U.S. GOVERNMENT PRINTING OFFICE

59–652 CC WASHINGTON : 1999

VA OUTREACH TO VETERANS AT RISK FOR

HEPATITIS C INFECTION

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

FIRST SESSION

JUNE 9, 1999

Serial No. 106–30

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: 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

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

STEVEN C. LATOURETTE, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

BOB BARR, Georgia

DAN MILLER, Florida

ASA HUTCHINSON, Arkansas

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

GREG WALDEN, Oregon

DOUG OSE, California

PAUL RYAN, Wisconsin

JOHN T. DOOLITTLE, California

HELEN CHENOWETH, Idaho

HENRY A. WAXMAN, California

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

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

CHAKA FATTAH, Pennsylvania

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

HAROLD E. FORD, JR., Tennessee

JANICE D. SCHAKOWSKY, Illinois

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

DAVID A. KASS, Deputy Counsel and Parliamentarian

CARLA J. MARTIN, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

MARK E. SOUDER, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

DAVID M. MCINTOSH, Indiana

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

HELEN CHENOWETH, Idaho

ROD R. BLAGOJEVICH, Illinois

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

JOHN F. TIERNEY, Massachusetts

THOMAS H. ALLEN, Maine

EDOLPHUS TOWNS, New York

BERNARD SANDERS, Vermont

(Independent)

JANICE D. SCHAKOWSKY, Illinois

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

MARCIA SAYER, Professional Staff Member

ROBERT NEWMAN, Professional Staff Member

JASON CHUNG, Clerk

DAVID RAPALLO, Minority Counsel

(III)

C O N T E N T S

Page

Hearing held on June 9, 1999 ................................................................................. 1

Statement of:

Baker, Terry, Vietnam Veterans of America and president of Veterans

Aiming Towards Awareness; George C. Duggins, president, Vietnam

Veterans of America, accompanied by Rick Weidman, director of Government Relations, Vietnam Veterans of America; Dr. Adrian

DiBisceglie, professor, Department of Internal Medicine, St. Louis University, and medical director of the American Liver Foundation; and

Dr. Alan Brownstein, president, American Liver Foundation .................. 26

Garthwaite, Dr. Thomas L., Veterans Administration, Deputy Under Secretary for Health, accompanied by Dr. Tom Holohan, Chief Patient

Care Services Officer; Dr. Toni Mitchell, MBA, chief consultant Acute

Care, Strategic Health Care Group; James J. Farsetta, director, VISN

Region III; and Dr. Simberkoff, chief of staff, New York Harbor Health

Care System .................................................................................................. 3

Letters, statements, etc., submitted for the record by:

Baker, Terry, Vietnam Veterans of America and president of Veterans

Aiming Towards Awareness, prepared statement of ................................. 30

Brownstein, Dr. Alan, president, American Liver Foundation, prepared

statement of ................................................................................................... 57

DiBisceglie, Dr. Adrian, professor, Department of Internal Medicine, St.

Louis University, and medical director of the American Liver Foundation, prepared statement of .......................................................................... 46

Duggins, George C., president, Vietnam Veterans of America, prepared

statement of ................................................................................................... 39

Garthwaite, Dr. Thomas L., Veterans Administration, Deputy Under Secretary for Health, prepared statement of .................................................... 5

Snyder, Hon. Vic, a Representative in Congress from the State of Arkansas, prepared statement of ........................................................................... 17

(1)

VA OUTREACH TO VETERANS AT RISK FOR

HEPATITIS C INFECTION

WEDNESDAY, JUNE 9, 1999

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

2203, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding.

Present: Representatives Shays, Biggert, Towns, Schakowsky,

and Sanders.

Also present: Representative Snyder.

Staff present: Lawrence J. Halloran, staff director and counsel;

J. Vincent Chase, chief investigator; Robert Newman and Marcia

Sayer, professional staff members; Jason Chung, clerk; David

Rapallo, minority counsel; and Jean Gosa, minority staff assistant.

