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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 cropped 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 her 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.

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[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:

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

Percent

Methadone maintenance..
Abstinence..
Other chemotherapy..

Total.

3,466
2, 182

359

6,007

100

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

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a

Of the total of 8,262 patients in treatment on March 31, 1973 those being treated for other addictions than opium or opium derivatives numbered 1,272.

With regard to average costs and duration of treatment associated with each treatment modality, the VA funded its stations for FY 74 using the following cost model: detoxification should cost $80 per patient day and last approximately 10–12 days, methadone maintenance and drug free inpatient treatment $25-$32 per day for 30–90 days and therapeutic communities $15–$20 per patient day for a stay of 3-9 months. Outpatient visits are funded on a sliding scale from $5–$8 per visit.

Senator CRANSTON. Regarding VA drug treatment, I note your answer to my April 10 question that there are 54 veteran assistance counselors. That is just a little more than one for each of the 44 units.

How many outpatients would be attached to the average drug treatment clinic?

Mr. MILLER. Mr. McKnight, can you answer that?

Mr. McKNIGHT. It would vary quite a bit because from the major metropolitan areas

Senator CRANSTON. What is the average ?

Mr. McKnight. I would say about 150 to 175 average, with about 7,000 in treatment and about 50 outpatient clinics, that would run right around

Senator CRANSTON. Can you explain how one counselor can do the job in any way, shape, or manner effectively for that number of patients in terms of comprehensive guidance?

Mr. McKNIGHT. He also has of course the whole back-up of the Veterans assistance program, and the community services specialists. There are two actually for about 80 all together, the community service specialists and the Veterans Assistance Counselors are both working in the program, not just one.

Mr. Wilson. I think this is the type of counselor that would give the vocational counseling and testing and that kind of thing, and having once given this, all of this, the man remains an outpatient, he would not then have to be the primary concern of this vocational counselor. Is this not true, Mr. McKnight?

Mr. McKNIGHT. That would be in addition. The Veterans Assistance Specialist—or actually the Vocational Rehabilitation Specialist is another person on the staff of the regional office, who is available for the educational testing and that sort of thing. But the Veterans Assistance Counselor and the Community Services Specialists would be those giving full time.

Senator CRANSTON. It seems to me a basic problem here is that in general, experience has shown that a veteran counselor has the empathy and understanding needed, and when the backup is a nonveteran there is a decline in what can be accomplished.

A former addict, as we all know, is the first person to deal in many cases with an addict.

Mr. McKNIGHT. Those persons are in addition to the Veterans Assistance Counselors. Those Veterans Assistance Counselors and the Community Services Specialists are the ones who are paid through the Department of Veterans benefits.

Now, in addition, we have over 200 ex-addict counselors working in the system at the present time, as of December 31. Those would be in addition.

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Senator CRANSTOX. Of the total 44 centers and two satellite clinics, how many are for opiate users on methadone?

Do you have an answer to that or do you want to submit that for the record ?

Mr. McKNIGIIT. We would sumbit it for the record. Every center provides an option, however, in connection with centers there may be two hospitals actually involved.

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

Of the total 44 drug centers and two satellite clinics in the VA, 43 are for opiate users on methadone maintenance. The DDTC's at VAH's Downey, Battle Creek, and Buffalo provide abstinence programs only, but methadone maintenance is available in community facilities.

Seantor CRANSTON. You identified $1.5 million to support rehabilitation of veteran drug addicts. If you serve the 28,000 addicts you estimate for fiscal 1974, this means $53.50 per veteran for rehabilitation, as opposed to medical care.

By contrast, the National Institutes of Mental Health estimated drug rehabilitation costs at about $35,000 per-addict, per year, and I would be interested if you could submit a rationale of that discrepancy for the record.

Subsequently, the Veterans' Administration submitted the following information :)

For FY 73, the amount budgeted for treatment and rehabilitation was $23,037,000. Of this sum, $1.5 million is used to support personnel assigned to the DDTC's from the Department of Veterans Benefits who support the education, training and employment needs of the patients. This, when divided by the projected number of admissions for FY 73 of 20,000 yields an average per patient of $75.00 per patient. This, however, should not be interpreted as the only money being spent on rehabilitation but is simply that portion of the services provided by DVB. Included in the $23 million figure are people paid for by the Department of Medicine and Surgery who plan an integral part in the rehabilitation of the patient. In DDTC's, there are Social Workers, Physical Medicine and Rehabilitation Specialists, Chaplains, Librarians, and, probably most important, 199 ex-addict counselors who all contribute to the eventual rehabilitation of the patient.

