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110th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     110-642

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



 
      DIRECTOR OF PHYSICIAN ASSISTANT SERVICES AT VETERANS HEALTH 
                             ADMINISTRATION

                                _______
                                

  May 15, 2008.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

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

                              R E P O R T

                        [To accompany H.R. 2790]

      [Including cost estimate of the Congressional Budget Office]

  The Committee on Veterans' Affairs, to whom was referred the 
bill (H.R. 2790) to amend title 38, United States Code, to 
establish the position of Director of Physician Assistant 
Services within the office of the Under Secretary of Veterans 
Affairs for Health, having considered the same, report 
favorably thereon with an amendment and recommend that the bill 
as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Discussion........................................     2
Hearings.........................................................     3
Committee Consideration..........................................     3
Committee Votes..................................................     3
Committee Oversight Findings.....................................     4
Statement of General Performance Goals and Objectives............     4
New Budget Authority, Entitlement Authority, and Tax Expenditures     4
Earmarks and Tax and Tariff Benefits.............................     4
Committee Cost Estimate..........................................     4
Congressional Budget Office Estimate.............................     4
Federal Mandates Statement.......................................     5
Advisory Committee Statement.....................................     5
Constitutional Authority Statement...............................     5
Applicability to Legislative Branch..............................     5
Section-by-Section Analysis of the Legislation...................     6
Changes in Existing Law Made by the Bill as Reported.............     6

                               Amendment

  The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. ESTABLISHMENT OF DIRECTOR OF PHYSICIAN ASSISTANT SERVICES AT 
                    VETERANS HEALTH ADMINISTRATION OF DEPARTMENT OF 
                    VETERANS AFFAIRS.

  (a) In General.--Section 7306(a) of title 38, United States Code, is 
amended by striking paragraph (9) and inserting the following:
          ``(9) The Director of Physician Assistant Services, who shall 
        be a qualified physician assistant who shall report to the 
        Under Secretary for Health on all matters relating to the 
        education and training, employment, appropriate utilization, 
        and optimal participation of physician assistants within the 
        programs and initiatives of the Administration. The Director of 
        Physician Assistant Services shall serve in a full-time 
        capacity at the Central Office of the Department.''.
  (b) Deadline for Implementation.--The Secretary of Veterans Affairs 
shall ensure that an individual is serving as the Director of Physician 
Assistant Services under section 7306(a)(9) of title 38, United States 
Code, as added by subsection (a), by not later than 120 days after the 
date of the enactment of this Act.

                          Purpose and Summary

    H.R. 2790 was introduced by Representative Phil Hare of 
Illinois on June 20, 2007. The legislation would establish a 
full-time Director of Physician Assistant Services within the 
Veterans Health Administration in the Department of Veterans 
Affairs (VA). This position would be located in the Department 
of Veterans Affairs Central Office.

                       Background and Discussion

    Physician Assistants (PAs) who choose to work for the 
federal government are credentialed health professionals. As of 
March 12, 1993, certification by the National Commission on 
Certification of Physician Assistants is a requirement for 
employment. PAs provide a comprehensive range of diagnostic and 
therapeutic services including performing physical exams, 
taking patient histories, ordering and interpreting laboratory 
tests, diagnosing and treating illnesses, and writing 
prescriptions. PAs practice medicine as delegated by, and under 
the supervision of, a physician. Physicians may delegate to PAs 
medical duties that are within the physician's scope of 
practice, and the PA's training and experience, as allowed by 
law. All states, the District of Columbia, and Guam authorize 
physicians to delegate prescriptive privileges to the PAs they 
supervise. According to the American Association of Physician 
Assistants, approximately 245 million patient visits were made 
and about 303 million medications were prescribed or 
recommended by PAs.
    The first physician assistants to graduate from PA academic 
programs were former medical corpsmen who had served in Vietnam 
and wanted to use their medical knowledge and experience in 
civilian life. Dr. Eugene Stead of Duke University Medical 
Center in North Carolina put together the first class of PAs in 
1965, selecting Navy corpsmen that had considerable medical 
training during their military experience. Today, there are 139 
accredited PA programs across the United States.
    Since the PA Advisor position was authorized by the 
``Veterans Benefits and Health Care Improvement Act of 2000,'' 
Public Law 106-419, the number of PAs within the VA health care 
system has increased 34 percent, from 1,195 to nearly 1,600 
today. VA is the largest single employer of PAs in the United 
States. PAs work in a wide variety of medical centers and 
outpatient clinics throughout the VA health care system.
    Although the institution of the part-time, field-based PA 
Advisor has improved the utilization of PAs, there continues to 
be inconsistencies in the way PAs are used across the system. A 
full-time director, located in VA central office, would ensure 
efficient utilization and full integration, when appropriate, 
of VA's PA workforce in VA's patient care programs and 
initiatives. The full-time PA Director would also work closely 
with other offices within the Veterans Health Administration, 
such as the Office of Rural Health, to ensure that veterans 
living in medically underserved communities receive timely 
access to medical care.