Mr. SHAYS. Let me call this hearing to order. Last year the

House adopted our committee’s call for a more aggressive, coordinated public health response to the silent epidemic of hepatitis C,

HCV, infection. We recommended steps to inform, test and offer

treatment to the 4 million Americans affected by the lingering viral

liver disease. Among those steps, we urged the Department of Veterans Affairs [VA], to determine the prevalence of HCV among VA

patients and reach out to those at risk.

Why ask the already burdened VA health system to take a lead

in a national public health effort? Because recent studies confirm

8 to 10 percent of all veterans suffer from HCV, four to five times

the rate of infection in the general population. At one recent VA

screening, more than a third of the veterans tested positive for

HCV antibodies, with almost two-thirds of those having served in

the Vietnam war era.

According to testimony we heard last year from former U.S. Surgeon General Dr. C. Everett Koop, the VA has a 5-year window to

‘‘head off very high rates of liver disease and liver transplants in

VA facilities over the next decade’’ when those exposed to infected

blood and blood products 20 to 30 years ago will seek care for acute

symptoms, cirrhosis and liver cancer.

Early this year, VA Under Secretary Dr. Kenneth Kizer launched

what he termed ‘‘an aggressive public health approach’’ to HCV by

issuing guidelines to all VA facilities for screening, counseling and

expensive drug therapies. His program calls for ambitious initiatives to educate patients and medical providers, expand epidemioVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 E:\HEARINGS\59652 pfrm09 PsN: 59652
2

logical and clinical research and extend treatment to all who might

benefit, regardless of other eligibility criteria. He has set the VA

on a bold, proactive, high risk course.

It was the right thing to do. In less than a year, the VA has

made an impressive start toward the HCV awareness, testing,

treatment and research some have been demanding for a decade.

The challenge now, and the subject of our discussion today, is how

the VA plans to sustain and expand that promising beginning.

We asked the VA to describe their program to translate a headquarters initiative into effective implementation strategies in all 22

VA service networks. We asked the department’s partners in this

effort—veterans service organizations and the American Liver

Foundation—to describe the barriers to outreach and care they see

every day, and which the VA must still overcome.

The hepatitis C initiative tests the VA capacity to inform patients, to educate physicians, to counsel those at risk and to deliver

consistent care across a decentralized health system. For the VA,

the price of success may be too high if estimates of prevalence are

low, outreach is effective, and a $15,000 course of treatment is indicated for more than a fraction of those with the disease. For veterans with HCV, and for the Nation, the price of failure will be incalculable.

Our goal this morning: To keep the wind in the sails of the VA

hepatitis C initiative and help guide the program toward sustainability and success. We appreciate the time, expertise, and dedication our witnesses bring to this important discussion, and we look

forward to their testimony.

Let me introduce our first panel, Dr. Thomas Garthwaite, Veterans Administration, Deputy Under Secretary for Health, accompanied by Dr. Tom Holohan, Chief Patient Care Service Officer; Dr.

Toni Mitchell, chief consultant Acute Care, Strategic Health Care

Group; and James Farsetta, director, VISN, and Dr. Simberkoff.

Dr. Simberkoff, your background is?

Dr. SIMBERKOFF. I am the infectious disease doctor and the chief

of staff for the New York Harbor Health Care System, which are

two of the facilities in network 3.

Mr. SHAYS. It is wonderful to have all of you here. At this time

I will swear you in and then we will see a quick advertisement on

the screen and then we will take your testimony.

[Witnesses sworn.]

Mr. SHAYS. I note for the record that all have responded in the

affirmative.

At this time before taking your testimony I would like to see the

new public service announcement on hepatitis C which is going to

air soon. It is sponsored by the American Liver Foundation and

Vietnam Veterans of America.

[Video shown.]

Mr. SHAYS. OK, Dr. Garthwaite, you have the floor. My assumption is that we have testimony from you, doctor, and then I will be

happy to take comments if any of you want to make a point or two.

It is important to put your comments on the record. Thank you for

being here.

