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OVERSIGHT OF VA HOSPITAL PROGRAMS, 1973

MONDAY, APRIL 16, 1973

U.S. SENATE,

SUBCOMMITTEE ON HEALTH AND HOSPITALS OF THE

COMMITTEE ON VETERANS' AFFAIRS,

Washington, D.C.

The subcommittee met, pursuant to notice, at 1:30 p.m., in room 412, Russell Office Building, the Honorable Alan Cranston, chairman of the Subcommittee on Health and Hospitals, presiding. Present: Senator Alan Cranston, chairman.

OPENING STATEMENT OF HON. ALAN CRANSTON, CHAIRMAN OF THE SUBCOMMITTEE ON HEALTH AND HOSPITALS

Senator CRANSTON. The hearing will please come to order. The hearings this afternoon, and those scheduled for a full day this Wednesday, the 18th, are designed to answer the question, "Whether or not it is the policy of the American people and its Federal Government that when the shooting ends, so does the compassion and concern for the veterans of the Indochina war and the veterans disabled from our earlier wars?"

These hearings are the third set of VA medical care oversight I have chaired since coming to the Senate in 1969. The first two were in 1969-70 and 1971. Based on the extensive data developed at those hearings, I made comprehensive recommendations to the Appropriations Committee Subcommittee regarding the VA hospital and medical program budget items for each of the last 3 fiscal years.

The result has been that the VA hospital and medical program budgets were increased by $450 million above the President's initial budget requests over the last 3 fiscal years. Other members of this committee and the House committee as well as the congressional leadership and members were involved in all of this and of course played a significant part in those increases.

On the basis of the data developed from these hearings, which we are about to begin, I plan to make similar such comprehensive recommendations on the VA fiscal year 1974 budget as well as on the implementation and nonimplementation of the fiscal year 1973 VA medical and hospital appropriations items. So, we will be looking at the VA hospital program with these budgetary considerations very much in the forefront. But, I wish to stress that our concern is not merely with finding areas requiring more money, but also finding areas in which savings can be effected.

We will also be focusing specifically on the VA's failure to issue regulations or take any other steps to carry out the provision of Public Law 92-541, the "VA Medical School Assistance and Health Manpower Training Act of 1972," which the President signed last October 24. In addition, the President's fiscal year 1973 and 1974 budget requests contained no funds to carry out this new law.

These questions must be viewed in the context of the steadily increasing demands being made on the VA in- and out-patient medical programs by Vietnam-era veterans. According to the most recent data, during fiscal year 1972, Vietnam-era veterans constituted 15.9 percent of all veterans discharged from VA hospitals, as compared to 13.2 percent in fiscal year 1971 and 9.9 percent in fiscal year 1970. The same pattern exists with respect to outpatient visits. In fiscal year 1972, Vietnam-era veterans accounted for 17.8 percent of all VA, staff and fee, outpatient visits, as compared to 14.9 percent and 10.8 percent in fiscal years 1971 and 1970, respectively.

Of particular significance, it seems to me, is that Vietnam-era veterans constituted 26.2 percent of all veterans discharged from VA hospitals in fiscal year 1972 after treatment for service-connected disabilities. Although the trends I have outlined toward greater care of Vietnam-era veterans by the VA hospital and medical program will not continue indefinitely at the same upward pace, I am aware of no indication that they will not continue upward over the next several years.

Thus, this is the time of the very greatest demands on the VA system by our most recent and, as our prior hearings illustrated only too plainly, our most seriously disabled veterans. This, then, is obviously no time for cutbacks in the quality and quantity of the VA medical program. We must consolidate the gains made over the last 3 fiscal years and continue to improve and expand the system and to stress the need for maximum responsiveness on an individualized, personalized basis.