This fiscal year we anticipate an average of $1,800 per patient. This figure places us within the guidelines of $1,500–$2,000 per year established by the Special Action Office for Drug Abuse Prevention and NIMH as an appropriate sum to be spent per year per patient for drug treatment and rehabilitation. It is our understanding that the $35,000 figure mentioned refers to the annual amount to be spent on inpatient detoxification.

Senator CRANSTON. The fiscal year 1974 budget indicates that 3.103 beds will be activated in new and replacement hospitals. Since there is no overall increase in operating beds for the VA hospital system, I assume there will be a corresponding deactivation of current operating beds of this system.

Would you please supply to the committee for the record a list by station of where those bed reductions are going to occur?

Dr. MUSSER. Yes, sir.

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

We are not activating 3,103 beds in FY 1974 in new and replacement hospitals. This figure approximates the total bed capacity of the 6 hospitals that will be in process of activation in FY 1974, not the number of beds that will be activated during the fiscal year. Many of these beds are already activated, others will not be fully activated in FY 1974 and some activated beds are only offsets of the beds they are replacing. We have not designed off setting bed reductions at any specific stations for the new beds which will be activated in FY 1974. Operating bed adjustments at individual stations will continue to be evaluated and adjusted based on factors such as construction, maintenance, demand, etc.

Senator CRANSTON. We will submit additional questions for the record in this general area, and Chairman Hartke will also submit some questions for the record.

Cliff, do you have any questions in this area?
Senator Hansen. I don't have any, Mr. Chairman.

Senator CRANSTON. Dr. Musser, could you please give us a brief indication and a detailed report for the record of expressions of interest that have been expressed as to each subchapter of Public Law 92-541 ?

Dr. MUSSER. Yes, sir. In regard to subchapter 1 we have had inquiries or statements of interest on behalf of 13 States, and I can provide you with a list of those States.

In regard to subchapters II and III, there have been about 27 inquiries for medical schools specifically concerned with subchapter II, and an additional 22 letters from institutions inquiring specifically about subchapter III. And, these range from schools of allied health to schools of pharmacy, and the like. Just within the last few weeks there has been some increase in the number of inquiries regarding subchapter III as it applies to schools of allied health. But in general, these are experiences to date, and I can list for you the sources of the inquiries.

Senator CRANSTON. For the record would you indicate who made the expressions of interest and the nature of the inquiries?

Dr. MUSSER. Yes, sir.

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

EXPRESSIONS OF INTEREST IN THE VETERANS' ADMINISTRATION MEDICAL SCHOOL

ASSISTANCE AND HEALTH MANPOWER TRAINING ACT OF 1972—PUBLIC LAW 92-541

SUBCHAPTER I

There have been inquiries or statements of interest on behalf of 13 states (Attachment A). This number, and the still lesser number (about seven) which reflect potential immediate eligibility, is probably accounted for on two bases : The Act itself requires that the applicant present reasonable assurance of appropriate accreditation of the new medical schools to be initiated with this assistance (Section 5073b 1 D). Implementing regulations, as presently drafted, would also eliminate from eligibility under this subchapter the “new”. schools which are provisionally accredited and receiving Federal assistance under one or more of the authorities contained in the Comprehensive Health Manpower Training Act of 1971 (PL 92–157) administered by the Bureau of Health Manpower, NIH, DHEW. Such schools, if they are presently affiliated with the VA hospitals, would be eligible for assistance under Subchapter II.

SUBCHAPTERS II AND III

There have been about 27 inquiries from Medical Schools specifically concerning Subchapter II, the majority of these also express interest in Subchapter III in behalf of nursing or other allied health programs conducted either by the School or by other Schools within the academic health center of which they are a part (Attachment B). There have been an additional 44 letters from institutions inquiring specifically about Subchapter III (Attachment C). These range from Schools of Allied Health, Schools of Pharmacy, etc. which are components of academic health centers to single programs conducted in community and junior colleges.

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