3

STATEMENT OF DR. THOMAS L. GARTHWAITE, VETERANS ADMINISTRATION, DEPUTY UNDER SECRETARY FOR HEALTH,

ACCOMPANIED BY DR. TOM HOLOHAN, CHIEF, PATIENT

CARE SERVICES OFFICER; DR. TONI MITCHELL, MBA, CHIEF

CONSULTANT ACUTE CARE, STRATEGIC HEALTH CARE

GROUP; JAMES J. FARSETTA, DIRECTOR, VISN REGION III;

AND DR. SIMBERKOFF, CHIEF OF STAFF, NEW YORK HARBOR HEALTH CARE SYSTEM

Dr. GARTHWAITE. Thank you, Mr. Chairman. We submitted a

written statement for the record and I would just like to make several points before we get into the question and answer portion.

First, I would just like to say that we believe that we have made

significant progress since the previous hearing on hepatitis C. We

have developed and promulgated policy about the diagnosis and

screening for patients with hepatitis C. We have developed policy

and promulgated it to patients with hepatitis C and we have dramatically increased the number of veterans who have been tested

for hepatitis C. We have conducted a 1-day surveillance study of

patients presenting to our medical centers who have had blood

tests for other reasons and tested their blood for hepatitis C, which

has given rise to a better sense of what the actual incidence might

be in the total veteran population. We have founded two centers for

the leadership in study and education, and our strategy is to meet

the challenge of providing care for veterans who are infected with

the hepatitis C virus.

We have conducted a conference where 500 caregivers came to

Washington and heard and were educated about strategies for diagnosis and treatment of hepatitis C. We have participated in an

interagency work group with the Department of Defense Health

and Human Services and VA about strategies of the government toward hepatitis C. We have introduced a budget initiative in our fiscal year 2000 budget to provide additional funding so we might

meet the treatment and diagnostic needs for patients.

Finally, we have continued our research of about $12 million, 137

projects with 30 investigators. All of this is designed to aggressively approach what is a very significant problem for veterans and

for all Americans infected with this virus. We face several challenges. One of the challenges is how to do outreach and how to

reach the right people without inducing undo concern in those who

don’t have the virus, and the video that we just saw will be an important part of that effort, and we will face significant challenges

in treating and teaching each of those individuals about the risks

and concerns about hepatitis C.

Second, we have an issue about how to take all of the patients

that we do treat on a regular basis and make sure that we appropriately screen those and then for those who are screened at high

risk, make sure that we test and educate them as well. We have

a policy that says we will do that today. The question is how do

you get policy to happen 100 percent of the time in a very large

system.

One of the things that we can do is education and we have taken

significant steps in education, including various conference calls

that we have had, and a variety of other methods. Another way is

to improve our computer systems and put automated reminders

4

into the encounter software so that it automatically checks to see

if screening and testing has been done, and if it hasn’t to remind

clinicians to do such things, and we are pursuing that as an avenue

to make sure that it only happens because of education, but there

are reminder systems to remind the myriad of clinicians who come

and go through VA hospitals to take that into account.

Finally, we need to make sure that treatment is uniform. We

have guidelines, but guidelines require education and human

beings are fallible when it comes to education so we need to provide

additional systems to make that happen and we are undertaking

a match of our pharmacy data bases with that of our test data

bases to see whether of those who are tested how many are treated,

and then we will sample that to see if those who are not treated,

whether the patient has refused treatment or whether there are

contraindications. I think our biggest fear is pressures on the budget will prevent people from getting treatment, and we don’t find

that acceptable and want to make sure that does not happen.

We have a series of challenges ahead of us, but we have made

significant progress. Like many other diseases of veterans, they are

highly complex issues and it is a very large system and it requires

a significant amount of teamwork and that is why we brought a

number of team members here to the hearing today. We hope that

we will be able to answer all of your questions and look forward

to dialog on this important topic. Thank you.

[The prepared statement of Dr. Garthwaite follows:]

5

6

7

8

9

Mr. SHAYS. Thank you. Any other comments before the questioning?

OK. What is the capacity of the VA to ensure that this program

is implemented uniformly and equitably nationwide in all of our facilities?

