[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]
HEPATITIS C: SCREENING IN THE VA HEALTH CARE SYSTEM
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
VETERANS AFFAIRS AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
JUNE 14, 2001
__________
Serial No. 107-97
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
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___________________________________________________________________________
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COMMITTEE ON GOVERNMENT REFORM
DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California PATSY T. MINK, Hawaii
JOHN L. MICA, Florida CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia ELEANOR HOLMES NORTON, Washington,
MARK E. SOUDER, Indiana DC
JOE SCARBOROUGH, Florida ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
BOB BARR, Georgia ROD R. BLAGOJEVICH, Illinois
DAN MILLER, Florida DANNY K. DAVIS, Illinois
DOUG OSE, California JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky JIM TURNER, Texas
JO ANN DAVIS, Virginia THOMAS H. ALLEN, Maine
TODD RUSSELL PLATTS, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
DAVE WELDON, Florida WM. LACY CLAY, Missouri
CHRIS CANNON, Utah ------ ------
ADAM H. PUTNAM, Florida ------ ------
C.L. ``BUTCH'' OTTER, Idaho ------
EDWARD L. SCHROCK, Virginia BERNARD SANDERS, Vermont
JOHN J. DUNCAN, Jr., Tennessee (Independent)
Kevin Binger, Staff Director
Daniel R. Moll, Deputy Staff Director
James C. Wilson, Chief Counsel
Robert A. Briggs, Chief Clerk
Phil Schiliro, Minority Staff Director
Subcommittee on National Security, Veterans Affairs and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida DENNIS J. KUCINICH, Ohio
BENJAMIN A. GILMAN, New York BERNARD SANDERS, Vermont
ILEANA ROS-LEHTINEN, Florida THOMAS H. ALLEN, Maine
JOHN M. McHUGH, New York TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
DAVE WELDON, Florida ------ ------
C.L. ``BUTCH'' OTTER, Idaho ------ ------
EDWARD L. SCHROCK, Virginia
Ex Officio
DAN BURTON, Indiana HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Kristine McElroy, Professional Staff Member
Jason Chung, Clerk
David Rapallo, Minority Counsel
C O N T E N T S
----------
Page
Hearing held on June 14, 2001.................................... 1
Statement of:
Bascetta, Cynthia, Director, Health Care, Veterans' Health
and Benefits Issues, General Accounting Office, accompanied
by Paul Reynolds, Assistant Director, Veterans' Health Care
Issues, General Accounting Office.......................... 6
Murphy, Frances M., M.D., M.P.H., Deputy Under Secretary for
Health, Department of Veterans Affairs, accompanied by Dr.
Lawrence Deyton, Chief Consultant for Public Health, DVA;
Dr. Robert Lynch, Director, Veterans Integrated Service
Network 16, DVA; Mary Dowling, Director, VA Medical Center,
Northport, NY, DVA; and James Cody, Director, VA Medical
Center, Syracuse, NY, DVA.................................. 38
Letters, statements, etc., submitted for the record by:
Baker, Terry, executive director, Veterans Aimed At
Awareness, prepared statement of........................... 26
Bascetta, Cynthia, Director, Health Care, Veterans' Health
and Benefits Issues, General Accounting Office, prepared
statement of............................................... 8
Brownstein, Dr. Allen, president, American Liver Foundation,
prepared statement of...................................... 30
Garrick, Jacqueline, deputy director, Health Care for the
American Legion, prepared statement of..................... 69
Murphy, Frances M., M.D., M.P.H., Deputy Under Secretary for
Health, Department of Veterans Affairs, prepared statement
of......................................................... 41
Shays, Hon. Christoper, a Representative in Congress from the
State of Connecticut, prepared statement of................ 3
HEPATITIS C: SCREENING IN THE VA HEALTH CARE SYSTEM
----------
THURSDAY, JUNE 14, 2001
House of Representatives,
Subcommittee on National Security, Veterans Affairs
and International Relations,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room B-372, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Members present: Representatives Shays, Schrock, Kucinich,
and Platts.
Staff present: Lawrence J. Halloran, staff director and
counsel; Robert Newman and Kristine McElroy, professional staff
members; Jason M. Chung, clerk; Kristin Taylor, intern; David
Rapallo, minority counsel; and Earley Green, minority assistant
clerk.
Mr. Shays. A quorum being present, the Subcommittee on
National Security, Veteran Affairs and International Relations,
hearing entitled, ``Hepatitis C: Screening in the VA Health
Care System,'' is called to order.
The Department of Veterans Affairs, VA Medical Network, has
the potential to function as an indispensable pillar of the
Nation's public health system. The question we address this
morning, is that potential being realized in the VA effort to
screen and test veterans for hepatitis C infection.
With more than 15,000 providers at 1,100 sites, the
Veterans Health Administration [VHA], will see and treat almost
4 million patients this year. Those patients may be
particularly vulnerable to the silent epidemic of hepatitis C
because so many veterans, particularly those who served in the
Vietnam era, may have been exposed to blood transfusions and
blood derived products before the hepatitis C virus, HCV, could
be detected.
In early 1999, the VA launched the HCV initiative, setting
a goal to screen and offer testing to all veterans passing
through VHA medical centers and clinics. It was a responsible
but daunting undertaking in response to a public health crisis
afflicting veterans at three to five times the rate of
infection found in the U.S. population as a whole.
In three previous hearings on the hepatitis C effort, we
heard of frustratingly slow but measurable progress as the
decentralized VA health system struggled to implement and fund
the program consistently across 22 regional networks. We heard
persistent reports of inconsistent outreach, perfunctory
screening and limited access to testing and treatment.
So we asked the General Accounting Office [GAO], to visit a
cross section of VA facilities to address the reach and
vitality of this important public health effort. The GAO
findings indicate the HCV initiative has failed to capture a
significant number of veterans who carry the hepatitis C virus.
Those veterans show no symptoms, do not know they are infected,
but they need medical help to protect their own health and the
health of those around them.
After almost 3 years of attempting to implement this high
priority initiative across the VA system, access to screening
remains inconsistent and limited. Heavy-handed, invasive
screening techniques at some VA facilities discourage
disclosure of HCV risk factors by patients. Many facility
managers see HCV screening and testing as an unfunded mandate,
unaware Congress appropriated $340 million this fiscal year for
the program.
Due to poor VA communication with regions and facilities,
inadequate data systems to measure program performance and
faulty budget estimates, more than half that amount will not be
spent on HCV related care. Adequately funded, the program still
appears to lack focus. According to one estimate, fewer than 20
percent of veterans using VA health care facilities were
screened or tested for HCV. Data recently obtained by VA
indicates up to 49 percent of VA patients may have been within
reach by the HCV initiative over the past 2 years.
But to redeem the promise of the HCV initiative, GAO
recommends VA screen 90 percent of regular VHA patients next
year. Reaching that target will require a far more sustained
and aggressive approach from VA leadership at all levels than
has been evident to date. We hope to hear today how the program
impediments and weaknesses observed by GAO can be addressed,
and how the VA will miss no further opportunities to improve
the public health and the health of the Nation's veterans.
We truly appreciate the skilled work of our oversight
partners, the General Accounting Office, in this ongoing review
of the VA's hepatitis C program. We also appreciate all our
witnesses who bring important perspectives, experience and
expertise to this discussion. We look forward to their
testimony.
[The prepared statement of Hon. Christopher Shays follows:]
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Mr. Shays. At this time I recognize the ranking member, Mr.
Kucinich.
Mr. Kucinich. I thank the Chair. Good morning. Let me
welcome the witnesses from the General Accounting Office and
the Department of Veterans Affairs. I'm glad all of you could
be here today. The issue of hepatitis C is an urgent one for
many veterans in all of our districts. For them, the prospect
of blood tests, biopsies, pharmacological treatments and in
some cases liver transplants can be tremendously frightening.
It's no wonder, therefore, that many veterans and many others
are hesitant to even get tested.
And in the case of hepatitis C, symptoms may not arise for
years, if not decades. So procrastination and avoidance can
have serious impact.
But it's for precisely these reasons that the screening
process, which helps veterans identify their conditions and
come to terms with them, must be an open process, one that is
informative, accessible and encouraging. A system that
arbitrarily restricts screening procedures, or worse, makes
them embarrassing to endure, will only complicate this process
needlessly.
For that reason, I want to thank the Department of Veterans
Affairs for their public statements and policies, recognizing
their lead role in this process. I'm confident of the agency's
commitment to help the veterans in need. However, I remain
skeptical that we're doing all we can to attack this problem
head-on. My skepticism is renewed today by the testimony that
will be presented by GAO.
I want to thank the chairman for calling this hearing, and
I appreciate the Chair's continued commitment in this area.
Mr. Shays. My colleague told me he has three hearings, I
think most of us do, and he already sounds tired.
Mr. Schrock.
Mr. Schrock. Thank you, Mr. Chairman. I too, want to thank
you for being here. I represent the Second Congressional
District, which probably has as many retired people and
veterans in it as any place in the world, and I know that's a
problem.
And I'm sure you're aware of it, this is National Men's
Health Week right now, so I think it's appropriate that you're
here, and I look froward to your testimony. Thank you.
Mr. Shays. I thank my colleague.
Let me just get the unanimous consents taken care of, and
then we will swear in our witnesses. I ask unanimous consent
that all members of the subcommittee be permitted to place an
opening statement in the record and that the record remain open
for 3 days for that purpose. Without objection, so ordered.
I ask further unanimous consent that all witnesses be
permitted to include their written statements in the record,
and without objection, so ordered.
I'd like to ask if you can hear us in the back of the room.
Is it OK? OK.
