay grades was sought for these 
        positions, and with respect to each such request for 
        extension, whether such request was granted or denied.]
  [(h)] (g) For the purposes of this section, the term 
``health-care facility'' means a medical center, an independent 
outpatient clinic, or an independent domiciliary facility.

           *       *       *       *       *       *       *


Sec. 7455. Increases in rates of basic pay

  (a) * * *

           *       *       *       *       *       *       *

  (c)(1) The amount of any increase under subsection (a) in the 
maximum rate for any grade may not (except in the case of nurse 
anesthetists, pharmacists, and licensed physical therapists) 
exceed by two times the amount by which the maximum for such 
grade (under applicable provisions of law other than this 
subsection) exceeds the minimum for such grade (under 
applicable provisions of law other than this subsection), and 
the maximum rate as so increased may not exceed the rate paid 
for individuals serving as Assistant Under Secretary for 
Health.

           *       *       *       *       *       *       *


           PART VI--ACQUISITION AND DISPOSITION OF PROPERTY

           *       *       *       *       *       *       *


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

           *       *       *       *       *       *       *


   SUBCHAPTER III--STATE HOME FACILITIES FOR FURNISHING DOMICILIARY, 
                   NURSING HOME, AND HOSPITAL CARE

           *       *       *       *       *       *       *


Sec. 8136. Recapture provisions

  (a) If, within the 20-year period beginning on the date of 
the approval by the Secretary of the final architectural and 
engineering inspection of any project with respect to which a 
grant has been made under this subchapter (except that the 
Secretary, pursuant to regulations which the Secretary shall 
prescribe, may at the time of such grant provide for a shorter 
period than 20, but not less than seven years, based on the 
magnitude of the project and the grant amount involved, in the 
case of the acquisition, expansion, remodeling, or alteration 
of existing facilities), the facilities covered by the project 
cease to be operated by a State, a State home, or an agency or 
instrumentality of a State principally for furnishing 
domiciliary, nursing home, or hospital care to veterans, the 
United States shall be entitled to recover from the State which 
was the recipient of the grant under this subchapter, or from 
the then owner of such facilities, 65 percent of the then value 
of such project (but in no event an amount greater than the 
amount of assistance provided under this subchapter), as 
determined by agreement of the parties or by action brought in 
the district court of the United States for the district in 
which such facilities are situated.
  (b) The establishment and operation by the Secretary of an 
outpatient clinic in facilities described in subsection (a) 
shall not constitute grounds entitling the United States to any 
recovery under that subsection.

           *       *       *       *       *       *       *


          SUBCHAPTER V--ENHANCED-USE LEASES OF REAL PROPERTY

           *       *       *       *       *       *       *


Sec. 8163. Designation of property to be leased

  (a) * * *

           *       *       *       *       *       *       *

  (c)(1) * * *
  [(2) The Secretary may not enter into an enhanced-use lease 
until the end of a 60-day period of continuous session of 
Congress following the date of the submission of notice under 
paragraph (1). For purposes of the preceding sentence, 
continuity of a session of Congress is broken only by an 
adjournment sine die, and there shall be excluded from the 
computation of such 60-day period any day during which either 
House of Congress is not in session during an adjournment of 
more than three days to a day certain.]
  (2) The Secretary may not enter into an enhanced use lease 
until the end of the 90-day period beginning on the date of the 
submission of notice under paragraph (1).

           *       *       *       *       *       *       *

                              ----------                              


 DEPARTMENT OF VETERANS AFFAIRS EMPLOYMENT REDUCTION ASSISTANCE ACT OF 
                                  1999



           *       *       *       *       *       *       *
            TITLE XI--VOLUNTARY SEPARATION INCENTIVE PROGRAM

SEC. 1101. SHORT TITLE.

  This title may be cited as the ``Department of Veterans 
Affairs Employment Reduction Assistance Act of 1999''.

SEC. 1102. PLAN FOR PAYMENT OF VOLUNTARY SEPARATION INCENTIVE PAYMENTS.

  (a) * * *

           *       *       *       *       *       *       *

  [(c) Limitation on Elements and Personnel.--The plan under 
subsection (a) shall be limited to the elements of the 
Department, and the number of positions within such elements, 
as follows:
          [(1) The Veterans Health Administration, 4,400 
        positions.
          [(2) The Veterans Benefits Administration, 240 
        positions.
          [(3) Department of Veterans Affairs Staff Offices, 45 
        positions.
          [(4) The National Cemetery Administration, 15 
        positions.]
  (c) Limitation.--The plan under subsection (a) shall be 
limited to 8,110 positions within the Department.

           *       *       *       *       *       *       *


SEC. 1105. ADDITIONAL AGENCY CONTRIBUTIONS TO CIVIL SERVICE RETIREMENT 
                    AND DISABILITY FUND.

  (a) Requirement.--In addition to any other payments which it 
is required to make under subchapter III of chapter 83 or 
chapter 84 of title 5, United States Code, the Secretary shall 
remit to the Office of Personnel Management for deposit in the 
Treasury of the United States to the credit of the Civil 
Service Retirement and Disability Fund an amount equal to [26] 
15 percent of the final basic pay of each employee of the 
Department who is covered under subchapter III of chapter 83 or 
chapter 84 of title 5, United States Code, to whom a voluntary 
separation incentive is paid under this title.

           *       *       *       *       *       *       *


SEC. 1109. LIMITATION; SAVINGS CLAUSE.

  (a) Limitation.--No voluntary separation incentive payment 
may be paid under this title based on the separation of an 
employee after December 31, [2000] 2002.

           *       *       *       *       *       *       *

                              ----------                              


                  SECTION 2 OF THE ACT OF JUNE 6, 1953

 AN ACT Authorizing the transfer of certain property to the Veterans' 
 Administration (in Johnson City, Tennessee) to the State of Tennessee.

  [Sec. 2. Such conveyance shall contain a provision that said 
property shall be used primarily for training of the National 
Guard and for other military purposes, and that if the State of 
Tennessee shall cease to use the property so conveyed for the 
purposes intended, then title thereto shall immediately revert 
to the United States, and in addition, all improvements made by 
the State of Tennessee during its occupancy shall vest in the 
United States without payment of compensation therefor.]