Dr. GARTHWAITE. When you say capacity?

Mr. SHAYS. Capacity, financial facilities.

Dr. GARTHWAITE. Well, we have certainly made the commitment

that we will make resources available to diagnose and treat hepatitis C among those veterans certainly for this year, and we assume

into the future. So capacity in terms of budget, at least in the immediate future, I think we made a commitment that that is not an

issue. We will diagnose and treat hepatitis C veterans.

There are some other clinical issues and I will ask my colleagues

to amplify, but one of the issues is how do you get the expertise

to each individual place a veteran can show up in the health care

system and that has been part of our education initiative in having

conferences and educating people from each network.

Mr. SHAYS. What would be helpful—let’s just focus on the costs

first. Break down the different elements that are involved. One is

just educating—one is to educate all of your facilities on what they

need to do. Another is how you educate the potential person with

the disease in terms of coming forward and being tested. So there

are costs involved there. Then there are other costs in terms of just

diagnosis and then there are other costs in terms of treatment and

maybe you can just—I would think if I were part of the VA system,

and if I was one of the veterans groups my biggest concern would

be that Congress will simply appropriate the same amount of

money and you will have to find it somewhere else. So just give me

a sense and make it a part of the record as to what the range of

costs could be.

This is kind of a long question so I am happy to have others of

you participate in the answer.

Dr. GARTHWAITE. Our budget estimate for the fiscal year 2000

budget was $250 million. But there are a lot of assumptions in

there that we don’t know whether they are accurate or not, but we

think——

Mr. SHAYS. Which budget, the one that we are in now?

Dr. GARTHWAITE. The fiscal year 2000, the cycle that is being debated at the present time.

Mr. SHAYS. The budget we are going into. By the way, I am taking off my coat and if any of you want to do the same feel free.

I would think of you better if you would remove your coat.

Mr. FARSETTA. Just don’t ask us to step outside.

Dr. GARTHWAITE. We believe the cost for testing and treatment

per case is about $15,000.

Mr. SHAYS. I just wanted to welcome our member from the minority side, Ms. Schakowsky, and if I could get some business out

of the way, I would ask unanimous consent that all members of the

subcommittee be permitted to place an opening statement in the

record and the record remain open for 3 days for that purpose and

without objection, so ordered. And ask further unanimous consent

that all witnesses are permitted to include their written statement

10

in the record and without objection, so ordered. Is there any point

that you would like to make?

Ms. SCHAKOWSKY. As a freshman I have proven that showing up

counts because I am the ranking member on this side.

Mr. SHAYS. And I want you to treat her with the respect that a

ranking member requires. It is very nice to have you here, Ms.

Schakowsky. Right now we are going to have the VA walk through

the potential cost of getting the system to know how to deal with

this issue, how to alert veterans that they need to come forward

and also the cost of diagnosis and the cost of treatment.

Dr. GARTHWAITE. Let me ask Tom Holohan, who has done a lot

of our cost estimating.

Dr. HOLOHAN. Let me briefly go through some of the factors that

are involved in any cost estimates and one of the distressing things

from a scientific or medical point of view versus a budgetary point

of view is the budget people don’t like ranges. They like a precise

figure. They want a number that they can write a check. Unfortunately in this instance, that is not really possible. The cost of testing an individual patient can run anywhere from $10 to $50. The

initial test is an immunoassay antibody test. If that is positive, it

is automatically repeated and depending on the risk factors you

may ask for an additional test called the RIBA, radio immune blot

assay. Subsequent to that testing if the patient is positive and you

are considering that they may be treatable, there are other tests

that are indicated. The standard of care now includes measuring

viral RNA, which is a moderately expensive test. It also requires— it is recommended that a liver biopsy be performed prior to treatment and there are also now recommendations for viral genotype

testing which are in the range of $200 to $300 because those provide you with prognostic factors which may tell you how long the

treatment should go on for. Mr. SHAYS. So if we add that up, it

amounts to how much per patient?

Dr. HOLOHAN. At that point you are probably talking about several thousand dollars before you initiate treatment. That is not including opportunity costs, physician time, nurse time.