We have two panels. Our first panel is Ms. Cynthia
Bascetta, Director, Health Care, Veterans' Health and Benefits
Issues, General Accounting Office, accompanied by Mr. Paul
Reynolds, Assistant Director, Veterans Health Care Issues,
General Accounting Office. I would invite both of you to stand,
we will swear you in and then we will hear your testimony.
Raise your right hands, please.
[Witnesses sworn.]
Mr. Shays. For the record, our witnesses have responded in
the affirmative. If you can say anything funny to keep us alive
and awake here, feel free. It's not required. [Laughter.]
We welcome your testimony. We'll get to the questions
afterwards, and then we'll go to our second panel.
STATEMENT OF CYNTHIA BASCETTA, DIRECTOR, HEALTH CARE, VETERANS'
HEALTH AND BENEFITS ISSUES, GENERAL ACCOUNTING OFFICE,
ACCOMPANIED BY PAUL REYNOLDS, ASSISTANT DIRECTOR, VETERANS'
HEALTH CARE ISSUES, GENERAL ACCOUNTING OFFICE
Ms. Bascetta. Mr. Chairman, and members of the
subcommittee, thank you for inviting us to discuss the VA's
efforts to identify veterans with hepatitis C.
Three years ago, VA set out to screen all patients for risk
factors and test those who had at least one. In its budget
justifications, VA made a compelling case that it needed more
money to identify veterans with hepatitis C and provide anti-
viral drug therapy where appropriate. In response, the Congress
provided over $500 million.
Today, we should be commending VA for a model public health
initiative, but instead, we're discussing why most veterans
still have not been screened. Two months ago, VA estimated that
as many as 800,000 veterans had been screened during fiscal
years 1999 and 2000, just 20 percent of those using VA health
care.
Yesterday, VA told us about a new source of data that had
just become available. It focuses on veterans who visited VA
facilities during March and April of this year, and it suggests
that many more veterans have been screened. This is consistent
with our impression that in fact the pace of screening has been
improving over the last few months.
However, VA's new data also suggests that significant
performance problems remain. Most notably, it reveals that
thousands of veterans visited VA facilities during those 2
months and left without hepatitis C screenings. Equally
disturbing, VA told us that the data suggests that about 50
percent of veterans screened nationwide were never tested, even
though they had known hepatitis C risk factors, results that
are consistent with our reviews of medical records at four
facilities we visited.
The sobering consequences are that the majority of VA's
enrolled veterans with hepatitis C likely remain undiagnosed,
potentially as many as 200,000 veterans. These veterans could
unknowingly spread the virus to others and miss important
opportunities to safeguard their health.
A most notable contributor to VA's disappointing
performance was the failure to act in accordance with the high
priority set in its budget submissions. Until early this year,
headquarters communicated its policy objectives through an
information letter that allowed room for interpretation instead
of using directives with clear expectations.
And managers and providers at local facilities told us that
they were unaware of the ability of funding for screening and
testing. As a result, they used their own discretion to
restrict screening. For example, by screening only on certain
days of the week or by letting individual providers use their
own judgment regarding who to screen.
Besides these restrictions, we found flawed procedures when
screening did occur. As you can see on the chart on my left,
many of the risk factors address sensitive topics. Yet at some
sites, providers required veterans to identify their risk
behavior, rather than allowing them to acknowledge that at
least one risk factor applied to them. At other sites, these
questions were asked in areas that lacked sufficient privacy.
As I mentioned earlier, many providers did not order blood
tests, even for patients with known risk factors. Often, these
tests were not ordered because a provider thought that a
patient's age, psychiatric illness or substance abuse would
make them ineligible for treatment.
Mr. Chairman, VA has operated its hepatitis C for almost 3
years without performance targets or adequate oversight. As the
chart on my right shows, the new program director is dependent
on the line authority of the Under Secretary, which extends
through the 22 networks and facility managers to more than
15,000 providers. This management structure suggests to us that
a more systematic approach may be warranted to screen veterans
appropriately and expeditiously.
This could include three key components. First, making
early detection of hepatitis C, a standard for care could
convey the higher priority that headquarters would expect local
managers to place on screening and testing. Second, performance
targets are essential to hold managers accountable. And from
our perspective, these should be results oriented and time
sensitive. And finally, clearer communication regarding
available funding could eliminate misperceptions that the
program is not adequately funded.
In summary, VA has the resources and the know-how to make
up lost ground very quickly. In our view, additional delays,
including this relatively straightforward initiative, are
unnecessary and inexcusable. Mr. Chairman, this completes my
statement, and we'd be happy to answer any questions that you
or other members of the subcommittee might have.
[The prepared statement of Ms. Bascetta follows:]
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Mr. Shays. Thank you. I'd like to get your response to a
few questions, and then we'll get into the next panel. Why
weren't network budget officers, facility managers and
providers aware that VA had received funding for hepatitis C
screening and testing?
Ms. Bascetta. Mr. Chairman, that's a question that brings
to my mind business as usual at the VA. They see their
appropriation as available for any medical care regardless of
how the budget request was developed. They in turn allocate the
money to the networks, and the networks in turn to the
facilities. They expect managers to understand the priorities
that have been set, and to manage to those priorities.
In this case, hepatitis C obviously was not set clearly
enough as an unambiguous priority.
Mr. Shays. So the bottom line is, and let me just say, I
believe that we have to allow flexibility in anyone who has to
manage a Government agency. Sometimes we request nine things
and we only fund for eight. But this was clearly a priority of
Congress and I thought as well the VA. You basically have
literally millions of people who may not know they have this
disease. And ultimately, they get pretty hard, and it's life-
threatening.
But your testimony is that you one, don't think it's a
priority, and two, you think there is the incentive to be using
these funds for other reasons?
Ms. Bascetta. Yes, clearly the funds were used for other
reasons. The problem appears to be a disconnect between the
high priority in the budget justifications and the way the
money was allocated. We agree that the networks and the
facilities need flexibility. And we're not suggesting that the
money be earmarked. We're suggesting instead that the
facilities be made aware of the fact that extra money was
provided for this program, and that the clear expectation of
headquarters is that is a top priority and funds will be
expended to achieve the hepatitis C program goals.
Mr. Shays. Basically, we're talking about 4 million
patients, not 4 million visits?
Ms. Bascetta. Four million patients, correct.
Mr. Shays. We're talking about 22 network directors, 145
facility directors and 15,000 health care providers. They all
need to be into the loop.
Did you determine where the system was breaking down? Did
it get as far as the network directors and the facility
directors? Did the network directors have different goals? You
didn't go into every network, obviously.
Ms. Bascetta. Correct.
Mr. Shays. But can you kind of describe to me where you
think it broke down? And I'm talking about the lack of
communication through the VA's management structure, and how it
affected the screening.
Ms. Bascetta. Right. I think that the first and most
important breakdown is in the vehicle that they chose to
communicate their goal, or their policy objective to screen and
test all veterans. What they did was they issued, in June 1998,
an information letter which is a vehicle that isn't used to
convey mandatory policy. In other words, although the
information letter stated that all patients will be evaluated
for hepatitis C and tested if a risk factor indicates that it's
warranted, so they used an information letter, which is a less
formal vehicle for communication.
What happened was, local managers, in reading this
information letter, didn't feel that it was a requirement or, I
should say, it was ambiguous whether or not there was a
requirement to screen all veterans. In addition, there was no
timeframe in the information letter. So it wasn't, the
information letter didn't convey a sense of urgency about when
headquarters would expect it.
Mr. Shays. So that leads to what recommendations you would
suggest?
Ms. Bascetta. Well, first of all, if in fact they intend it
to be a high priority----
Mr. Shays. You know what? I'm going to actually ask this
question first. Why hasn't the VA completed a performance
standard? In other words, you're talking about, it all relates,
there should be certain goals set out, given to the various
directors, filtered all the way down to the various health care
providers. And I want to know why those standards haven't been
put in place and then your recommendations.
Ms. Bascetta. Unfortunately, I don't have a good answer to
that question. The last two budget submissions have indicated
those performance standards are TBD, to be developed.
Mr. Shays. Say it again?
Ms. Bascetta. TBD----
Mr. Shays. No, I understand to be developed, but the last
two?
Ms. Bascetta. Budget submissions indicated that they
intended to set performance standards.
Mr. Shays. But this is an issue that, it didn't happen in
the last budget and it hasn't happened in this budget?
Ms. Bascetta. Correct. And they're promising that they will
have them for 2003. What we find----
Mr. Shays. Let me understand. What's involved with
getting--I'm not quite sure why it has to wait until 2003.
Ms. Bascetta. Well, we're not either. It's clearly not
rocket science, and they use performance measures in many of
their other programs. It seems to us to be as simple as saying
you'll screen 80, 90, 100 percent of your population within 12
months, whatever the timeframe might be.
Mr. Shays. So at any rate, what's your recommendation?
Ms. Bascetta. With regard to performance standards?
Mr. Shays. Yes. And how they can communicate better.
Ms. Bascetta. First of all, they obviously need to set
those performance targets. They need to be quantifiable and
measurable and results oriented, not process oriented. As I
just said, pick a high percentage, 80, 90 or 100 percent of the
population to be screened, and to be screened within a
specified time limit, say 1 year from the date of the
directive.
Another way to emphasize the urgency of screening this
population as expeditiously as possible is to write into the
directive that veterans are to be screened at their next visit.
In addition, with regard to performance measures that would
convey the urgency of the testing portion of the program, we
think that they need to minimize the gap between assessing a
risk factor and ordering the blood test. And certainly, they
need to order the blood test. As we said, 50 percent of the
tests aren't ordered, even when there is a risk factor.
Mr. Shays. Describe a risk factor.
Ms. Bascetta. The risk factors are the 11 on the chart.
Mr. Shays. So a veteran who comes in, they want to ask
questions about, were you a Vietnam veteran, did you have a
blood transfusion, were you a drug user, that's when it gets a
little more intrusive, some people may not want to admit to
that.
