II 114th CONGRESS 1st Session S. 1676 IN THE SENATE OF THE UNITED STATES June 24, 2015 Mr. Tester (for himself and Mrs. McCaskill ) introduced the following bill; which was read twice and referred to the Committee on Veterans' Affairs A BILL To increase the number of graduate medical education positions treating veterans, to improve the compensation of health care providers, medical directors, and directors of Veterans Integrated Service Networks of the Department of Veterans Affairs, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Delivering Opportunities for Care and Services for Veterans Act of 2015 or the DOCs for Veterans Act of 2015 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Medical Education and Training Sec. 101. Disregard of resident slots that include VA training against the Medicare graduate medical education limitations. Sec. 102. Extension of period for increase in graduate medical education residency positions at medical facilities of the Department of Veterans Affairs. Sec. 103. Pilot program on graduate medical education residency programs in behavioral medicine in underserved areas. Sec. 104. Inclusion of mental health professionals in education and training program for health personnel of the Department of Veterans Affairs. Sec. 105. Expansion of qualifications for licensed mental health counselors of the Department of Veterans Affairs to include doctoral degrees. TITLE II—Health Care Providers of the Department of Veterans Affairs Sec. 201. Requirement that physician assistants employed by the Department of Veterans Affairs receive competitive pay. Sec. 202. Modification of education debt reduction program of Department of Veterans Affairs to require a certain amount to be spent in rural and highly rural areas. Sec. 203. Report on medical workforce of the Department of Veterans Affairs. TITLE III—Leadership of the Veterans Health Administration Sec. 301. Establishment of positions of Directors of Veterans Integrated Service Networks in Office of Under Secretary for Health of Department of Veterans Affairs and modification of qualifications for Medical Directors. Sec. 302. Pay for Medical Directors and Directors of Veterans Integrated Service Networks. TITLE IV—Other Health Care Matters Sec. 401. Pilot program on providing nurse advice line for veterans in rural and highly rural areas. I Medical Education and Training 101. Disregard of resident slots that include VA training against the Medicare graduate medical education limitations (a) Direct GME Section 1886(h)(4)(F) of the Social Security Act ( 42 U.S.C. 1395ww(h)(4)(F) ) is amended by adding at the end the following new clause: (iii) Disregard of certain resident slots that include VA training For portions of cost reporting periods beginning on or after July 1, 2016, in applying the limitations regarding the total number of full-time equivalent residents in the field of allopathic or osteopathic medicine under clause (i) in a hospital's approved medical residency training program, the Secretary shall not take into account any resident within such program that counts towards meeting the obligation of the Secretary of Veterans Affairs under section 301(b)(2) of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 7302 note). . (b) Indirect GME Section 1886(d)(5)(B)(v) of the Social Security Act ( 42 U.S.C. 1395ww(d)(5)(B)(v) ) is amended, in the second sentence, by striking subsection (h)(4)(F)(ii) and inserting clauses (ii) and (iii) of subsection (h)(4)(F) . 102. Extension of period for increase in graduate medical education residency positions at medical facilities of the Department of Veterans Affairs (a) In general Paragraph (2) of section 301(b) of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 7302 note) is amended— (1) in the paragraph heading, by striking Five-year and inserting Ten-year ; and (2) in subparagraph (A), by striking 5-year period and inserting 10-year period . (b) Report Paragraph (3)(A) of such section is amended by striking until 2019 and inserting until 2024 . 103. Pilot program on graduate medical education residency programs in behavioral medicine in underserved areas (a) Pilot program Commencing not later than one year after the date of the enactment of this Act, the Secretary of Veterans Affairs and the Secretary of Health and Human Services shall jointly conduct a six-year pilot program to establish not less than three graduate medical education residency programs in behavioral medicine in underserved areas in the United States. (b) Elements Each graduate medical education residency program established under the pilot program shall— (1) provide residents participating in the graduate medical education residency program with an opportunity to work with a diverse patient population through a rotation between medical facilities of the Department of Veterans Affairs, facilities of the Indian Health Service, and facilities participating under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ); (2) include graduate medical education in the field of behavioral medicine; (3) be carried out in a manner consistent with graduate medical education residency programs supported and funded by the Department of Veterans Affairs and the Department of Health and Human Services; (4) be located in a community that— (A) is designated as a medically underserved area under section 330(b)(3)(A) of the Public Health Service Act ( 42 U.S.C. 254b(b)(3)(A) ); (B) is in a State with a per capita population of veterans of more than 9 percent according to the National Center for Veterans Analysis and Statistics and the United States Census Bureau; and (C) is within 100 miles of a Reservation (as defined in Section 3(d) of the Indian Financing Act of 1974 ( 25 U.S.C. 1452 )). (c) Report (1) In general Not later than 180 days after the date of the