Mr. SHAYS. First the test to show if someone has hepatitis C,

what does it cost?

Dr. HOLOHAN. The initial testing would be in the range of $10 to $20 per head.

Mr. SHAYS. By then we know that they are at risk?

Dr. HOLOHAN. Yes.

Mr. SHAYS. And the next test is to decide what kind of treatment

is advisable?

Dr. HOLOHAN. The next test is the radio immune blot assay. That

is a confirmatory test that is in the range of $50. Subsequent to

that——

Mr. SHAYS. And that tells you what?

Dr. HOLOHAN. That confirms that the patient is antibody positive, it is not a false positive.

Mr. SHAYS. They are at risk, and the next one is they have it or

don’t have it, and we are up to about $70 give or take?

Dr. HOLOHAN. That is correct. The next set of tests would include

measurement of viral RNA, and that is in the range of $200 and

that is both diagnostic and prognostic. That is repeated during any

11

treatment phase so you know whether or not you are in fact eliminating the virus. It is recommended that every patient prior to

treatment have a liver biopsy, and the private sector estimates of

those costs are in the $1,000 to $2,000 range. The VA estimates are

that we can do that for about $500 in round numbers.

Mr. SHAYS. You do it internally?

Dr. HOLOHAN. Yes. We can do it for less cost than the private

sector. The viral genotyping is approximately $300. These are estimates. You might get a better buy in California than in Peoria.

Those tests would have to be repeated at various intervals. The

viral RNA test you would repeat because one of your determinations at the end of treatment is whether the patient has in fact responded to treatment and there are two measures of that. One are

routine liver function tests which are relatively inexpensive and

whether in fact you have eliminated the viral RNA. The treatment

costs for the currently recommended dual therapy are probably in

the range of $12,000 to $15,000 for a course, which is recommended

to be 48 weeks or approximately a year.

Mr. SHAYS. What does that buy you?

Dr. HOLOHAN. That buys you treatment with interferon and

ribavirin.

Mr. SHAYS. And the outcome is what?

Dr. HOLOHAN. I am not sure, what do you mean? What proportion of patients——

Mr. SHAYS. We treat patients because we hope to have a positive

impact. What is the positive impact?

Dr. HOLOHAN. In general most studies have shown that combined

treatment with ribavirin with interferon will clear the virus 6

months after treatment in somewhere between 40 and 50 percent

of cases. That is about twice as high as the viral clearance rate

with treatment with interferon alone. I should caution, however,

that we don’t know that those data will necessarily apply when we

treat veteran patients because the demographics of the patients

treated in most of the published literature with those regimes are

dissimilar demographics from our veteran demographics. We have

a higher number of minority patients who tend not to respond as

well to treatment. In the VA we may get a lower rate of viral clearance, but we don’t know that yet.

Mr. SHAYS. I was told that when we do this type of treatment,

about 40 percent will see a very noticeable benefit.

Dr. HOLOHAN. Right.

Mr. SHAYS. But I didn’t pursue it to know—are we extending

someone’s life? Is the liver going to last a little longer? Are people

literally healed? I have been led to believe that hepatitis C, you are

not going to be healed, at least what we know now.

Dr. HOLOHAN. Again, some of the answers—the difference between what we can provide an opinion on medically——

Mr. SHAYS. I don’t mind a range of possibilities here.

Dr. HOLOHAN. There are liver specialists who have used the word

‘‘cure’’ with respect to sustained viral elimination in hepatitis C.

Dr. Schiff, who works with the VA in the Miami Center of Excellence, has used that word, but then we will routinely qualify it and

say as far as we know.

12

Mr. SHAYS. Your expertise primarily is on the financial side of

this?

Dr. HOLOHAN. No, which should be apparent as I continue to

speak.

Mr. SHAYS. You have endeared me to you already.

Dr. HOLOHAN. Thank you.