Instead, preliminary indications are that OMB is once more in the process of imposing restrictions, freezes and other funding controls with a view toward seriously constricting the scope and effectiveness of VA treatment programs; $64 million appropriated by the Congress for the VA for this fiscal year have been impounded, and another $35 million of that medical care appropriation have been applied to pay for the January 1973 pay raise for the Department of Medicine and Surgery. In addition, the one-tenth of a grade rollback imposed by OMB continues in force at least through fiscal year 1973, with the effect through January 8, 1973, that of 22,457 essential promotions reported by each of the 168 VA hospitals throughout the country, only 2,610 of these 22,457 were accomplished. The resulting serious, negative impact on overall VA hospital staff morale, accompanied by the loss of medical care competence and experience as lesserqualified staff must be hired to replace existing hospital workers leaving under normal attrition, poses a continuing serious problem for the caliber of care for our disabled veterans.

Also, regarding the fiscal year 1973 budget, $4.8 million is being held back by OMB directive which was appropriated for VA medical and prosthetic research.

The situation regarding the fiscal year 1974 budget request of the President can only be viewed in the context of these fiscal year 1973 aspects. But, there is plenty of bad news itself in the VA fiscal year 1974 budget submissions. The most serious of these is the requirement that the VA reduce the average daily patient census in existing hospitals by 2,698, which in individual patient-care terms translates down to denying VA hospital care to between 20,000 and 54,000 disabled veterans who would otherwise receive it.

All of this will come-if the Congress permits it-at a time when the VA will be activating 5 new hospitals and 17 new affiliations with medical schools-all requiring millions of new dollars and hundreds of new staff in order to be carried out.

I plan to make additional comments about the fiscal year 1974 budget at Wednesday's hearing when the VA witnesses appear. But, I think I have said enough to indicate that this is the year of decision. If OMB succeeds in its effort to arbitrarily reduce the VA hospital average daily patient census down to 80,000 from the most recent level of approximately 83,500 at present, the downward trend and the steady erosion of the VA hospital system may well be irreversible. In my view, this would be an enormous tragedy both in terms of meeting our obligation to care for those who have served our Nation in times of national emergency, and in terms of wasting, and inviting dissipation of a highly cost-effective national medical care resource, which performs an indispensable role in the total provision of health care in America.

In terms of the failure to carry out Public Law 92-541, through the end of February of this year the VA received more than 40 expressions of interest from State governments, medical schools, nursing and allied health schools, universities and other health manpower training institutions about utilizing the new authorities in that public law, to establish new medical schools using VA clinical facilities, or to expand the education and training capacities of medical and other schools affiliated with existing VA health facilities.

We have a very distinguished list of witnesses this afternoon and on Wednesday, April 18, 1973, representing not only the leadership of the Veterans' Administration and its extremely able and dedicated Department of Medicine and Surgery, but also some of the most outstanding medical school and other university and health manpower institution officials and experts in the Nation. We will also receive testimony from all the major veterans' organizations and look forward to their special insights and always valued contributions.

Now, proceeding with the witnesses, our first witness is Dr. James L. Dennis, vice president for health sciences, University of Arkansas Medical Center, Little Rock, Ark. Dr. Dennis, we welcome you.

STATEMENT OF DR. JAMES L. DENNIS, VICE PRESIDENT FOR HEALTH SCIENCES, UNIVERSITY OF ARKANSAS MEDICAL CENTER, LITTLE ROCK, ARK.

Dr. DENNIS. Chairman Cranston, distinguished colleagues, fellow veterans, I am Dr. James L. Dennis, vice president for health sciences at the University of Arkansas Medical Center.

I might add further identification by pointing out that prior to assuming this position, I was dean of the School of Medicine and the Dean's Committee Affiliate Hospital and the director of the University of Oklahoma School of Medicine and Medical Center. I am immediate past president of the Association of Academic Health Centers, and currently on its board of directors.

As a veteran, I am very much interested in the challenges that are before us but my presentation today will be primarily from the evaluation of medical education and its impact upon that veteran.

It has been my privilege, Senator, to have experienced my professional career during the period of time that has seen medicine emerge from an empirical art to a skillful, scientifically based discipline.

During the same period, the Veterans' Administration hospitals, through the dean's committee medical school affiliations have emerged from a status of third-rate institutions to rank among the very best in the country. This partnership has provided the opportunity to develop a critical mass of excellence that could not otherwise have been possible for either the medical school or the VA teaching hospitals.

