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NATIONAL EXECUTIVE COMMITTEE: FRANK R DE GEORGE

JOHN H. RINE JR. GERALD D. DANIELL

GERALD I DOYLE GEORGEL GENTRY. JR

WILLIAMP GREEN CARLOS RODRIGUEZ

JAMES E SE Y BOLD

Dear Senator:

DIRECTORS: LAWRENCE D BALLENGER

JACK BLACK
FDWIN BOYLES
ARCHIE M.BRADLEY
LESLIE P. BU'RGHOFF
ERNEST L CHAVEZ

WALTER E EMGE
TERRY G. HOLDER
RAYMOND J. HUNT

JAMES AJACHIM
EDWARD JASPER
BURTON LITTLE
GLENN E MAYER
HAROLD D. MILLER

JAMES J. PETERS
FRANK PYCHA III
JOHN HRINE, JR.
BOLIVAR RIVERA
BUDDY C. ROGERS

ERNEST M. SAWYER
JOHN E. SMERBECK, JR.
CONRAD M. STANDINGER

BENNY TSCHETTER

LOUIS C. WEBER
JAMES R. WORKMAN

JOHN T. WOSCEK

Two questions asked us by the Senate Veterans Affairs
Committee Subcommittee on Health Care and Hospitals were
left unanswered during the hearings. The first question
dealt with the cost of physical therapy for VA spinal
cord injury centers. These are the results of our research.
Based on a Full-time Employment Equivalent of 155.9 at
fourteen (14) centers, the total cost, excluding equipment,
was $1,647,018 for the past fiscal year. It must be
recognized that not all of this money was spent on spinal
cord injuried veterans. Many of the therapy clinics
do double duty serving other type of disabilities,
Therefore, it is very difficult to extract the exact
cost of physical therapy for spinal cord injuried veterans.

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The second question unanswered was what ways do we,
representatives of PVA, suggest the Federal government
reduce its expenditures and save the taxpayers' money?
We can only respond to these areas pertaining to the
paralyzed veteran and his care. One very simple way
in which taxpayers' money can be saved is to increase
the non-service connected veteran pension to a level he
can leave the VA hospital. At a cost of $80 per day or
$29,000 per year, it makes good economic sense to increase
pension and aid & attendance to a level the veteran can
support himself outside the hospital.

APPOINTMENTS:
PETER L. LASSEN
Architectural Barriers

ROBERT L. WEBB
Paraplegia News Editor
JAMES E, SEYBOLD

Research Director
CLIFFORD D. CRASE

Sports Coordinator
JACK E. SCHNAITTER

WVF Delegate

JAMES A. MAYE
Executive Director

Another area of saying could be in the rehabilitation
program. Through the utilization of trained professional
rehabilitation counselors and veteran priority on
government jobs, many seriously disabled veterans such
as the spinal cord injuried could be placed back into

a paraplegic
is an individual...

THE PARALYZED VETERANS OF AMERICA IS AN ORGANIZATION FORMED BY AND FOR THE MOST SERIOUSLY DISABLED IN THE WORLD. IT IS
DEVOTING ITS LIFE AND EFFORT TO EVERY PROBLEM OF EACH PARAPLEGIC REGARDLESS OF RACE, CREED OR COLOR. THESE PROBLEMS
ARE MANY, FOR A PARAPLEGIC HAS SUFFERED A SPINAL CORD INJURY RESULTING IN PARALYSIS: (1) INABILITY TO WALK; (2) LOSS OF
CONTROL OVER INTERNAL FUNCTIONS; (3) LOSS OF SENSATION BELOW LEVEL OF INJURY; (4) PERMANENT CONFINEMENT TO A WHEELCHAIR.

Senator Cranston

part or full-time employment resulting in a reduction of tax burden on the public, making a taxpayer out of the veteran and better utilization of the Federal monies spent in the rehabilitation of that veteran. An area of multiple saving for everyone. In general a small portion of the taxpayers' dollar goes towards the support or restoration of the veteran. If money and energy were made available with the ultimate goal of complete rehabilitation of the veteran much of what is now a growing tax burden could be changed into a tax credit. The Congress has a financial obligation to the citizens of this nation and a moral obligation to the disabled veteran. There is no conflict between the two if good sound principles of economics are put to practice. The investment of funds towards restoration of those accounts in order they may become paying accounts. In this case the disabled veterans' restoration back to a whole, useful taxpaying citizen.