The bottom line is we are not certain if there will be an absolute

cure. We do have data that show patients who have cleared virus

and have remained virus free for some years after completion of

dual treatment therapy. There is some hope that you can put yourself in the circumstance of HIV infection where you can very

strongly effect the prognosis of the patient but perhaps not totally

cure him. We don’t know the answer to that yet.

Mr. SHAYS. We really got into the whole issue of hepatitis C kind

of as a silent disease following the infection of blood supply with

AIDS.

Dr. Simberkoff.

Dr. SIMBERKOFF. Yes, if I can amplify on Dr. Holohan’s answer,

the cure rate that is being quoted involves precisely that, eradication of the virus from the blood. None of the patients have been

followed long enough to determine whether their life expectancy is

affected by these treatments or whether or not they will go on to

develop further liver disease. So I think these treatments are relatively new and we need to have lots and lots of followup of patients, particularly in our population.

Mr. SHAYS. How much is spent so far? How much did we put in

this year’s budget just capturing from other parts of your budget.

You are asking for 250 in our next year’s budget, in fiscal year

2000, but what did we put in 1999?

Dr. GARTHWAITE. There is no specific targeted amount for hepatitis C in this budget.

Mr. SHAYS. You are just absorbing it?

Dr. GARTHWAITE. Right.

Mr. SHAYS. Do you know how much you have spent so far?

Dr. GARTHWAITE. I don’t know that we are able to make that assessment.

Mr. SHAYS. Can you give me a sense what you have learned to

date, and we can go from there.

Dr. GARTHWAITE. We have tested approximately 200,000 veterans and diagnosed 38,000 give or take.

Mr. SHAYS. Out of 200,000?

Dr. GARTHWAITE. Right. 200,000 individual tests have been done

in the last 18 months, and about 38,000 unique individuals tested

positive for hepatitis C.

Mr. SHAYS. Let me ask you the basic question, a veteran comes

in routinely or you ask them to, or is it a combination of both?

Then tell me how they are told about hepatitis C and then what

you do.

Dr. HOLOHAN. Well, the information letter that was sent out last

June instructs clinicians to ask patients if they have any of the

specific risk factors for hepatitis C. If they do, they are supposed

to be counseled on the advisability of antibody testing for hepatitis

C. We don’t routinely test everyone who walks in the door because

13

the false positive rate is not insignificant in this disease and it

would be——

Mr. SHAYS. Give me a sense of what not insignificant means to

you?

Dr. HOLOHAN. If the prevalence in the population that you are

testing is below 10 percent, the likelihood of the test reported as

positive being true positive is lower than the likelihood that it is

false positive. And most of that data are available from the routine

hepatitis C testing of donated blood.

Mr. SHAYS. You have a double negative in there. I am having a

hard time in sorting that out.

Dr. HOLOHAN. The likelihood of a positive test being true positive

relates to what the pretest probability of the disease was.

So if you screen all donated blood from let’s say healthy active

duty military people and you get a positive result from John Smith,

the likelihood is that is a false positive.

Mr. SHAYS. And you have to spend $50 more to find that out?

Dr. HOLOHAN. Right. The biggest problems in our assumptions

about the financial implications of hepatitis C relate to the problem

that we don’t know at least two facts, one of which is what is the

true prevalence of hepatitis C in our patients. We think we have

a better handle on it now than we did 6 months ago, but we are

uncertain and the projected cost is very dependent on the prevalence of the disease. The second thing we don’t know is what percentage of our patients are treatable. You will hear testimony later

today that talks about 10 percent. One of our hepatology experts

has provided her opinion that it is 20 percent and other people in

the VA who are equally knowledgeable have said 40 percent. So

when you are making predictions on the cost, it is extraordinarily

dependent on that. Finally, we are not sure what percentage of our

patients will continue with the full 48-week treatment course. As

you will probably hear, these drugs have very, very significant side

effects and it takes a high degree of motivation for a patient who

may not feel ill when you start treatment and you make him feel

much worse.

Mr. SHAYS. I am going to give up the floor but I will want to

come back later and see how we deal with it in a particular area.

Mr. Farsetta, I will be coming back to you.

