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81–591 PDF 2002

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

(II)

COMMITTEE ON GOVERNMENT REFORM

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

STEVEN C. LATOURETTE, Ohio

BOB BARR, Georgia

DAN MILLER, Florida

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

PATSY T. MINK, Hawaii

CAROLYN B. MALONEY, New York

ELEANOR HOLMES NORTON, Washington,

DC

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

——— ———

——— ———

———

BERNARD SANDERS, Vermont

(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

BENJAMIN A. GILMAN, New York

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEVEN C. LATOURETTE, Ohio

RON LEWIS, Kentucky

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

DENNIS J. KUCINICH, Ohio

BERNARD SANDERS, Vermont

THOMAS H. ALLEN, Maine

TOM LANTOS, California

JOHN F. TIERNEY, Massachusetts

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

——— ———

——— ———

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

(III)

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

(1)

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

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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.

6

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.

7

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

20

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

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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, Vietnamera 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;

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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.

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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

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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.]

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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

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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.

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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

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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?

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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.

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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

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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

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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.

59

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

41⁄2 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.

60

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

61

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

62

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

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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 needVerDate 11-MAY-2000 09:17 Sep 25, 2002 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 C:\DOCS\81591.TXT HGOVREF1 PsN: HGOVREF1
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ed 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 evVerDate 11-MAY-2000 09:17 Sep 25, 2002 Jkt 000000 PO 00000 Frm 00068 Fmt 6633 Sfmt 6633 C:\DOCS\81591.TXT HGOVREF1 PsN: HGOVREF1
65

erything 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.

66

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?

67

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?

68

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:]

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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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