Only those who have lived with it can appreciate the significant contributions the Veterans' Administration hospitals have made to the production of health manpower in this Nation. At our institution, our medical students devote as much as 40 percent of the time spent in their clinical education and training at the VA hospital. Currently, 80 percent of the Nation's medical school graduates have received some of their education or training in an affiliate VA hospital. Twentyfive percent of this Nation's housestaff, intern or resident physicians, in training today are in our Veterans' Administration teaching hospitals. In these VĂ institutions are 2,200 health professionals who have faculty appointments in an affiliated university medical school. Too few people are aware of the gradual emergence of the VA hospital system as by far the largest single resource for the production of the Nation's health manpower needs. The enlightened congressional support that has made possible this notable VA contribution to health education and health manpower must be enhanced, not retracted. I ask you to consider the following:

One, health care services are in short supply and for many people even unavailable.

Two, health care services are skilled people at work-they can only be produced by a process of education and training, which depends on the availability of appropriately staffed teaching hospitals and clinics.

Three, the only nationwide network of teaching hospitals in existence in this Nation is that provided by the Veterans' Administration hospitals.

Four, no longer available to medical schools are Federal HEW moneys that have provided funding for the expansion or construction of medical schools for the purpose of producing more physicians and other health manpower. Since the vast gap between the availability of health care and the demands for health care remains, the essential role of the VA hospital system, in terms of manpower production, requires your most conscientious considerations and unequivocal support.

Five, in this Nation today the greatest undeveloped potential for sustaining an increased level in the production of all of the various

kinds of health manpower that are in short supply resides in the medical school Veterans' Administration teaching partnership models. Paradoxically, the growing pressures to produce more and serve more, at less cost, have peaked at a time the demands and costs are going up and appropriations are leveling off, or are going down.

On the basis of information provided to us, our VA-Dean's Committee Hospital can, with the projected budget for fiscal year 1974, July 1973-June 1974, expect to be fortunate to maintain operations at the 1973 level, yet the service demands are increasing and will be greater.

They can employ no more than the current number of housestaff, residents and interns, at a time the medical school enrollments are increasing and the need for an additional 10 resident positions are essential. Other deficiencies in the fiscal year 1974 budget include:

(1) inability to obtain additional staffing that would permit employment ratios of staff to patients equivalent to that of the average private hospital;

(2) inability to recruit additional professional and allied health personnel required to serve ever increasing demands, particularly in the outpatient areas;

(3) inability to fund the new school of health related professions in order to provide for the students, programs and facilities that would permit even a fraction of the tremendous growth potential in this short supply field of health manpower, and

(4) indefinitely delayed are plans, meticulously generated over a period of several years, to activate an innovative, critically needed program for high-quality geriatric medical care and a unique program of geriatric home care. These latter programs were designed to provide the basis for a new medical school department for research and teaching in the field of aging. Neither institution can do this alone. The importance of the intolerable neglect of research, teaching and care for the aged required no amplification. This is just one aspect.

I think at the other end of the spectrum, Chairman Cranston, are our immediate concerns for our Indochina veterans and their acute needs. I happen to be a World War II veteran, and we are getting older, and we are going to have a very large, aged population of veterans, which has not yet hit us. We are not prepared for this, and if we are going to be, we have to plan and develop now.

Another area in which Veterans' Administration budgeting has been unrealistic is in the pay rates for its top professional staff. I am presenting this from the viewpoint of the person who has to deal with keeping superbly-qualified men on the job who want to stay there, but they see their colleagues in practice or even in the medical school with a differential in pay. VA service chiefs with medical school appointments at the rank of full professor are paid $30,000 to $36,000 per annum. Medical school professors, chiefs of service, receive salaries that are from $5,000 to $15,000 per year above the equivalent VA position.

The immediate impact of the "status quo" annual appropriation has been readily identified; less visible is the long-range impact which is even more significant. New teaching and training programs always require several years of planning, organization and recruitment prior to implementation.

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