Ms. Bascetta. Right.
Mr. Shays. But they need to be told that if they were, they
could have this disease, and they need to have someone describe
the impact of this disease on them and their loved ones.
Ms. Bascetta. That's correct.
Mr. Shays. A tatoo, body piecing, all those are issues that
you would ask.
Ms. Bascetta. Right.
Mr. Shays. And should be asked. Now, are those questions
out to everyone? All the health care providers, they have that
list?
Ms. Bascetta. They are now. Recently, the first one,
Vietnam-era vet, was added to their guidance. In our visits, we
noticed that some of the sites did not include Vietnam-era vet
as one of the risk factors. And of course, as you can see,
that's one of the ones that would be easiest to answer, because
there isn't a stigma.
Mr. Shays. All Vietnam-era veterans should be asked some
very significant questions.
Ms. Bascetta. Right.
Mr. Shays. OK. In terms of, we have two different
statistics. We have the statistic that basically your feeling
is 20 percent were screened, and we have the VA saying their
new data, since you've done the report, indicates that up to 40
percent may be screened, 49, I'm sorry. Have you had a chance
to look at that data and see--we just received it yesterday.
Were you notified of that?
Ms. Bascetta. Yes, we received it yesterday as well, and we
did spend a number of hours trying to do some very quick
analysis.
Mr. Shays. I'd love to just have your sense of it. I
realize, and this is not a criticism of the VA, but this is new
information. Depending on its accuracy, and I'm assuming that
it obviously points us in the right direction, we should be
happy to see that level. But I'd love to just have a sense of
how comfortable you can be with it. If you can't tell me your
comfort level, I understand.
Ms. Bascetta. Well, I can tell you that the external peer
review program is very rigorous, methodologically sound data.
The frustrating part about this whole analysis has been that,
of course, the VA doesn't have a management information system
that can give us timely and accurate tracking of how well
they're doing.
So just as with their external peer review program
providing some results yesterday, the system wasn't designed to
track and monitor how many veterans have been screened and how
many are positive. The timeframes are different than the
timeframes that we used to do our analysis and that VA in fact
used to do its estimates that it provided for the appropriators
a couple of months ago.
So it seems to me that all the data have basic limitations.
The uncertainty revolves around three key numbers: the number
yet to be screened, the number screened for the risk factor but
not tested; and the overall prevalence. Our conclusion at this
point is that our numbers and our analysis are conservative,
and that there still need to be about 3 million veterans
screened.
So if in fact the conservative prevalence of 6.6 percent is
accurate, that leave potentially 200,000 veterans with this
virus.
Mr. Shays. I'm going to invite counsel to ask questions.
Mr. Halloran. So say that again, the prevalence indication
from this new data is 6.6? Or is that what you found?
Ms. Bascetta. No, 6.6 is the number that VA used to develop
its budget estimates, based on its 1 day survey.
Mr. Halloran. What's the prevalence indicated by the
internal review data? None.
Ms. Bascetta. I don't know.
Mr. Shays. When we're talking prevalence--speak my
language.
Mr. Halloran. How many people were found to have the
disease.
Ms. Bascetta. We don't know the answer to that.
Mr. Halloran. It doesn't show that?
Mr. Reynolds. If it does show it, they didn't share it with
us yesterday.
Mr. Halloran. I see. In your work, did you come across any
indication, in the places you visited, come across any
indications of any other outreach or lookback efforts that VA
was feeling the impact of, a local hospital blood center had
sent back a lookback notice and did a veteran present
themselves to say, hey, I got this letter, I don't quite
understand it, they think I have hepatitis C, did you come
across any trace of anybody else beating the bushes and driving
the veterans toward the VA system on hepatitis C?
Ms. Bascetta. I believe that in Spokane, there was an
outreach letter that went out to all veterans. But I don't know
that we have information on the impact at that facility at that
outreach.
Mr. Halloran. Was it a VA letter, or some externally
derived letter?
Ms. Bascetta. I think it was a VA letter, from the
facility.
Mr. Reynolds. That was a VA letter that they sent out to
everyone in that network. But as we did go around, quite often
concerns were expressed that when other private providers or
insurers would find people that had hepatitis C, and they found
that they were a veteran, that they would strongly encourage
them to go to VA.
Mr. Halloran. On the screening for risk factors, what did
you find in terms of the consistency of the process and the
procedure for presenting information about the risk factors,
and in particular, the need to get the patient to identify one
particular risk factor versus being susceptible to one of those
in a less specific fashion? Why one versus the other?
Ms. Bascetta. Well, in the sites that we visited, a couple
of them did require that the veteran admit to a specific risk
factor. In one location, the form was presented to the veteran
to fill out essentially in the waiting room. And in that case,
the disadvantage was that the kind of counseling that you'd
like to see happen wasn't happening. But I suppose an advantage
was that the veteran didn't have to specify a particular risk
factor.
Mr. Halloran. What is the standard that is recommended and
the VA guidance that you saw in terms of them administering it?
Ms. Bascetta. Well, the guidance isn't as clear as we would
like it to be. It presents the questions and then says,
document the risk factor, but it doesn't say document a
specific risk factor, or document that the veteran acknowledged
one of them. The guidance is unclear.
Mr. Halloran. And in your written testimony, you suggested
that it would be a reasonable target for VA to look to be able
to screen 90 percent of the patients passing through the VHA
system in the next 12 months. Given the resources and the
current state of play as you found it, do you think that's
still possible?
Ms. Bascetta. Yes, we do.
Mr. Halloran. Thank you.
Mr. Reynolds. It's especially possible, if I could add,
because the veterans come many times during the year. I think
that most come four or five times or more. So there's several
opportunities to screen them during the 12 months.
Mr. Shays. Thank you. I want to ask one last question. You
looked at seven facilities, correct?
Ms. Bascetta. Correct.
Mr. Shays. And only one of those facilities used the
clinical reminder system. Explain what the clinical reminder
system is and why only one used it.
Ms. Bascetta. The clinical reminder system is a very
powerful tool. When a patient is in a physician's office, the
computer screen actually displays that the patient needs to be
screened for hepatitis. It's essentially a flag that process
needs to happen.
And we actually found that at one site, they had tremendous
success in using the clinical reminder system. In April 2000,
they were at 13 percent screened. They began publishing the
results by clinic of the numbers, the percentages that were
screened. By September they were up to 50 percent screened, and
by the end of the year, they were actually at 89 percent
screened, because the peers actually saw one another's data and
they did better to perform on that particular clinical
reminder.
Mr. Shays. And this clinical reminder reminds them to ask
questions, not just as it relates to hepatitis C but other
issues as well?
Ms. Bascetta. Correct, yes.
Mr. Shays. What was that facility? Congratulations to them.
Ms. Bascetta. That was the Bronx.
Mr. Shays. The Bronx, OK.
Mr. Reynolds. If I may, what we're talking about, I think,
with the one facility, was using that system as a management
tool for the managers to look and see how well the providers
were doing screening veterans. All of the facilities we went to
used, it was turned on and the providers were getting the
message on their screens, although some of them only turned it
on a week or two or three before our visit.
So the system, from last July through now, has been slowing
been implemented in the system. It's possible that to this day,
there are a couple that don't have it turned on.
Mr. Shays. One of the values of having GAO inspector
general look at issues is that it sometimes encourages people
to look at what they're doing and say, are we meeting the
standards and are we doing what we should do. We got into the
whole issue of hepatitis C in a hearing we had, a monumental
hearing on the safety of the blood supply. We learned that HHS
was not using their review panel to come up with new
recommendations as this Congress had mandated.
But instead of being critical of the agency, the
Department, for not doing it, we just were grateful that they
started. But in the process of looking at the safety of the
blood supply, we invited hemophiliacs, 10,000 of whom had died
during the infection of AIDS. We were told about this kind of
silent killer, and it was called hepatitis C. It was new to us,
and we learned that in the process of the taint of HIV, there
was also hepatitis C.
And this really kind of opened up this understanding to the
committee and I think also to the various departments that it
needed to. It's just sad that we haven't made as much progress
as I think we all have wanted to make. We're just trying to see
that come to conclusion.
Let me ask you, is there any question you feel we should
have asked?
Mr. Platts, welcome. I understand you may have questions
for the next panel, but not this panel.
Is there any question you would like to ask yourself and
then answer?
Ms. Bascetta. No, but I don't think I answered the second
part of your question, which is why aren't more facilities
using the clinical reminder system. The answer is that, there's
very complex software, actually that needs to be installed. And
the computer systems at most of the facilities vary. So it's
almost as though the reminder system needs to be customized,
there has to be custom programming, which requires a high level
of expertise to not only install it but have it produce
reliable information.
There were some initial startup difficulties for both
hardware and software. In some cases, if the hardware was
inadequate, the entire CPRS system, the computerized patient
records system, could be running slowly, which of course would
frustrate providers and cause them not to use it. As well as,
there's always a learning curve with any new technology and
some initial resistance. Frankly, the managers in those
facilities need to tell providers that this is a way that will
dramatically improve quality of care in the long run, and that
they need to get used to the new system.
But we think that one of the most important things that VA
can do is get that clinical reminder system and the
computerized records running everywhere.
Mr. Shays. Individuals who have other jobs but then have to
deal with technology sometimes postpone. I have a computer
that's been sitting on my desk for the last few weeks, and it
is still a mystery to me, but it won't be hopefully for long.
Ms. Bascetta. Once you get used to it, you'll never go
back.
Mr. Shays. I know. But you've got to make that initial
step. So I have to cancel a hearing so I can have the
opportunity. [Laughter.]
Let me thank you. Is there any question, Mr. Reynolds, that
you want to respond to? Anything we should have asked you that
we didn't?
Ms. Bascetta. I don't think so.