commencement of the pilot program and not less frequently than once each year thereafter while the pilot program is being carried out, the Secretary of Veterans Affairs and the Secretary of Health and Human Services shall, in consultation with representatives from facilities participating under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) that are participating in the pilot program, jointly submit to Congress a report on the implementation of the pilot program. (2) Elements Each report required by paragraph (1) shall include the following: (A) A description of the patient population served by the residents participating in a graduate medical education residency program under the pilot program. (B) A description of the behavioral medicine services provided under the pilot program, including the extent to which those services were provided using telemedicine services. (C) The academic affiliation of each resident participating in a graduate medical education residency program under the pilot program. (D) A description of any impediments faced in carrying out the pilot program and actions taken by the Secretary of Veterans Affairs and the Secretary of Health and Human Services to address those impediments. 104. Inclusion of mental health professionals in education and training program for health personnel of the Department of Veterans Affairs (a) In general In carrying out the education and training program required under section 7302(a)(1) of title 38, United States Code, the Secretary of Veterans Affairs shall include education and training of marriage and family therapists and licensed professional mental health counselors. (b) Apportionment of funding The Secretary shall apportion funding for the education and training program described in subsection (a) equally among the professions included in the program. 105. Expansion of qualifications for licensed mental health counselors of the Department of Veterans Affairs to include doctoral degrees Section 7402(b)(11)(A) of title 38, United States Code, is amended by inserting or doctoral degree after master's degree . II Health Care Providers of the Department of Veterans Affairs 201. Requirement that physician assistants employed by the Department of Veterans Affairs receive competitive pay Section 7451(a)(2) of title 38, United States Code, is amended— (1) by redesignating subparagraph (B) as subparagraph (C); (2) by inserting after subparagraph (A) the following new subparagraph (B): (B) Physician assistant. ; and (3) in subparagraph (C), as redesignated by paragraph (1), by striking and registered nurse and inserting registered nurse, and physician assistant . 202. Modification of education debt reduction program of Department of Veterans Affairs to require a certain amount to be spent in rural and highly rural areas Section 7681 of title 38, United States Code, is amended by adding at the end the following new subsections: (c) Limitation on amounts Not less than 30 percent of the amount of debt reduction payments paid under the Education Debt Reduction Program each year shall be paid to individuals who practice medicine in a rural area or highly rural area or demonstrate a commitment to practice medicine in such an area. (d) Definitions In this section: (1) The term highly rural area means an area located in a county or similar community that has less than seven individuals residing in that county or community per square mile. (2) The term rural area means an area that is not an urbanized area or a highly rural area. (3) The term urbanized area has the meaning given that term by the Director of the Bureau of the Census. . 203. Report on medical workforce of the Department of Veterans Affairs (a) In general Not later than 120 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall submit to the Committee on Veterans Affairs of the Senate and the Committee on Veterans Affairs of the House of Representatives a report on the medical workforce of the Department of Veterans Affairs. (b) Elements The report required by subsection (a) shall include the following: (1) With respect to licensed professional mental health counselors and marriage and family therapists of the Department— (A) how many such counselors and therapists are currently enrolled in the mental health professionals trainee program of the Department; (B) how many such counselors and therapists are expected to enroll in the mental health professionals trainee program of the Department during the 180-day period beginning on the date of the submittal of the report; (C) a description of the eligibility criteria for such counselors and therapists as compared to other behavioral health professions in the Department; (D) a description of the objectives, goals, and timing of the Department with respect to increasing the representation of such counselors and therapists in the behavioral health workforce of the Department; and (E) a description of the actions taken by the Secretary, in consultation with the Director of the Office of Personnel Management, to create an occupational series for such counselors and therapists and a timeline for the creation of such an occupational series. (2) A breakdown of spending by the Department in connection with the education debt reduction program of the Department under subchapter VII of chapter 76 of title 38, United States Code, including— (A) the amount spent by the Department in debt reduction payments during the three-year period preceding the submittal of the report disaggregated by the medical profession of the individual receiving the payments; (B) a description of how the Department prioritizes such spending by medical profession, including an assessment of whether such priority reflects the five occupations identified in the most recent determination by the Inspector General of the