We in the Central Office do provide policy and guidelines and, of course, a clinician's decisions are subject to concurrent and retrospective review by peers and by local management authority. When a clinician's performance is found to be inadequate, corrective action is taken by local medical authorities.

We also believe that the advent of the DRG, resource allocation methodology, and the PRO, the peer review organization, on retrospective case review, in the VA medical district will have an additional positive impact on reducing average length of stay of patients in these categories.

We are not aware of any significant problems in the clinical management of these patients. However, I assure you, Mr. Chairman, that we do and will respond fully and take corrective action as troubles arise.

There are two measures before this committee dealing with the management of VA programs to provide care for veterans suffering from post-traumatic-stress disorder. A clinical understanding of this disorder as well as the development of appropriate treatment modality are rapidly evolving. We believe that the agency's record in this area reflects national leadership and amply demonstrates that legislation is really not necessary.

Accordingly, we urge that the agency be permitted to manage PTSD care in accordance with the evolving medical needs rather than pursue it in legislative mandates.

Mr. Chairman, section 5 of S. 2269 and S. 2278 would make permanent the VA's authority to contract in the community for halfway house treatment and rehabilitation for alcohol and drug dependence abuse disabilities. We fully support a 3-year extension in both of these initiatives. Our evaluation of this program shows that it provides an important treatment option for certain veterans who require care beyond existing VA hospital capabilities to restore the veteran to successful community functioning.

In the area of aging, section 3 of S. 2269, would authorize continuation of bereavement counseling for family members of veterans, including those participating in a hospice care program. This provision is needed to provide a fully functioning hospice care program and we fully support it.

Section 6 of S. 2269 provides important new authorities that will improve the effectiveness of VA security forces. We fully support these initiatives with a 3-year limit on special pay authority with the technical modifications discussed in our formal testimony.

Mr. Chairman, S. 2269 contains other important program improvements that we need to fully support or support with modifications as detailed in my formal statement.

S. 2210 places limits on VA's authority to provide automotive adaptive equipment for certain veterans who suffer from severe service incurred disabilities. This bill would provide that such equipment could not be provided more than once in a 3-year period, except when circumstances justify earlier vehicle replacement and would remove the bar to transfer such vehicles earlier. Mr. Chairman, my formal testimony discusses this program and the VA's analysis of this provision.

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Mr. Chairman, there are other important legislative initiatives before the committee that I have not discussed. However, in the interest of time, I will stop now and will be pleased to respond to any questions that you or other members of the committee might have. Chairman SIMPSON. Thank you very much, Dr. Custis.

[The prepared statement of Donald L. Custis, M.D., Chief Medical Director, Veterans' Administration, follows:]

PREPARED STATEMENT OF DONALD L. CUSTIS, M.D., CHIEF MEDICAL DIRECTOR, VETERANS' ADMINISTRATION

Mr. Chairman, and members of the Committee, I am pleased to be here to present the views of the Veterans Administration on S. 2514, the "Veterans' Administration Health Care Amendments of 1984"; S. 2210, a bill to revise and clarify the eligibility of certain disabled veterans for automobile adaptive equipment; S. 2269 and subsequent amendments,, the "Veterans' Administration Health-Care Program Improvements Act of 1984"; and S. 2278, the proposed "Care for Chemically Dependent Veterans Act".

VA/COMMUNITY COORDINATION

S. 2514

S. 2514 contains five major provisions.

First, it would require the VA to designate an office in each health-care facility and in the Central Office to coordinate and make arrangements for the provision of referral services to veterans in obtaining healthrelated services from non-VA sources available in the community. The VA favors the stated purpose of this provision to encourage greater coordination and use of private and non-Federal resources to assist veterans who need additional care following their discharge from VA facilities.

It is not clear that this provision provides VA any enhanced authority, although your comments in the Congressional Record express such an intension, Mr. Chairman.

The VA provides referral services which are already routinely furnished by various personnel including nurses and social workers at all VA medical centers. This is currently an activity which comes under the umbrella of the Information and Referral Program that is the subject of an Interagency Agreement. We see no need for legislation which would simply provide authority for ongoing

activities.

DRUG AND ALCOHOL TREATMENT

Second, this bill would extend the VA's authority to provide contract care to veterans in halfway houses for alcohol or drug abuse disabilities and would mandate certain actions in the administration of the VA's care of veterans suffering such disabilities. We favor an extension of VA's authority under section 620A of title 38, United States Code, as provided for in section 5 of S. 2269 and in S. 2278. However, we favor a three-year extension of the program in order to allow periodic review of the program's effectiveness.

be submitted proposing such an extension.

Legislation will shortly

We object to the alcohol treatment and rehabilitation provisions of S. 2514 because of requirements which tend to prescribe in statute the manner in which VA should treat these disorders. For

example, this provision rigidly limits halfway house treatment for each episode to 60 days. It is already our policy to review all cases at a 60-day point of length of stay, and limit further care based on an individual case review. The average length of stay for our contract halfway house program is 41 days. However, 12 percent of our patients do exceed 60 days based on their need for a longer period of care. The imposition of a 60-day limit on this program would jeopardize the clinical management of this significant number of cases.

Mr. Chairman, this section would also require the VA to promulgate regulations to govern the VA-operated programs for care of veterans for alcohol and drug dependence disorders. Regulations on the use of individualized treatment plans and on the maximum duration of care based on non-VA program averages would be mandated.

Perhaps the regulatory scheme as outlined would be appropriate as a basis for making third-party payment for such service. However, for a direct care provider it will interfere with the clinical management of the individual case. Obtaining valid non-VA wide averages for periods of such treatment is not possible at this time.

Mr. Chairman, we should point out that VA policies do address the apparent purposes of this provision. We have published a program guide which recommends procedures for establishing and operating