Mr. Shays. OK. Thank you very much.
I'll call our next panel. Let me invite our panel to come.
We have Dr. Frances Murphy, Deputy Under Secretary for Health,
Department of Veterans Affairs, accompanied by Dr. Lawrence
Deyton, Chief Consultant for Public Health, Department of
Veterans Affairs, Dr. Robert Lynch, Director of Veterans
Integrated Service Network 16, Department of Veterans Affairs.
Everyone is from the Department of Veterans Affairs. Ms. Mary
Dowling, Director of the VA Medical Center, Northport, NY, and
Mr. James Cody, Director, VA Medical Center, Syracuse, NY.
I was trying to read quickly so I could keep you standing,
but if you would all rise and raise your right hands, please.
[Witnesses sworn.]
Mr. Shays. Note for the record that we have one statement
which would be you, Dr. Murphy, but all will be invited, in
fact, encouraged to respond. Let me ask unanimous consent to
include in the record statements submitted for the record by
Terry Baker, executive director, Veterans Aimed At Awareness.
Without objection, so ordered. And Dr. Allen Brownstein,
president of the American Liver Foundation. Their statements
will be in the record.
[The prepared statements of Mr. Baker and Dr. Brownstein
follow:]
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Mr. Shays. I think what we'll do is we'll get your
statement on the record and then I'll come back for questions.
STATEMENTS OF FRANCES M. MURPHY, M.D., M.P.H., DEPUTY UNDER
SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY DR. LAWRENCE DEYTON, CHIEF CONSULTANT FOR PUBLIC
HEALTH, DVA; DR. ROBERT LYNCH, DIRECTOR, VETERANS INTEGRATED
SERVICE NETWORK 16, DVA; MARY DOWLING, DIRECTOR, VA MEDICAL
CENTER, NORTHPORT, NY, DVA; AND JAMES CODY, DIRECTOR, VA
MEDICAL CENTER, SYRACUSE, NY, DVA
Dr. Murphy. Thank you, Mr. Chairman and members of the
subcommittee. I appreciate this opportunity to discuss VA's
hepatitis C screening, testing, treatment and prevention
programs. With me today are Dr. Lawrence Deyton, Chief
Consultant for Public Health, who coordinates VA's hepatitis C
programs; Dr. Robert Lynch, who is the Network Director in
Network 16, in the southern part of the United States; Mr.
James Cody, the Director at the VA Medical Center in Syracuse,
NY; and Ms. Mary Dowling, who's the Director at the Northport
VA Medical Center in New York.
Hepatitis C, as you know, is a major public health program
for the VA and the United States as a whole. VA has responded
vigorously to the challenges by creating the largest hepatitis
C screening testing and treatment program in the world.
Let me briefly mention just a few of our activities. VA has
issued three directives for information letters outlining
hepatitis C screening and testing guidelines. Over 800 front
line clinicians have participated in VA national education
programs for hepatitis C screening, testing and treatment.
In July 2000, the National Clinical Reminder System was
initiated to alert clinicians about the need for hepatitis C
screening at the time of each patient visit. Even though it is
new, the clinical reminder system shows VA has screened over
734,000 veterans for hepatitis C infection during the last 2
fiscal years, plus the first quarter of this fiscal year, 2001.
We believe that is an underestimate. From fiscal year 1999
through the second quarter of fiscal year 2001, VA performed
over 800,000 hepatitis C tests and identified over 77,000
veterans who currently are under care for hepatitis C.
As you previously acknowledged, I'm pleased to report to
you today on hepatitis C specific aspects of our external
performance review program that reported results to us for the
first time last Friday. The EPRP reviewed nearly 18,000 medical
records of veterans using VHA facilities. In that review, they
found that 49 percent of those veterans had either been
screened or tested for hepatitis C.
Since this is a random review of a very large number of
records, this we believe is a more reliable number than other
data that can currently be derived from our clinical reminder
system, since it has not uniformly been implemented in every
medical center, due to software and computer compatibility
problems.
These data from our external peer review program
demonstrate the VA providers have responded vigorously to
screen and test veterans for hepatitis C. Nearly 2 million
veterans have likely been screened or tested for hepatitis C in
the last 2 years. We are increasing our efforts to ensure that
all VHA users are screened for hepatitis C. I believe these
data also demonstrate that the problem we have is primarily
with our data system and our recording of our efforts. We
depended on these to report on screening and also for budget
estimates. But it appears we have underestimated the screening
activities that have already gone on.
However, despite our successes, we intend to do even more
for hepatitis C screening and testing. We're improving the use
of the clinical reminder system for hepatitis C screening to
make it uniformly available and used across the VHA system.
We've initiated an epidemiologic study, so that we can
determine the actual prevalence of hepatitis C among VA health
care users, and to identify the risk factors in this veteran
population. This will allow us to better target veterans who
are at greatest risks.
We have learned from front line providers and
administrators that we can do a much better job of
communicating our hepatitis C program priorities and the
resources that are available. We have therefore initiated a
number of activities that will improve communications with
front line providers. The National Hepatitis C program office
and VHA's chief information officer are working to establish a
new national hepatitis C registry. This registry will assist us
in accurately tracking veterans with hepatitis C and managing
the resources that VA devotes to helping them.
VA's hepatitis C clinicians are among the most experienced
and well trained in the world. We have hepatitis C lead
clinicians at each VA facility where hepatitis C care takes
place. These clinicians are extraordinarily capable and
experienced in the treatment of this disease. They have
averaged 14 years experience in the care of hepatitis C and
chronic liver disease. These clinicians average 11 years
serving in VA health care. Ninety-four percent of these
physicians have specialty or sub-specialty board certification
in gastroenterology, internal medicine, family practice or
infectious disease. Sixty-two percent of these have academic
affiliations at the level of full professor or associate
professor of medicine, and 44 percent have treated over 500
patients with hepatitis C or chronic liver disease, and 84
percent have treated over 100 patients.
VA makes available all licensed drugs to treat hepatitis C.
We've added to our national formulary the new form of alpha
interferon and made that available as soon as it was licensed
by FDA. Our National Hepatitis C program office informs all of
our clinicians and pharmacists treating hepatitis C patients of
the availability of new treatments upon licensure by the FDA.
The treatment for hepatitis C, as you know, changes rapidly
as new drugs and new information is developed. Thus, the
National Hepatitis C program office is now updating VA's
hepatitis C treatment guidelines and will distribute them to
the field shortly.
Before I close my statement, I would like to address issues
that we have concerning VA's projections about the utilization
of hepatitis C----
Mr. Shays. Maybe I need to ask you, how much time would
that take?
Dr. Murphy. Another minute.
Mr. Shays. I think we can do that. I don't want to rush
you, I'm happy to come back, but if it's a minute, we'll do it
now.
Dr. Murphy. We recently submitted a report to Congress that
articulates the reasons for the differences between our
projections and VA's budget formulation requests. Hepatitis C
is a new disease, the hepatitis C virus was only identified in
1988, the blood test in 1992 and the first treatments approved
in 1997. The previous budget estimates were based on
assumptions that were not informed by reliable data, because
there was no experience on which to base these projections. Our
estimates of the numbers tested, the prevalence and the
treatment acceptance were larger than proved to be the actual
case.
At the same time, our ability to accurately capture
hepatitis C treatment related costs likely missed significant
costs to the VA health care system. Today, based on actual
experience in testing and treating hepatitis C, we feel we
better understand where early assumptions were inaccurate, and
intend to continue to improve the projections for the future.
Because of the magnitude of difference between previous
models and our actual experience, VA revised its projections
for hepatitis C expenditure in fiscal year 2002 to $171
million. The budget planning for 2003 will include use of
improved data.
With that, also, the National Hepatitis C registry will
allow much more accurate reporting and tracking. So we believe
that we'll be able to perform better in the future.
Mr. Chairman, my colleagues and I will be happy to answer
questions.
[The prepared statement of Dr. Murphy follows:]
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Mr. Shays. Let me just say, if you felt a little rushed, we
can have you make any other statement you want. I'll come back.
I have two votes, so it may take a while. We stand in recess.
[Recess.]
Mr. Shays. We were in recess, and we are back in session. I
just want to make sure, just to make sure we get back into
this, if there's any comment that any of you want to make
before we start the questions.
Let me start the process by asking you, we have GAO coming
in and obviously doing a sample study, and then you have a peer
review study. Tell me why you think the numbers differ, and
tell me what you think the peer review study really tells us.
Dr. Murphy. The peer review study was done on a random
selection of charts during a 2-month period in VA. It's part of
our routine peer review quality assessment program. With the
larger number of charts over a broader range of medical
centers, we believe that the data is more accurate than doing a
small number of charts.
That's not a criticism of the GAO methodology. It's simply
a difference in the screening technique that was used and the
depth of the analysis that was done by EPRP.
Mr. Shays. What is the timeframe used in that study?
Dr. Murphy. The charts were pulled from patients who were
seen during March and April. But the analysis was actually
whether risk factor screening was done during the 2-year period
prior to that.
Mr. Shays. How was it conducted?
Dr. Murphy. By actual medical record review. So the way the
information was gathered was that a random number of charts
were selected, 18,000 medical records were reviewed, and in
those medical records, the health care provider would have had
to record risk factor screening for hepatitis C or a positive
test for that chart to be included in the 49 percent positive
for screen.
Dr. Deyton. Positive or negative test, juste any testing.
Mr. Shays. I'm sorry?
Dr. Deyton. The review looked for risk factor screening or
a test for hepatitis C. So the test could be either positive or
negative.
Mr. Shays. OK. By the way, I welcome anyone else jumping in
here. We'll get out into the field and just question. Tell me
how the sample was drawn?