                                Hearings

    On January 17, 2008, the Subcommittee on Health held a 
legislative hearing on a number of bills introduced in the 
110th Congress, including H.R. 2790. The following witnesses 
testified: The Honorable Phil Hare of Illinois; The Honorable 
Stephanie Herseth Sandlin of South Dakota; The Honorable 
Zachary T. Space of Ohio; The Honorable Shelley Moore Capito of 
West Virginia; The Honorable Michael M. Honda of California; 
The Honorable Leonard L. Boswell of Iowa; The Honorable Steve 
Kagen of Wisconsin; Mr. Joseph L. Wilson, Deputy Director, 
Veterans Affairs and Rehabilitation Commission, The American 
Legion; Ms. Joy J. Ilem, Assistant National Legislative 
Director, Disabled American Veterans; Mr. Christopher Needham, 
Senior Legislative Associate, Veterans of Foreign Wars of the 
United States; Mr. Richard F. Weidman, Executive Director for 
Policy and Government Affairs, Vietnam Veterans of America; 
Gerald M. Cross, M.D., FAAFP, Principal Deputy Under Secretary 
for Health, Veterans Health Administration, U.S. Department of 
Veterans Affairs, accompanied by Mr. Walter A. Hall, Assistant 
General Counsel, U.S. Department of Veterans Affairs. Those 
submitting statements for the record included: American Academy 
of Physician Assistants; The Honorable Shelley Berkley of 
Nevada; Mental Health America; and the Paralyzed Veterans of 
America.

                        Committee Consideration

    On April 23, 2008, the Subcommittee on Health met in open 
markup session and favorably forwarded H.R. 2790, as amended, 
to the full Committee for consideration by voice vote.
    An amendment by Mr. Hare of Illinois to establish the 
position 120 days after the date of enactment.
    On April 30, 2008, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 2790, as 
amended, favorably reported to the House of Representatives, by 
a voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report the legislation and amendments thereto. 
There were no record votes taken on amendments or in connection 
with ordering H.R. 2790 reported to the House. A motion by Mr. 
Buyer of Indiana to order H.R. 2790, as amended, reported 
favorably to the House of Representatives was agreed to by 
voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are reflected in the descriptive portions 
of this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  Earmarks and Tax and Tariff Benefits

    H.R. 2790 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the 
House of Representatives.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate on H.R. 
2790 prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               Congressional Budget Office Cost Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 2790 provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 12, 2008.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 2790, a bill to 
amend title 38, United States Code, to establish the position 
of Director of Physician Assistant Services within the office 
of the Under Secretary of Veterans Affairs for Health.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Sunita 
D'Monte.
            Sincerely,
                                         Robert A. Sunshine
                                   (For Peter R. Orszag, Director).
    Enclosure.

H.R. 2790--A bill to amend title 38, United States Code, to establish 
        the position of Director of Physician Assistant Services within 
        the office of the Under Secretary of Veterans Affairs for 
        Health

    H.R. 2790 would require the Department of Veterans Affairs 
(VA) to establish the position of Director of Physician 
Assistant Services within the office of the Under Secretary of 
Veterans Affairs for Health. As required under current law, VA 
has an Advisor on Physician Assistants who reports to the Under 
Secretary. VA indicated that the current advisor works part 
time. CBO expects that to meet the bill's requirements, VA 
would make the position full time and require small additional 
appropriations for salaries, expenses, and travel. CBO 
estimates that implementing the bill would cost less than 
$500,000 over the 2009-2013 period, assuming availability of 
the estimated amounts. Enacting the bill would have no effect 
on direct spending or revenues.
    H.R. 2790 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act and 
would not affect the budgets of state, local, or tribal 
governments.
    The CBO staff contact for this estimate is Sunita D'Monte. 
This estimate was approved by Theresa Gullo, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 2790 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
2790.

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that the 
Constitutional authority for H.R. 2790 is provided by Article 
I, section 8, of the Constitution of the United States.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Establishment of a Director of Physician Assistant Services 
        at the Veterans Health Administration of the Department of 
        Veterans Affairs

    This section amends section 7306(a) of title 38, United 
States Code, to make the Advisor of Physician Assistant 
Services a Director of Physician Assistant Services, and also 
mandates that the position be a full-time position, based in 
the Central Office of the Department of Veterans Affairs.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

              SECTION 7306 OF TITLE 38, UNITED STATES CODE


Sec. 7306. Office of the Under Secretary for Health

  (a) The Office of the Under Secretary for Health shall 
consist of the following:
  (1) * * *

           *       *       *       *       *       *       *

[(9) The Advisor on Physician Assistants, who shall be a 
physician assistant with appropriate experience and who shall 
advise the Under Secretary for Health on all matters relating 
to the utilization and employment of physician assistants in 
the Administration.]
  (9) The Director of Physician Assistant Services, who shall 
be a qualified physician assistant who shall report to the 
Under Secretary for Health on all matters relating to the 
education and training, employment, appropriate utilization, 
and optimal participation of physician assistants within the 
programs and initiatives of the Administration. The Director of 
Physician Assistant Services shall serve in a full-time 
capacity at the Central Office of the Department.

           *       *       *       *       *       *       *