Senator CRANSTON. Moving on to the matter of medical care now. I would appreciate it if you would provide for the record a complete breakdown-including FTEE and budget authority-for each activity which was to be supported by the $173 million in the medical care item deleted by OMB.

Dr. MUSSER. Yes, sir.

[Subsequently, the Veterans' Administration submitted the following information:]

The following chart represents the breakdown of Budget Authority and FTEE difference by activity from the OMB Medical Care request to the Congressional submission:

Senator CRANSTON. Would you please also provide for the record a complete analysis of all change-by FTEE and budget authority-between the OMB submission and the congressional submission? Dr. MUSSER. Yes, sir.

[Subsequently, the Veterans' Administration submitted the following information:]

The following chart is an analysis by line item of the change from the OMB Budget Authority and FTEE request vs. the Congressional request:

Senator CRANSTON. I know, Dr. Musser, that in the Department of Medicine and Surgery budget submission within the agency, you projected a census of 86,000 for fiscal 1974 and then in the VA submission to OMB the agency itself estimated a census of 83,000.

Given the 80,000 census mandated by OMB, which I presume you can defend in a most articulate manner in terms of shortening length of stay and increases in ambulatory care, don't you think the agency has a serious professional problem in its ability to accurately project its own work loads, or is it possible you were right and OMB was wrong?

Dr. MUSSER. Well, I think in this instance we probably were wrong in that these figures were put together a good many months before we had an opportunity to see what our current experience was, and also what the impact was of broader use of the prebed care and posthospital care programs.

Senator CRANSTON. Let me say that I suspect that you are being far too modest, I have not found you wrong very often in your analysis of what is needed.

Specifically, the length of stay that you projected to OMB was considerably higher than the one that OMB decided upon. What are those two figures?

Dr. MUSSER. I know there is a difference, but I would have to get those for the record.

[Subsequently, the Veterans' Administration submitted the following information:]

ESTIMATED LENGTH OF STAY

The VA Budget estimated length of hospital stay equivalent of the turnover rate was 30.1 days vs. OMB's estimate of 29.0 days for FY 1974. For FY 1973 the respective figures were 30.9 days and 30.5 days.

Senator CRANSTON. On what basis did OMB revise your lengthof-stay estimates, how were they

Dr. MUSSER. Well, they had access to more current experience than we had when we put together our figures.

Mr. WILSON. Senator, our figure is in that series of charts that was submitted in our letter of April 17.

Senator CRANSTON. Do you really think that you were wrong in that case?

Dr. MUSSER. I don't know that anyone can predict the types of things like that with complete accuracy; an awful lot depends on the kind of performance that we get from our people. And, we think that at best these are guesstimates of sorts.

Senator CRANSTON. Of course you can't be precise about these estimates, but that can be an excuse for cutting down, down, down each year. At some point you have got to reach a point where obviously you can't

Dr. MUSSER. Of course there is a point below which you won't be able to go, the state of the art won't allow that. On the other hand I think the experiences that were shown on the transparencies is that there are ways still to improve the efficiency of our hospitals.

Senator CRANSTON. Would you also submit for the record the figures estimated for outpatient care in your submission to OMB and the congressional submission with a breakdown for direct outpatient visits and by fee?

[Subsequently, the Veterans' Administration submitted the following information:]

The following chart is a comparison of OMB outpatient visits vs. the Congressional submission for FY 1974:

Senator CRANSTON. In response to question three of my letter, you indicated that the census by the end of June would be 82,450 based on current experience. What is going to happen to immediately start reducing that census down to the 80,000 level?

Dr. MUSSER. Well, as I am sure you are aware, there is a very marked seasonal fluctuation in our census. We happen to be in a period of high occupancy at the present time. You will find, though, that by June there will be an increasing dropoff in the census, and it will drop even lower in July, and it will remain low until the beginning of the winter at which time it probably will come up again.

So, when we talk about 80,000 average daily patient census, we are talking of the average for the year. We estimate that this year for instance, we will probably come out with an average of slightly over 82.000. Isn't that about right, 82,450?

Senator CRANSTON. Don't you figure it is going to be hard to get down to 80,000 if you are not fairly close to that at the start of the year?

Dr. MUSSER. Perhaps; on the other hand, these figures which we have indicated for May and June are simply estimates, and I think it is entirely possible that we will find a lower census in May and June than these estimates depict.

Senator CRANSTON. If in fact you cannot get down to the 80,000 level are you not then going to have to reduce your staff-to-patient ratio?

Dr. MUSSER. Actually, the ratio of staffing, staff to patients, fluctuates from day-to-day anyhow because the ratio is between staff and the census.

Senator CRANSTON. If you are operating at 82,000 and you try to get it to 80,000 and set your staff-to-patient ratio on that basis, you are going to have a shortage for a while.

Dr. MUSSER. It will do that for a period of time. On the other hand, there were months in this fiscal year when we had 79,000 patients in the hospital, and the staffing ratio then was higher at that time than it is right now, when we are running about 84,000 patients; it varies from day-to-day, and so we talk of averages.