Dr. Murphy. We have a standard sampling methodology that
EPRP uses. What they do is they randomly select from among the
veterans charts who are seen at our facilities nationwide over
a 1-month period. The EPRP reviewers will send a list of charts
to the medical center just prior to their visit to pull, so
that they can be reviewed for a number of quality measures.
Mr. Shays. I was going to ask, and am going to ask, but I
get the inference that it wasn't just one network, it was all
the networks?
Dr. Murphy. Yes.
Mr. Shays. It was random throughout the system. And what is
the margin of error when we do this?
Dr. Deyton. I believe I heard yesterday when we were
discussing this with GAO, I think I recall the EPRP programs
testing, the margin of error is very small, like 97 to 98
percent accuracy. And I should point out, sir, that this is
performed by an external contractor group. They're
professionals in going in and monitoring medical records. So
this is a contract that VA has external to us to review the
quality of the work we're doing in specific areas.
Dr. Lynch. It's in fact a State peer review organization
that does Medicare work for the State of West Virginia. So
they're already an existing group in the State of West Virginia
that does Medicare peer review. And we contracted so we kept it
outside of VA. The sample sizes are designed to be
statistically significant at the network level, so they make
sure they extract enough charts.
Mr. Shays. And how is it determined that a veteran had been
screened and tested for hepatitis C? How did they determine
that?
Dr. Murphy. They actually looked at the medical records,
went back through the progress notes for a 2-year period. And
in one of those progress notes or in a discharge summary, there
needed to be evidence that the veteran was screened for
hepatitis C, and specifically screening for the risk factors
that are on your chart, or that there was a test for hepatitis
C ordered.
Dr. Deyton. I'd be glad to provide to your or your staff,
sir, the specific questions that the reviewers do go and look
in the charts for over the last 2 years. Because they're very
specific instructions, and the reviewers are certified on doing
this in a very accurate way.
Dr. Lynch. They're in fact required to be medical record
technicians or registered record technicians. This is their
job.
Mr. Halloran. And hepatitis C questions were just added t
the external review process?
Dr. Deyton. Yes, sir. Back in I think it was February or
March, when the EPRP staff were developing the questions to go
out in the latest cycle, we were able to insert six specific
questions about hepatitis C for the reviewers to go and look
at.
Mr. Halloran. How often is this done?
Dr. Deyton. Constantly.
Mr. Halloran. The EPRP process?
Dr. Deyton. It's a constant, ongoing process. There are new
questions added every cycle.
Mr. Halloran. A cycle being--my question is, when can we
expect to see another set of data with hepatitis C questions in
it?
Dr. Deyton. We don't have a set time plan, obviously. When
Dr. Garthwaite gave us responsibility for this program, we
wanted to immediately insert in the EPRP some of these
questions to just get a baseline. So obviously we will be going
back to EPRP in the near future to followup on some of these
and other issues that we'll need to for better management of
the program. But I don't have a specific time date in mind.
Mr. Halloran. Let's go down the data and get from it what
we can, and I know it's preliminary and there will be
subsequent analysis. But just to decode some of the data
elements here, the 49 percent is derived from the sample six,
the 17,994, that's the charts reviewed, right?
Dr. Deyton. Yes.
Mr. Halloran. And they found in those 17,994 charts 8,846
showed indications of screening and/or a test, is that correct?
Dr. Deyton. Yes, sir.
Mr. Halloran. Positive or negative. Moving down the rest of
the data, tell me what they represent, if you would.
Dr. Deyton. What I get from these data, and again, we just
got these data the other day, and staff hasn't even had a
chance to do all the analysis and the final sort of summary of
it. But what I get from these data, the important messages,
that first message that of the nearly 18,000 charts that were
reviewed, there was evidence of screening for hepatitis C or a
test in a 49 percent.
The other very important factor to me is that of those who
tested, or who had a risk factor, only 49 percent of those
people actually went on to get a hepatitis C blood test. So
there's another 50 percent that had identifiable risk factors
and were not tested for some reason. I don't know what those
reasons are.
Mr. Halloran. That's the differential the GAO was talking
about?
Dr. Deyton. That's exactly what GAO found as well, yes. So
I think that's a very important lesson here, that there's risk
being identified in the screening, and there is about half who
are not going on to get a blood test for some reason.
Mr. Halloran. What are the possible reasons? I mean, maybe
a veteran says no?
Dr. Deyton. Yes, the veteran says no, or it may be a
situation where the veteran is at incredibly low risk for a
problem, that is, a 90 year old veteran who is in the hospital
with dementia, you might not want to get tested there. Other
reasons may be that the screening itself may be again, I think
GAO found some evidence of this, screening may be going on in a
way where it's happening in a clinic, a waiting room setting or
something like that where the information actually doesn't get
to the doctor or nurse to order the test.
So those are all issues which we need to identify and
figure out how to correct that problem, so that in fact,
testing of all 100 percent who do have a risk factor does
happen.
Ms. Dowling. I would add something to that, just to share
my experience. In the way we rolled out the program, we started
in our primary care area, one team, and then rolled it out
across the team. Over a 12 month period, if you look at our
average of patients who were tested, those who had a risk
factor and were tested, it was 48 percent.
But if you look at how it was rolled out in the beginning,
it was 23 percent, and at the end, it was 90 percent. So it's
really progressed remarkably well in terms of improvement.
Mr. Halloran. I'm glad you raised that. My next question
was to ask the other facility directors here if this data
comports with your experience in the field. Is there any other
surprise besides the 49 percent?
Mr. Cody. I'm from Syracuse. I wasn't surprised at the
data. I thought we were screening much more than the 20 percent
than was being quoted before. I was surprised at that figure.
And at Syracuse, I could show that 20 percent was not the
figure. It's in excess of at least 30 percent that I know have
been screened and given the blood test, at this point, just
over the last year.
What I am finding though, I am a little bit surprised that
of the one that we do the actual questioning or screening on,
most of them are getting the blood test at our place. I'm not
finding that half of them are not getting it. I can't explain
that.
Mr. Halloran. So most who have an identified risk factor--
--
Mr. Cody. Right, just to throw out some numbers, just in
the last 6 months, 6,011 were screened, 41 percent of them
presented some risks. And of those, 98 percent of them got the
blood test.
Mr. Shays. And then what happened?
Mr. Cody. Out of those, then about 15 percent came out
positive.
Mr. Shays. Fifteen of the 41 percent?
Mr. Cody. Yes. Excuse me, 15 percent of the people had the
blood test, which is essentially all the 41 percent that you
just mentioned. So about 15 percent were positive, then they
have the confirmatory test. Of those, it varied between 25 and
40 percent were again positive.
So the numbers diminish very quickly as to who should go on
for treatment. Then I have numbers after that who have actually
gone on for treatment. But that varies significantly. A lot of
people don't go on for treatment for very many reasons.
Mr. Halloran. Right. But that raises the question I think
GAO came across, I think it was your facility or one of them
here, that there was a concern at the provider level about the
implications of the screening and testing, that care was
expensive, or that, why would we test somebody who may be, the
risk factors are so pronounced that they're likely to be
ineligible or not tolerate the care? Is that----
Mr. Cody. I'm not finding that at Syracuse, if I understand
the question. From the whole process, we start with a process
of the patient filling out the screening. That is done in
private with a nurse. The nurse presents it to the provider at
the time in the primary care visit. The provider and the
patient then discuss the results of it. There is a decision
made as to whether the patient wants to get a subsequent blood
test on that.
Once the blood test results come back, then there is
specific counseling with people trained to do the counseling to
tell them what the implications are, what the possible
treatments are, there are contraindications for getting the
treatments. But those are discussed, a decision is made between
provider and the patient to go on or not. And some patients
don't come back.
Mr. Halloran. What is or was your understanding of the
fiscal implications of this program in terms of the facilities,
resources to undertake the screening and testing?
Mr. Cody. The preliminary indications were that this was
going to be very, very expensive. As we've slowly, continuously
progressed and we're actually seeing and actually having to
treat those figures are not coming out as high as we thought
they were going to be. It's still very significant. But I think
originally it was 18 percent of the veteran population was
going to need to treatment at $10,000 apiece. Well, that's not
going to happen, because we're not finding that's going on. Is
that your question?
Mr. Halloran. Yes, exactly.
Dr. Lynch. I think you asked two questions. The first is on
the issue of why this 49 percent is not getting, why we have
this large group of patients who are screened, appear to have
these factors and don't get tested. I don't have the perfect
answer for that, either, but we do have data on people who have
a positive hepatitis C blood test who don't get treated. We've
been able to analyze why they don't get treated, and I suspect
some of that also speaks to this group, why they don't get
tested.
For example, we can go in and look at codes for things that
are objectively codeable that, or laboratory tests, for
example, that would exclude patients from treatment, a low
blood count, which is a contraindication to treatment. We find
that about two-thirds of the patients who have a positive blood
test have a codeable contraindication to treatment.
And I suspect that's also true in this screening group.
Because I suspect, as Dr. Deyton pointed out, we have non-
physicians doing some of the screening, then when it gets to
the physician, they apply a little cognitive input and they can
discriminate and make a decision that probably would not agree
with, but that's probably what's happening.
Mr. Halloran. A codeable diagnosis or condition that would
exclude somebody from treatment is not an exclusionary factor
from testing, is it?
Dr. Lynch. I think in some cases you're right. I think Dr.
Deyton pointed out a case where we'd say it is exclusionary.
For example, I don't think there's much benefit to testing
someone, say, who's institutionalized with advanced dementia.
They won't change their behaviors and we won't change ours.
Somebody who is still functional and has a lot of years to
live, we want them to modify their risk factors, and that
person we should test. So it depends who you're asking the
question about.
The issue of resources, in our network, when the Under
Secretary pulled money out of the reserve to fund, we sent a
specific disbursement agreement through a methodology we used
in the network to our facilities. In fact, I think that was
shared with the GAO site visitors when they visited in Gulfport
and Biloxi. Since that time, we've made it very clear to our
managers how our budget is generated in terms of how hepatitis
C has gone to the that formulation.