Department of Veterans Affairs as having the largest staffing shortages in the Veterans Health Administration; and (C) a description of the actions taken by the Secretary to increase the effectiveness of such spending for purposes of recruitment of health care providers to the Department, including efforts to more consistently include eligibility for the education debt reduction program in vacancy announcements of positions for health care providers at the Department. (3) A description of any impediments to the delivery by the Department of telemedicine services to veterans and any actions taken by the Department to address such impediments, including with respect to— (A) restrictions under Federal or State laws; (B) licensing or credentialing issues for health care providers, including non-Department health care providers, practicing telemedicine with a veteran located in a different State; (C) the effect of limited broadband access or limited information technology capabilities on the delivery of health care; (D) the distance a veteran is required to travel to access a facility or clinic with telemedicine capabilities; (E) the effect on the provision of telemedicine services to veterans of policies of and limited liability protection for certain entities; and (F) issues relating to reimbursement and travel limitations for veterans that affect the participation of non-Department health care providers in the telemedicine program. (4) An update on the efforts of the Secretary to offer training opportunities in telemedicine to medical residents in medical facilities of the Department that use telemedicine, consistent with medical residency program requirements established by the Accreditation Council for Graduate Medical Education, as required in section 108(b) of the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012 ( Public Law 112–154 ; 38 U.S.C. 7406 note). (5) An assessment of the development and implementation by the Secretary of succession planning policies to address the prevalence of vacancies in positions in the Veterans Health Administration of more than 180 days, including the development of an enterprise position management system to more effectively identify, track, and resolve such vacancies. (6) A description of the actions taken by the Secretary, in consultation with the Director of the Office of Personnel Management, to address any impediments to the timely appointment and determination of qualifications for Directors of Veterans Integrated Service Networks and Medical Directors of the Department. III Leadership of the Veterans Health Administration 301. Establishment of positions of Directors of Veterans Integrated Service Networks in Office of Under Secretary for Health of Department of Veterans Affairs and modification of qualifications for Medical Directors Section 7306(a)(4) of title 38, United States Code, is amended— (1) by inserting and Directors of Veterans Integrated Service Networks after Such Medical Directors ; and (2) by striking , who shall be either a qualified doctor of medicine or a qualified doctor of dental surgery or dental medicine . 302. Pay for Medical Directors and Directors of Veterans Integrated Service Networks (a) In general Chapter 74 of title 38, United States Code, is amended by adding at the end the following new subchapter: VII Pay for Medical Directors and Directors of Veterans Integrated Service Networks 7481. Pay for Medical Directors and Directors of Veterans Integrated Service Networks (a) Elements of pay Pay for a Medical Director or Director of a Veterans Integrated Service Network appointed under section 7306(a)(4) of this title (in this section referred to as a Director ) shall consist of basic pay set forth under section 7404(a) of this title and market pay determined under subsection (b). (b) Market pay (1) Each Director is eligible for market pay determined under this subsection. (2) The amount of market pay payable to a Director under this section shall be determined by the Secretary on a case-by-case basis and shall consist of pay intended to reflect needs of the Department with respect to the recruitment and retention (as determined by the Secretary) of such Director. (3) In determining the amount of market pay payable to a Director under this section, the Secretary shall— (A) consult not less than two national surveys on pay for hospital directors, medical facility directors, or other similar positions, whether prepared by private, public, or quasi-public entities, to make a general assessment of the range of potential pay for the Director; and (B) take into account— (i) the experience of the Director in managing facilities or program offices of the Department, including the complexity of such facilities or offices; (ii) the complexity of the facility or facilities to be managed by the Director; (iii) the labor market, in such geographic area as the Secretary considers relevant, for hospital directors, medical facility directors, and other similar positions; (iv) the experience of the Director in managing medical facilities for other Federal agencies, private entities, or non-profit entities; and (v) such other considerations as the Secretary considers appropriate. (4) (A) The Secretary shall evaluate the amount of market pay payable to a Director under this section not less frequently than once every two years and may adjust the market pay payable to such Director as a result of such evaluation. (B) A Director whose market pay is evaluated under subparagraph (A) shall receive written notice of the results of such evaluation. (c) Requirements and limitations on total pay (1) Not less frequently than once every two years, the Secretary shall set forth a Department-wide minimum and maximum amount for total annual pay under subsection (a) that may be paid to a Director and shall