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ASSOCIATION OF AMERICAN MEDICAL COLLEGES,

SUITE 200, ONE DUPONT CIRCLE, N.W.,

Washington, D.C., July 19, 1973.
Hon. ALAN CRANSTON,
Chairman, Senate Subcommittee on Health and Hospitals,
Senate Office Building, Washington, D.C.

DEAR SENATOR CRANSTON : The Executive Council of the Association of American Medical Colleges adopted the following resolution at its June 22 business meeting:

The value of biomedical science in an educational environment is long recognized. This is particularly true in the function of the VA hospital. The Executive Council of the Association of American Medical Colleges strongly endorses and reaffirms the role of basic and clinical research in the goal of

health care delivery by the VA. I am pleased to transmit to you this resolution supporting the role of the VA in promoting basic and clinical research. Sincerely,

JOHN A. D. COOPER, M.D.

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(From the Journal of the American Medical Association, June 5, 1972)

HELPING TO MEET THE HEALTH CARE NEEDS OF THE NATION
THE POTENTIAL ROLE OF THE VETERANS' ADMINISTRATION'S HEALTH CARE SYSTEM

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At no time in modern history has there been a greater need for expanding and coordinating the existing elements of the health care system in America. The demands on this system have been created by a number of factors which can be expected to continue to increase for the foreseeable future. Among these factors are the following:

Greater public expectations and demands for improved quality of care as a result of the new knowledge and technical advances made possible by biomedical and social research in disease, health, and medical care.

The desire for maximum application to all the people of that knowledge for the maintenance of health, the prevention of disease, and the treatment of illness at reasonable cost.

Greater expectations for increased and more equitable availability of quality health care to all segments of the population.

Extension of existing voluntary and legislated prepayment plans and the creation of new systems for purchasing health care for the entire population.

Increased amount and scope of social legislation.

Changing age distribution of population, with increasing numbers at both ends of the age spectrum.

Ever-increasing need for continuing education of the health professions and the public for the appropriate and efficient utilization of health care knowledge and resources.

It is evident that the present and future health care needs of all the people cannot be met without improving the delivery systems. In view of this, it is inevitable that some form of national health care program will be adopted within the next few years to meet this need. This will further increase the demand on the system, and exert increasing pressures on the existing resources and those that can be developed in the immediate future.

Although a variety of studies for meeting these health care needs have resulted in legislative proposals in Congress, none yet appears to have achieved a critical mass of acceptance or coordinated support. At this time, no single proposal can be identified as acceptable to all of the organizations, institutions, sociopolitical forces, or individuals involved in the nation's health care system as either deliverers or consumers.

(342)

A Health Care System.-If all persons are to receive the maximum benefits of the increasing knowledge of health maintenance and disease, a health care system must be devised which will work in a coordinated manner. By definition, a comprehensive health care system is a viable formal or informal dynamic, cooperative, cohesive, and coordinated organization of health care agencies, facilities, and staff designed to render a full spectrum of health care, ranging from primary prevention to extended care for all segments of a geographically defined population.

A creatively developed health care delivery system must meet certain professional and economic requirements:

A functional integration of the health services and resources of any region and their effective utilization for the transmission and encouragement of new knowledge and techniques in order to provide high quality care, and make optimal use of all health manpower.

Comprehensive health care services that are available, accessible, and economically feasible for all U.S. citizens, with participation by the recipient in the financing of the service, depending on his ability to pay.

Maintenance of choice in selection of the type of service and the professional providing the service.

Maintenance of the quality of health services through peer review, continuing education, and continuing professional evaluation of all health professionals.

Built-in tangible and scaled incentives for both professionals and institutions for effecting economy of operation.

Built-in mechanisms for protection of the necessary traditional types and for the creation of new types of health manpower and facilities, and for continuous evaluation and improvements in the system for health care delivery.

Built-in mechanisms for maintaining a steady progress in the state of the art and science of health through research.

Improved awareness by those who use the system of where and how services are available, and assurance that they will be available and continue as long as needed.

Provision of health services by a method that enhances not only the dignity and self-respect of the individual, but which contributes to the total society of which he is a part.

There is need for vigorous effort to accomplish these objectives.

Historical Framework of the Current VA System.-Some systems already exist as models for meeting some of these requirements. They have potential for improving the delivery of health care. One such system is that operated by the Department of Medicine and Surgery of the Veterans Administration.

The Veterans Administration's medical program is the largest health care system under centralized management in the United States today. Its antecedents can be traced to the first programs of hospital and domiciliary care established by the federal government in national homes for disabled volunteer soldiers in 1865.