Our policies, we've had a policy since March 1999 which is
developed by a committee that consists of our associate
directors, chiefs of staff and nurse executives. That policy is
confirmed and voted on by our PLC, which is our directors,
which basically has to do with how we're going to do these
things. So there should be no ignorance in our facilities about
where the moneys come from, that it's out there and what our
expectations are.
Now, when you get down to the end clinician, I will be the
first to admit we don't always get the perfect information out
to them and a lot of stuff is being thrown out there and things
get confused and there's a lot of competing agendas.
Mr. Shays. I have a few interests. One obviously is that we
have a study that says approximately 20 percent are being
tested, and another study that we received last night,
yesterday, 49 percent. When did you get the results of that
study?
Dr. Deyton. We heard about the results of the EPRP, first
news that we might be able to get an analysis out was Friday
night. I actually was able to see the data and talk to staff
about it Monday morning, this week. We took Monday to
understand it more and shared it immediately then with GAO and
your staff.
Mr. Shays. And immediately is when?
Dr. Deyton. I sent an e-mail to GAO Tuesday, and we talked
Wednesday morning.
Mr. Shays. When did we get this study?
Dr. Deyton. Yesterday.
Mr. Shays. So why do you use the word immediately? Today is
Thursday. And you got the study Friday of last week, and now
you wanted to analyze it before you shared it with the
committee?
Dr. Deyton. I actually was able to talk to staff about the
data Monday morning.
Mr. Shays. Our staff?
Dr. Deyton. No, the staff at the EPRP program at VA.
Mr. Shays. So you knew about the study last Friday, you had
the information on Monday?
Dr. Deyton. Yes.
Mr. Shays. With all due respect, why would we get it
Wednesday afternoon?
Dr. Deyton. I needed to understand if it was real. I was
not as familiar with the EPRP program on Monday morning as I am
now. It was really just a, this has been my education about
that program.
Mr. Shays. Well, I'll tell you how I would have, you had a
study, it's relevant, even whatever it says, there's something
relevant to it. We appreciate getting it before the hearing,
but last night is not very helpful, because then we have a
difficult time making our assessment. So your team immediately,
I just want to take issue with, you didn't do it immediately.
Dr. Murphy. Congressman Shays, I apologize for that. And we
won't let it happen again. We really, at the time that Dr.
Deyton got this information on Monday, needed to verify in fact
what it meant.
Mr. Shays. No, I understand, but I'm just saying to you,
and given the way we interact with each other and the long term
relationship we have, you could have said, by the way, we got
this on Friday, we started to ask questions about it on Monday,
we don't know if it will help or hurt our understanding, but we
want you to be aware it's there, and here's what we know, and
we haven't figured out what it actually says yet, and we'll
invite you to do some questions yourself. I think it would have
been helpful.
Dr. Murphy. It was an error in judgment on our part, and
we'll work more closely with your staff in the future.
Mr. Shays. Yes, there's no reason not to.
When I look at the questions, what I wanted to say is that
whether it's 29 percent or 20 percent or 49 percent, I'm struck
with the fact that it's been over a decade since we've known
about hepatitis C. Now, there's not a cure, and there wasn't
always a way to always identify it. But we knew there was a
problem there. One of the things that we've had a problem with
HHS and with VA is that we weren't getting the word out to
people that they may in fact have hepatitis C.
Now, what I'm struck with is, we're debating 20 or 49
percent, and you gave us a statistic that says 41 percent of
the people who came in were at risk, and of the 41 percent, 15
percent. So we're talking about at least 5 percent of the total
population. If it was 15 of the 41, not 15 of your total. So
we're talking approximately 5 percent.
That's a huge number of people if I projected it out to 4
million. Did you want to say something?
Dr. Murphy. I believe it's 5 percent of those who have risk
factors.
Mr. Shays. Right, and the risk factor was 41 percent. No,
it was 15 percent, I thought you said?
Mr. Halloran. That were positive.
Mr. Shays. What were the numbers, Dr. Lynch? I wrote them
down. I wrote 15, if I wrote incorrectly and I even asked you.
Mr. Cody. I believe you're talking about numbers that I was
providing----
Mr. Shays. I'm sorry, Mr. Cody, you said 41, then said 15
percent of those proved positive.
Mr. Cody. Over the last 16 months, yes.
Mr. Shays. Of the 41, yes. So of the 100 percent, 41
percent were at risk, and you had almost 41 percent take the
test. And of that, 15 percent showed positive, correct?
Mr. Cody. Yes, and then there's one more going down from
that. Of the 15 percent, then you do a confirmatory test, and
about 25 percent of those were confirmed.
Mr. Shays. OK, so 15 percent said, we need to do another
test, in other words. I just want to make sure we agree on
these numbers, my question still stands.
Dr. Lynch. I apologize for the confusion, I think I
understand it now. But I have similar numbers, and it does make
a somewhat different point. We've seen the prevalence, this is
the number of tests, the number of positive tests as a
percentage of patients tested. This is the first time a patient
has been tested, not repeat testing, decline significantly
since we've tracked this now for the last 4\1/2\ years, while
the number of tests have gone up significantly.
For example, this year we're on track to do about four
times as many hepatitis C screening and blood tests as we did
in fiscal year 1996, 1997.
Mr. Shays. You're telling me a point you want me to know,
but I at least want to get an answer to the point I've asked.
Is that all right?
Dr. Lynch. Sure.
Mr. Shays. We had 41 percent who basically showed up as
risks. We had 15 percent of those who, in the initial test,
said we'd better test further to nail it down. Of that 15
percent, 25 percent of the 15 percent proved to have hepatitis
C, correct?
Dr. Lynch. That's correct.
Dr. Murphy. Yes.
Mr. Shays. Which is basically one quarter of the 15
percent?
Dr. Lynch. It's a prevalence rate of about 3 to 4 percent.
Mr. Shays. Yes. Now, 3 to 4 percent of 4 million people is
a large number.
Dr. Murphy. Note those numbers are from one medical center
with a different population and shouldn't be translated to the
national----
Mr. Shays. Fair enough. It could be larger or it could be
smaller.
Dr. Murphy. Right.
Mr. Shays. But those are the numbers we've got, and I
appreciate your qualifying that, because we're going to qualify
the 49 percent, too.
Dr. Lynch. The point I was trying to make was relevant to
that, I didn't mean to interrupt.
Mr. Shays. OK. I just want to nail down that number. We're
making one point, now you make your point.
Dr. Lynch. Well, it's just that these figure change through
time. And I think it has to do with the fact that when you go
and you screen by risk factors, you're trying to narrow down on
a population that has a higher prevalence than the general
population. If you go toward the highest risk factors, you'll
obviously find more patients positive than if you go to a low
risk population. In fact, when we tested in 1997, 27 percent of
the people who had a blood test were positive. This year it's
only 9.84 percent, and it's fallen every year.
In other words, what we're finding is, since we've started
aggressively screening, using risk factors as a screening----
Mr. Shays. But that tells me we should speed up the
process.
Dr. Lynch. Well, I'm not disagreeing with that----
Mr. Shays. No, numbers, let's leave that as the point.
Dr. Lynch. It's just that the prevalence is going to
decline, or the positive are going to decline----
Mr. Shays. The more we test and the more we identify, the
more the numbers are going to decline. So let's get on with it.
The one, I think, problem I have with the VA, almost more than
anything else, and it's a culture that exists, I feel like I
could ask my interns over to the left of me to design a system
that would ensure that every veteran was asked this question,
and they don't have the mind set that we have in the VA, they
wouldn't think that they're allowed a margin of error. I mean,
if I had traffic controllers here, they wouldn't tell me, it's
20 percent or its 49 percent, they don't have those margins of
errors.
We're talking about people's lives, and I don't want to
sound like I'm talking and preaching to you, but we are. And I
need to know this question. I need to know why a simple, now,
I'm looking at the questions you ask, or recommend, this is
Center of Excellence in Hepatitis C Research and Education.
That is VA?
Dr. Lynch. Yes.
Mr. Shays. Now, some of these questions, why did you come
to be tested for hepatitis C, have you ever been tested for
hepatitis C, have you ever received a blood transfusion, have
you ever injected drugs, gets a little more sensitive, if yes,
do you currently inject drugs, have you ever snorted cocaine,
people are probably going to respond not as honestly. Asks
about condoms, it asks about, have you ever been tested for
HIV, how many sex partners have you had, it gets on, have you
ever been tattooed, have you ever had a body piecing, have you
ever been in drug treatment, have you ever felt that you should
cut down on your drinking, have people annoyed you by
criticizing your drinking, have you ever felt bad or guilty
about your drinking.
So these get a little more sensitive with people, but we're
still talking about their lives. And I want to know why every
health care provider isn't required to ask these questions of
the veterans who come in. I need to know why there would be one
person, why even one would escape these questions. I just need
to know. It's like, it's almost like, I'll just make this point
to you, it's like, my gosh, if it's not 20, it's 49, case
closed, let's get on with it. Tell me why there should even be
one person that comes to a VA facility who is not asked this.
And tell me why it wouldn't be the mandate and directive of the
Director of the VA, the Secretary of the VA, to basically say,
this will be done.
Dr. Deyton. Mr. Chairman, we certainly agree that these are
questions that the hepatitis C screening needs to happen much
more. We've got many veterans that need to be screened. There
are occasional examples where it's not appropriate. I have a
clinic at the VA medical center here. And if I have a patient
who comes in with a 104 fever and evidence of bacteria running
through his or her system, I think it's more appropriate for me
to handle that medical situation that's an emergency and then
get to the hepatitis C question later.