Senator CRANSTON. How does the 82,450 average census you are predicting for the end of June compare with the June census figures in 1972 and 1971?

Dr. MUSSER. On the same page 2 of the answer to this question you will note that if you take the figures as of June 26 for fiscal year 1972 and June 25 estimated for June 1973, in 1972 the census on that day was 80,949. Now, that was actual. However, in 1969, 3 years before, the census was 91,165.

Senator CRANSTON. What was the census for the month of June in 1971?

Dr. MUSSER. I don't have that, I just have these three figures, but I can get the 1971 figure. It would be about 81,000.

[Subsequently, the Veterans' Administration submitted the following information:]

The average daily patient census in VA Hospitals was 79,865 during June 1971 and 80,837 during June 1972.

Senator CRANSTON. 81,000?

Dr. MUSSER. Yes, sir.

Senator CRANSTON. So it has been moving up those 3 fiscal years? Dr. MUSSER. No, sir; in 1972 it was 80,949 actual.

Senator CRANSTON. 1,500 above that and 1,000 above where we were 2 years ago, right?

Dr. MUSSER. Approximately, yes.

Senator CRANSTON. Isn't it a fact that the reason the census dropped at the end of fiscal year 1971 was because of OMB controls applied to reduce the census to the 79,000 level which OMB was then mandating for fiscal 1972? And, isn't it a fact that there is no historical precedent for the enormous drop in census which occurred between March and July 1 of 1971?

Dr. MUSSER. Well, the way it happened one could presume that, but I am not absolutely certain that I could say without question that that is what the reason really was. Many other factors can influence the rate of application, and therefore the census in the hospitals.

Senator CRANSTON. You are not very sure, you are 60 percent sure of the reasonable possibility, or what?

Dr. MUSSER. We are at least 60 percent sure all the time.

Senator CRANSTON. Isn't the fact that it has taken a full year or more for the census to recover from these arbitrary controls which were finally removed in November of 1971?

Dr. MUSSER. Well, in my opinion I would answer that "No", because I have had many meetings with our hospital directors. And, as I indicated earlier, we have urged them to give the patients the benefit of the doubt in every circumstance, and I think that our experience this past year has been a pretty honest illustration of the performance of the system without restraint.

Senator CRANSTON. Would you agree that it is a fact that the census as of right now, which for last week was 83,450 as I understand it, is floating at a relatively normal level unheeded by any arbitrary controls?

Dr. MUSSER. Yes, sir, and as I said, this is a time of year when we expect to have more patients in our hospitals than at other times of the year; this is the end of the winter period.

Senator CRANSTON. I note the very promising expansion of VA hospital and medical schools affiliations, and I congratulate you and all those responsible for that.

I know that there are 19 new affiliations. What has the cost been historically on the average to establish the training and research essential to implement such relationships?

Dr. MUSSER. There is no way to derive that in a fixed formula; costs will differ, will vary depending on the size of the medical school, the physical plant of the medical school; it will vary depending on what kind of support we might provide to the school, the character of the hospital

Senator CRANSTON. Could you give an average figure historically? Dr. MUSSER. I will try to get one, yes, sir.

Senator CRANSTON. Please do that.

[Subsequently, the Veterans' Administration submitted the following information:]

AVERAGE COST TO ESTABLISH A MEDICAL SCHOOL AFFILIATION

It is not possible, within the scope of our cost system, to isolate the costs applicable to the implementation of any of the existing medical school affiliations. Even an estimate of average costs is not feasible due to the complexities of school size, scope of the affiliation and the character of the hospitals involved. These affiliations are phased in over a period of several years and encompass not only the direct costs of students, instructors and facilities but indirect costs applicable to support functions which lose their identity the total operating cost of each facility.

Further, as we move into an affiliation gross changes in mission, complexity of services rendered, and quality of care ensue. These then represent qualitative changes.

Senator CRANSTON. Regarding your response to my question number nine regarding drug treatment, the data you provided is not broken down in terms of opiate and nonopiate users as I had requested. I would appreciate it if you would cover that specifically if you can for the record.

Dr. MUSSER. We will.

[Subsequently, the Veterans' Administration submitted the following information:]

Of the 13,120 patients admitted to VA inpatient programs in treatment and rehabilitation of drug abuse from July 1, 1972 to March 31, 1973, 77% or 10,153 were admitted for dependence on opium drugs. Of the 9,230 patients admitted to outpatient care during the same period, 86% or 7,901 were admitted for dependence on opium drugs.

The number of inpatients receiving treatment for opiate and opiate derivative addiction as of March 31, 1973 under each of the following therapies was:

The number of outpatients receiving treatment for opiate and opiate derivative addiction as of March 31, 1973 under each of the following therapies was:

Of the total 6,990 patients in treatment for opiate and opiate derivative addiction on March 31, 1973, those being treated under the following therapies