From that time until 1918, there were no essential changes in this elementary system, except that it was complemented by the legislatures of many of the states of the union and of the old Confederacy by the establishment of “soldier's homes" with associated hospital-type facilities. Parenthetically, it should be noted that, except for the expansion of its institutions and their activities in gross terms, there were few significant changes in the nonveteran health care systems during this same period.

After World War I, responding to the needs of a large number of returning veterans with service-connected disabilities, Congress established a more organized and comprehensive federal medical care system as its first effort to provide both inpatient and outpatient care.

During the subsequent decades, further laws entitled veterans to receive care in VA hospitals if they were not able to pay the cost of private care. This program required the veterans to declare themselves unable to pay for their own care.

Unfortunately, but quite naturally, the initial laws which established the VA as a provider of health care and subsequent extensions of those laws have resulted in anomalies in terms of today's practice of medicine and the system for delivery of care. The fact is that entitlements to service are not in terms of groups of veterans, but in terms of disabilities. While a veteran with a serviceconnected condition could be given care on an inpatient or outpatient basis, a veteran with a non-service-connected condition could only be treated on an inpatient basis. Simply put, this meant that the applicant for care of a nonservice-connected condition not only had to have a condition sufficiently serious to require hospital care, but also had no legal right to care before or after hospitalization. No provision was made for illnesses which can be prevented or stabilized outside the hospital in terms of preventive medicine or ambulatory care.

As time passed, the hospitals of the VA became increasingly the institutions to which veteran-patients turned for their health care needs. This resulted in legislative and administrative accommodations to the aforementioned inconsistencies to ensure that the system remained workable and responsive to professional, social, and economic changes.

The developments and changes within the VA system have been well documented. The important events of the 1960's are of great significance to the issues and suggestions contained in this report. In general, during that period certain legislation and its implementation made inroads toward correcting some of the anomalies referred to earlier, and toward broadening the entitlements to care within the VA system. The following are specific examples :

Care before and after hospitalization was authorized and utilized as an initial method for meeting the pressing need for outpatient services.

Nursing home care was established both as a service within VA facilities and contracted for in community nursing homes.

A grant-in-aid program was authorized to provide assistance to states for construction of additional nursing homes for veterans' care.

Authority was established to provide for sharing of scarce medical resources and facilities within the VA system and with facilites of the private sector.

The Department of Medicine and Surgery was authorized to engage in programs for exchange of medical information to provide a system for continuing education of physicians and other allied health professionals.

Comprehensive care was authorized for veterans totally disabled as a result of service-connected conditions.

The requirement that veterans aged 65 or more certify their inability to defray the cost of hospital care for non-service-connected conditions was removed.

In recent years, the VA departed from prior methods of funding hospitals on the basis of average daily patient census. This change, along with previous provisions for treatment before and after hospitalization, led to a sharp drop in the average length of patient stay, and this trend has continued.

STRENGTH AND POTENTIAL OF THE CURRENT VA HEALTH CARE SYSTEM

The laws under which the VA health care system operates limit its ability to provide many of those services and facilities that are recognized as essential to the new patterns of care. However, there are many strengths and potentials in the system that commend it as a model for the future.

It is a system in being for 25 years, and represents a federal investment in excess of $50 billion for operating funds and capitalization.

That system and a commitment to support it can be expected to continue as an integral part of the federal government's responsibility to veterans.

As such, it is not only essentially a prepayment system, for an identified section of the population, but it is a functional system for the delivery of care to those who are so "insured."

The locations of its facilities provide geographic accessibility through an excellent pattern for regionalization, so that a facility is within 100 miles or a twohour drive from 90% of the 28 million veterans.

Its current plans for regionalization not only involve a potential for maximum use of existing facilities and professional manpower, but also provide a potential for a viable and expandable network of continuing education and collaborative research activities.

As already implemented, such regionalization permits both a minimum of expensive duplication and a maximum potential for integration with health

1 Kracke, R.E. : The medical care of the veteran. JAMA 143 : 1321-1331, 1950.

2 Armstrong G.E.: The medical program of the Veterans' Administration. JAMA 171 : 540-544, 1959.

3 Hill, S.R. Jr. : Degrees of freedom open to new and developing medical schools in the utilization of Veterans' Administration hospitals. J Med Educ 45 : 564-570, 1970.

4 Lewis, B.J.: VA medical program in relation to medical schools. House Committee Print No. 170, 91st Congress, 2nd Session, Jan. 19, 1970.

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