Mr. Shays. Right, OK, later means before they leave the
hospital?
Dr. Deyton. Probably, yes.
Mr. Shays. My dad, at one time I told my dad I forgot
something. He said, if I gave you $1 million, would you have
forgotten? I wouldn't have. It just wasn't important to me. And
the question, I almost find it irrelevant what you said to me,
with no disrespect, you're making a point you wouldn't ask them
in the beginning, but now let me ask you why you wouldn't ask
them before they leave.
Dr. Deyton. I would.
Mr. Shays. OK, then why aren't 100 people, why isn't it 100
percent?
Dr. Murphy. Our hepatitis C policy is in directive. And we
have put a clinical reminder system in place in the
computerized patient records system. This year we will require
that clinical reminder system be loaded in every medical center
around the country.
That will allow us to not only require the screening, but
also remind our clinicians on an ongoing basis that if a
patient has not been screened, that they will be.
In addition to that, we've done a number of things to try
to ensure that all of our clinicians are informed about
hepatitis C and the need for screening in the veteran
population. We're going to be doing more education of
clinicians. We've set up a system so that there is a lead
hepatitis C clinician at every facility that does the screening
and testing for hepatitis C.
Mr. Shays. Explain that one. I was going to ask earlier, we
have 11,000 facilities, but that can just be even a small,
intake, outpatient facility. But you say in a place that does,
you said screening? Why wouldn't every place that a veteran
comes in, why wouldn't we be asking these questions?
Dr. Murphy. We should be asking the questions. In some
cases, the lead clinician may be at the parent VA medical
center, rather than out in the contract VA facility. We believe
that if we have a point of contact, so that we can constantly
and continuously feed information to that clinician, and
continue to share information about changes in treatments and
policy, that they can then work within their system to get the
information out to every front line health care provider.
Mr. Shays. Why haven't performance targets been developed
yet?
Dr. Murphy. Performance targets are under development for
fiscal year 2002. They will be in place during the next fiscal
year.
Mr. Shays. We're in fiscal year 2001. So why wouldn't they
be ready for fiscal year 2002? Why not get it ready now? I
don't understand.
Dr. Murphy. They will be in place in October 1st at the
beginning of the next fiscal year.
Mr. Shays. And then what does that mean?
Dr. Murphy. That means that starting in that fiscal year,
on October 1st, we will begin monitoring the performance of
every facility and every network based on the measures that
have been agreed upon.
Mr. Shays. In all facilities?
Dr. Murphy. Yes.
Mr. Shays. OK, so why do we say 2003? That's 2002.
Dr. Murphy. GAO reported to you that it was 2003, sir, but
in fact, we will have them in place in 2002.
Mr. Shays. OK, and that's a certainty, no reason not to?
Dr. Murphy. No reason not to.
Mr. Shays. Technically, there's no reason, tell me why they
couldn't be done in a month? There has to be a reason, I just
don't understand why.
Dr. Murphy. By July, we'll have them developed and then
we'll negotiate the performance agreements for every network
director and they'll be in place----
Mr. Shays. Do they need to be negotiated?
Dr. Lynch. I don't think negotiation is the issue, it's
that our performance contracts run on the fiscal year basis. We
also need to have a system in place to measure the performance.
That's one of the most challenging aspects of this, how do you
tell whether I did what you asked me to do.
Dr. Murphy. That's the reason, in fact, that they're not in
place currently. Because without the clinical reminder system
in place, so that we can track the performance at the facility
level and at the network level, it's difficult for us to set a
measure that was objective and reasonable. The only way to do
that is to have a data system in place to collect the
information and to track it over time.
Mr. Shays. So right now, there is not an incentive for the
managers to be moving forward with asking these questions, at
least in terms of an evaluation. But they're not evaluated
based on their success in this area?
Dr. Deyton. Right now, that's correct. And that will be in
place as Dr. Murphy has said, immediately, and negotiated in
the contracts of the network managers.
Mr. Shays. I'm showing my ignorance here, obviously, but I
guess, it again still sounds a little bureaucratic. It's saying
to me that because of a contract with our managers, we're not
going to do something that would be beneficial to our veterans.
I'm wondering, if you were a competitive business, whether we
would think that way.
Dr. Murphy. No, I think that we've been very clear what our
expectation is of our managers, in terms of implementing the
screening, testing and treatment of hepatitis C in the veteran
populations. We've also improved our prevention and education
efforts. The program has been very aggressive.
What we haven't been able to do is to develop an objective
performance measure to put in the contract, because of the lack
of an adequate data base.
Mr. Shays. See, when you say very aggressive, I'm reacting
the same way that I reacted when you said you gave us the
material immediately, which you didn't. Very aggressive would
mean 100 percent. Why is it very aggressive? We have two people
who are from the district, out in the district who, when GAO
met with them, they did not have aggressive programs. And they
had different reasons for that.
I mean, Mr. Cody, would it be fair to say, Ms. Dowling,
that you have aggressive programs in your facilities?
Ms. Dowling. Through this time period, I would say at this
point I'm working toward that. I would not say that when the
GAO came that I had an aggressive program.
Mr. Shays. OK. And it's not to throw stones, because I'm
sure that your facility does some great things in other areas.
But this is an area that needs improvement. And you could come
to my office and you could point out areas in my own office
that we need improvement.
But let me ask you, why was this an area that was not
getting as much attention as some of the other things that you
were handling?
Ms. Dowling. I think the program was far more complicated
than I initially understood. It took a great deal of time, for
example, to make sure that the education took place across all
of, not just the physicians, but our nurses, we have an
interdisciplinary team in the areas. We had to plan how we
would roll it out. Perhaps this approach other people would not
agree with, but most of our patients go through our primary
care area.
It took some time to plan how we would phase in and test
and make sure things were working and then roll it out across
all of the primary care areas. We're continuing to build on
that. As we measure how we're doing in the progress, we are
improving. But clearly, we're not where you and I think where
we need to be in terms of the 100 percent screening.
Mr. Shays. Is there any reason why on your level you
couldn't make it 100 percent, forget what they did elsewhere,
but in your own facility?
Ms. Dowling. At this point, I absolutely can make it 100
percent.
Mr. Shays. And it shouldn't have to wait until 2 years from
now?
Ms. Dowling. Oh, no, it will not take 2 years.
Mr. Shays. Mr. Cody.
Mr. Cody. To add to what Mary is saying, at Syracuse, we
developed this progressively as well. There was a lot of things
that needed to occur, education, setting it up, tracking it,
making it happen, using the clinical reminders and then
actually gaining the experience from the original estimates of
how significant it was going to be to how it looks like it's
something that is more manageable in that sense.
On July 1st, we're going to be at 100 percent, all our
primary care clinics will be screening the patients in all our
community based outpatient clinics at the medical center, 100
percent is going to be happening just in a couple of weeks.
Mr. Shays. In your facilities?
Mr. Cody. Yes.
Mr. Shays. How is that going to happen?
Mr. Cody. By the use of the clinical reminder system, when
the patient comes in, it comes up actually on the screen.
There's a lot of other things in there, other than hep C, but
that will be up there and the provider will know that the
screening tool needs to be used at that time, and our whole
process will start from there. That will generate need for
blood tests.
Mr. Shays. How much additional time does this add? Is this
a factor in discouraging, in other words, you are understaffed,
I make that assumption, probably pretty accurate, so you're
understaffed, you have people waiting in line, so that
discourages asking a lot more questions. How much time does
this add?
Mr. Cody. I don't treat the patients, so I don't know how
many minutes it's going to take. But it's part of a lot of
other things that we do that have been showing, because of our
preventive approach to care, we've been making a tremendous
difference in the veterans that are coming to us. Hep C is one
of them, but diabetes screening, which helps in reduction in
the number of amputations, pneumonia vaccination. We have
studies showing a number of patients that were caught because
of what we're doing on a preventive nature. These are a lot of
things. Yes, they do take time. I couldn't tell you what
exactly.
Mr. Shays. Mr. Deyton.
Dr. Deyton. Mr. Chairman, in my experience with my
patients, this is not a simple procedure at all. You see the
kinds of questions we have to get into. So on an average,
depending on the patient's receptivity, it probably adds 15
minutes to half an hour to every visit.
Mr. Shays. Why would it have to add 15 minutes?
Dr. Deyton. Oh, Mr. Chairman, you don't just launch into
these questions if you want to get an honest response. You need
to explain, I need to ask you some questions about a blood-
borne infection called hepatitis C. And talk about what that is
and why that might be important to them. You are a Vietnam-era
vet, therefore you might have been exposed to this virus, and
what it means. So I talk to them about the disease, that the
liver----
Mr. Shays. So if I started out and said to you, Dr. Deyton,
we are extraordinarily grateful for your service, but we are
very concerned about the health of you and your colleagues
because of this incredible silent killer called hepatitis C, I
need to ask you some questions that could help extend your
life, and some of them may be very intrusive, but I need to ask
them and you need to give me honest answers in order for us to
make sure that we are doing everything we can for you. You're a
Vietnam veteran, did you have a blood transfusion, and go
through this. I would think that fairly quickly you could ask
it.
Dr. Deyton. Maybe I'm a slow clinician, but I find that
when I ask these questions patients bring up other issues that
are medically germane.
Mr. Shays. Fair enough. So is this a factor in discouraging
these tests? Aside from the fact that you all weren't aware
that some of the money was available out in the field, is
there, we did not appropriate money for the extended--this is a
mandate, in a sense. We require more work to process. Did the
money we appropriate go in part for this? It did?
Dr. Deyton. Yes, it did. And I think GAO found in their
other investigation that there certainly has been sufficient
money to support this screening, testing and treatment.
Mr. Shays. Let me do this. It's 12 o'clock, and this is an
ongoing process. I welcome any of you--did you have a question?
Mr. Halloran. Yes. Two quick ones.