publish each such amount in the Federal Register. (2) The minimum and maximum amounts set forth under paragraph (1) shall take effect not earlier than the date that is 60 days after the publication of such amounts under such paragraph. (3) The sum of the basic pay set forth under section 7404(a) of this title and market pay determined under subsection (b) for a Director for a calendar year— (A) may not be less than the most recent minimum amount set forth under paragraph (1) before the beginning of such calendar year; and (B) may not be more than the most recent maximum amount set forth under such paragraph before the beginning of such calendar year. (4) The total amount of compensation paid to a Director under this title in any calendar year may not exceed the amount of annual compensation (excluding expenses) of the President under section 102 of title 3. (5) The Secretary may not delegate to an officer or employee of the Department the requirement of the Secretary to set forth a Department-wide minimum and maximum amount under paragraph (1). (d) Treatment of pay Pay under this section shall be considered pay for all purposes, including retirement benefits under chapters 83 and 84 of title 5 and other benefits. (e) Ancillary effects of decreases in pay (1) A decrease in pay of a Director resulting from an adjustment in the amount of market pay of the Director under subsection (b) shall not be treated as an adverse action. (2) A decrease in the amount of pay of a Director resulting from an involuntary reassignment in connection with a disciplinary action taken against the Director is not subject to appeal or judicial review. . (b) Clerical amendment The table of sections at the beginning of chapter 74 of such title is amended by adding at the end the following: Subchapter VII. Pay for Medical Directors and Directors of Veterans Integrated Service Networks 7481. Pay for Medical Directors and Directors of Veterans Integrated Service Networks. . IV Other Health Care Matters 401. Pilot program on providing nurse advice line for veterans in rural and highly rural areas (a) In general Commencing not later than one year after the date of the enactment of this Act, the Secretary of Veterans Affairs shall conduct a two-year pilot program to assess the feasibility and advisability of implementing in rural areas and highly rural areas with a large percentage of veterans a nurse advice line to furnish to veterans medical advice, appointment and cancellation services, and information on the availability of benefits from the Department of Veterans Affairs. (b) Nurse advice line In carrying out the pilot program under subsection (a) the Secretary shall establish a nurse advice line that— (1) operates free of charge; (2) is based on, and improves upon, the nurse advice line implemented by the Department of Defense for beneficiaries under the TRICARE program (as defined in section 1072(5) of title 10, United States Code); (3) complies with call center requirements set forth by URAC; (4) operates in close consultation with the Secretary to— (A) establish a process through which the eligibility of a caller for the nurse advice line can be validated; (B) allow eligibility and benefit information in possession of the Department of Veterans Affairs to be shared with the nurse advice line; and (C) allow the nurse advice line to connect with appropriate technology and personnel of the Department for purposes of scheduling appointments for the receipt of health care from the Department; and (5) maintains quality controls to ensure that calls are answered by a customer service representative within 30 seconds and with an abandonment rate of less than 5 percent. (c) Services provided The nurse advice line established under the pilot program shall provide an array of services to veterans, including the following: (1) Medical advice from licensed registered nurses who assess the symptoms of the caller using a proprietary clinical algorithm that— (A) has been shown in peer-reviewed medical journals to most closely emulate the clinical decisionmaking processes of physicians; and (B) triages the caller to the appropriate venue at which the caller may receive the health care that they need. (2) Information to address basic questions regarding the eligibility of the caller for benefits from the Department of Veterans Affairs and the availability of those benefits. (3) Use of an appointment clerk to facilitate the scheduling, rescheduling, and cancellation of appointments for health care from the Department. (d) Report (1) In general Not later than 120 days after the date of the completion of the pilot program, the Secretary of Veterans Affairs shall submit to Congress a report on the findings of the Secretary with respect to the pilot program. (2) Elements The report required by paragraph (1) shall include the following: (A) A description of the veterans who have benefitted from advice through the nurse advice line under the pilot program, including the locations of the veterans served. (B) A description of any impediments to the Secretary in carrying out the pilot program. (C) A description of any impediments encountered by individuals in seeking advice or services through the nurse advice line under the pilot program. (D) An assessment of the feasibility and advisability of expanding the pilot program to include more veterans. (e) Definitions In this section: (1) Highly rural area The term highly rural area means an area located in a county or similar community that has less than seven individuals residing in that county or community per square mile. (2) Rural area The term rural area means an area that is not an urbanized area or a highly rural area. (3) Urbanized area The term urbanized area has the meaning given that term by the Director of the Bureau of the Census.