Mr. Shays. Dr. Murphy, I'm very content to have you and Dr.
Deyton leave, with no problem at all. We'll just finish up, Dr.
Lynch and Mr. Cody and Ms. Dowling, if you could stay. We'll
let you get on your way.
Dr. Murphy. We'll be happy to stay until we're finished,
sir.
Mr. Shays. We'll just be a little longer, but I'm happy to
have you leave, no problem.
Dr. Murphy. Thank you.
Mr. Halloran. I just want to ask two quick questions, and
one I asked GAO, which is, and for the facility directors, have
you come across evidence of other outreach or lookback efforts
that your facilities feel the impact of? Has a local blood
center or hospital done anything, or the Liver Foundation done
some letter writing or advertising, have you seen the effects
of other attempts to identify potential hepatitis C infection?
Dr. Lynch. There's a couple things. One is a national
lookback at the blood supply, which every entity that gives
blood participated in. Obviously we did that as a system, and
there were a fair number there. We've seen a number of
independent outreach groups in places like Houston and what
have you. I cannot quantify what that's meant, but yes, it's
been in----
Mr. Halloran. You felt some impact of it?
Dr. Lynch. Yes.
Mr. Cody. I'm not aware of any specific impact on the
Syracuse area. I couldn't comment on that.
Ms. Dowling. There was, to my knowledge, the same as Jim
Cody, I'm not aware of specific efforts of these external
groups that you mentioned.
Dr. Deyton. Could I add to that? I think there have been
some really extraordinary efforts made by several organizations
and as some in collaboration with us. For example, as you may
know, we're working in collaboration with the American Liver
Foundation to distribute 3.4 million brochures to veterans who
use the VHA system, just education brochures on hepatitis C.
Because we recognize that not everybody accesses the system all
the time, and they may have risk factors.
Also the American Legion and Veterans Aimed Toward
Awareness, which is a hepatitis C specific veterans group, have
put together really, I think, helpful education programs for
veterans and their members to learn about hepatitis C that we
are totally supportive of, and glad to see is happening.
Because getting the word out there is how we're going to get
these folks to get screened.
Mr. Cody. As Dr. Deyton just added that, I have to qualify
or add something to my answer before. Through the efforts of
some of the service organizations, like DAV and American
Legion, yes, they have been educating their members. People do
come into our clinics saying, I've read this, I'd like to hear
about it.
Ms. Dowling. I would agree with that, too, Vietnam Veterans
of America.
Mr. Halloran. There was, you mentioned the availability of
the screening of primary care facilities. There was some
indication that GAO worked that in specialty care facilities,
is this more of a challenge there? In a heart clinic or a
diabetes clinic, I presume you have them, other more
specialized care facilities, is this a tougher sell there?
Dr. Lynch. I would answer definitely. Not sell. I think
it's much harder to do it there for a couple of reasons. As you
are probably aware, we do have performance measures we're
trying to improve, the time it takes for a veteran to get into
certain clinics, you named some of them. And I would be loathe
to put an additional burden on those if I felt I could do it
someplace else.
Mr. Halloran. Might those not be some of the only entrance
points for a veteran in the VA system?
Dr. Lynch. That is becoming less and less the case. We are
approaching rather high percentage, at least in our network, I
don't have a figure at hand, of all of our patients who see us
on an ongoing basis who are now enrolled in primary care. Our
goal is to have anybody who's enrolled on an ongoing basis in
primary care.
But also, if you listened to what Dr. Deyton had to say,
I'm less confident that some of these subspecialists would
spend the amount of time necessary and would have the
background and the interest to do what we've asked them to do.
In addition, we've got tight timeframes where we are asking
them to do it.
Dr. Deyton. And in those specific situations, there are
multiple approaches that we can take and that some VAs are
already doing, to do the proper screening in a way that will be
successful and not, say, take a super-subspecialist's time and
energy away. For example, we have great examples of teams of
providers, a nurse, nurse practitioner, somebody even trained
in the testing and counseling area, who can service those areas
to in fact do the screening in all clinics.
So one of the things that we're learning are some of the
best practices that have been put in place in many facilities
and beginning to promulgate those throughout the rest of the
system.
Mr. Halloran. And finally, among the things you gave us
yesterday was a copy of the solicitation for applications for
additional, not centers of excellence, I forget what you called
them, they were field resource centers or something. Why?
Dr. Deyton. Why?
Mr. Halloran. Yes, why?
Dr. Deyton. Why do we need them?
Mr. Halloran. Yes. What's the point? Why are we identifying
more kind of nodes of----
Dr. Deyton. Because what we've learned in talking to the
front line providers in various settings is that they have a
need for some specific products and resources to in fact do
this job. So we are investing in four hepatitis C field based
resource centers to in fact develop those materials to be used
across the system. Those resource centers will focus in four
different areas. One is in patient and patient's family
education, so that we get the proper kinds of materials
together to educate the patient, who's either in screening, or
has tested positive.
The second area is in clinician education and preparedness.
The third area is in prevention and risk reduction,
particularly for those veterans who test positive. What can
they do to modify their lifestyle to keep their livers as
healthy as possible. And the fourth area is in what we were
just talking about, models of care and best practices, and how
to promulgate those across the system.
We believe that these four centers will serve the whole VA,
so that we can have the best practices possible.
Mr. Halloran. And the relationship of these centers to the
existing centers of excellence?
Dr. Deyton. It's the same program. It's just being
redefined and recompeted.
Mr. Halloran. OK.
Dr. Deyton. I'm pleased to say that even as the early word
has leaked out to the VA that these resources will be
available, the competition is going to be very stiff. There's a
lot of interest that has been developed around the hepatitis C
treatment areas by all the work that you've heard has happened.
So we're going to have some excellent centers.
Mr. Halloran. And I didn't notice any particular
application or qualifying criteria to be one of these centers
that you actually treat or have been successful so far in
screening. One hopes that these lessons learned would be
derived from places that have been doing it.
Dr. Deyton. That is certainly the criteria, so I'm sorry
you missed that. But in the application process, the criteria
that each applicant will be judged on is what experience do
they have in the area that they want to work, what successes
have they had, what resources are they going to put to it.
Mr. Shays. I think Mr. Halloran may have asked this
question. Before I go, I want to be clear on this, because I'm
intrigued by the comment that it could take a half hour. I have
15 minute meetings and sometimes they go to 20 or 30, and they
may be interesting, but I then know everything is backed up and
I get anxious and it discourages me from asking questions. But
Mr. Rapallo was asking the same question as well, on minority
staff.
Why can't you, first off, I assume most of our veterans
know how to read. But if they didn't, we could just ask them
orally. Why can't you just give them the questions, say, do any
of the above apply, without having to say which ones?
Dr. Deyton. That certainly is an approach which some places
do, and I think it's one of the best practices that we want to
promulgate around the system.
Mr. Shays. It wouldn't have to take 15 or 20 minutes. After
they say yes, it might. And it puts a little bit of risk on
their part. It may be that if you asked more questions directly
and looked into their eyes, are you sure you're right, you
could, but at least this way you could start to cover more
quickly.
Dr. Deyton. I think there's certainly benefit in that. Let
me tell you the risk of it, too. In many years of experience of
handing out questionnaires to patients in waiting rooms, they
sometimes don't fill those out either or don't fill them out--
--
Mr. Shays. Even if you tell them they could die if they
don't?
Dr. Deyton. Congressman, I think people are worried about
putting something down on paper. And some of these behaviors
are behaviors which have great ramifications to their
eligibility for certain care. And that was drilled into them in
the service. So that gets translated to us as well.
In the HIV arena, sir, I have certainly found that people
don't want to put down on any piece of paper what risk factor
they might have, because they're afraid----
Mr. Shays. Am I reading that if one was a little more so-
called innocent, they wouldn't want to say yes, because someone
might assume it's something worse?
Dr. Deyton. Yes.
Mr. Shays. Well, let me say this. You all are coming back
next year to deal with the treatment side. We are going to ask
you questions about what we asked here. We're going to make an
assumption that you're going to be screening everyone, and that
when we meet next year, we're going to see that it's in place
and that you're screening everyone. Is that a false assumption?
Dr. Murphy. Our goal will be to screen everyone, or at
least offer the opportunity for the screening questionnaire. I
think in any public health program, it is very difficult to
reach 90 percent or 95 percent. So I would have to say
honestly, sir, that I don't think we're going to be able to
come back and tell you that we've screened 100 percent of
patients, no matter how hard we try. We're going to make every
effort to.
Mr. Shays. We're going to be able to know that the
evaluation process will be in place, and I would like to think
it will, maybe the process will be in place, even if you don't
evaluate until the start of the next fiscal year, but you can
give your managers some practice with it. That will be 100
percent. And then you're telling me there are going to be some
that fall through the cracks. But I would like to think that it
would be a very small percent.
Is there any comment that anyone wants to make,
particularly those of you that are out in the field doing this
work?
We'll let you get on your way. Thank you for your time, and
this time when I say the hearing is adjourned--no, it's not
adjourned yet. We have a statement from Jacqueline Garrick, who
is the Deputy Director of Health Care for the American Legion.
I ask unanimous consent that it be submitted into the record,
and it will be.
[The prepared statement of Ms. Garrick follows:]
[GRAPHIC] [TIFF OMITTED] 81591.038
[GRAPHIC] [TIFF OMITTED] 81591.039
[GRAPHIC] [TIFF OMITTED] 81591.040
[GRAPHIC] [TIFF OMITTED] 81591.041
[GRAPHIC] [TIFF OMITTED] 81591.042
Mr. Shays. We are not recessed, we are in fact adjourned,
and you can get on your way. Thank you very much.
[Whereupon, at 12:12 p.m., the subcommittee was adjourned,
to reconvene at the call of the Chair.]
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