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. I wanted to ask a

couple of questions about health care workers and the exposure

and the risk that they are at. According to the Centers for Disease

Control, health care workers are one of the groups that are most

at risk of hepatitis C infection due to needle sticks and so I was

wondering if the Veterans Administration plans to adopt the use

of safety design needles and sharps in order to reduce the risk to

health care workers?

Dr. GARTHWAITE. Clearly we have already been using universal

precautions for a long period of time. To my knowledge a significant number of our medical centers already have adopted safe needles and advanced needle and IV designs that decrease the likelihood of needle sticks in health care workers.

Ms. SCHAKOWSKY. Is that policy though or is that just procedure

at some of the places?

14

Dr. HOLOHAN. It is not policy. Actually this has been around for

a little while. There are differences of opinion on the design of various needle arrangements that have automatic sheath retraction

and so on and so forth. In fact, I guess within the past 6 months

I have discussed this with the FDA, and there doesn’t appear to be

a single design that stands out above the others, although some of

the early studies indicate that there is a reduced likelihood of accidental needle stick.

Ms. SCHAKOWSKY. Apparently OSHA in California did a cost-benefit analysis on the use of these safety design needles and sharps

and found because of the testing and treatment costs it saves, businesses and facilities across the State would save a $103 million

each year if safer needles and sharps were utilized, not to mention

that we might save—the estimates of the number of workers that

become infected, it is a wide range but the outside is 5,900 health

care workers who are potentially affected and it seems to me that

this would be a reasonable procedure. What would it take—I am

a cosponsor of legislation that would require that, but I am wondering if that is in the works anyway.

Dr. MITCHELL. Actually, the area that is involved, that is not Patient Care Services. It is the Division for Public Health and Environmental Health. And they are reviewing the use of that. I have

not seen final data, although I have seen a draft review of that.

The major step that was taken that has probably improved that

more than anything else is just not recapping needles because the

initial reason that most people were—had needle stick injuries was

attempting to recap a needle that had already been used. We do

have a policy of not recapping open needles and that they should

be disposed of and every room should have an appropriate OSHA

approved disposal area. So that has been the major thing. And I

know that Dr. Fran Murphy is looking at the issue of needle sticks.

However, the CDC also does not recommend routine testing for

health care workers. What they say is that the testing should take

place only in the circumstance where the needle stick occurred with

a known hepatitis C positive patient so that the testing is very focused in that particular situation.

Dr. GARTHWAITE. I would just say that we totally agree with you

that we must do everything that we can to minimize any chance

of a health care worker being infected and we will double-check

where the review from our occupational health people is and get

back. We have no disagreement whatsoever, we fully believe that

we have to do everything to protect our health care workers.

Mr. SHAYS. Bernie, do you want to vote?

Mr. SANDERS. First of all, my apologies for being late and thank

you for calling this hearing on this very important issue. If I am

asking a question that you already asked, Chris, I apologize. Many

of us have been concerned that the budget for VA health care has

been grossly inadequate, no ifs, ands or buts. My understanding is

that treating hepatitis C is a very expensive proposition. I ask you

a very simple question. If you treat folks with hepatitis C, what

does this mean? Do you have the resources to do it? If you do it,

are you taking money away from other desperately needed areas?

We won’t tell anybody what you said, just between us.

15

Dr. GARTHWAITE. We put forward a budget initiative in the fiscal year 2000 budget for an additional $250 million to treat hepatitis

C. The President’s budget that was submitted did contain the ini- tiative for $250 million. The total budget level kept to the previously agreed upon balanced budget agreement which was no increase, only any increase of medical cost recovery funds we could

make. Therefore, any money for hepatitis C will come from offsets

in efficiencies in other parts of the system.

Mr. SANDERS. In other words, you are going to have to take from

Peter to pay Paul? And Peter is really hard pressed today.

Dr. GARTHWAITE. In the ideal circumstance, we will find efficiencies that don’t affect patient care, obviously.

Mr. SANDERS. I know that you share that concern.

Mr. SHAYS. The bottom line is that there is a line item in the

budget but no money in essence for it.

Dr. GARTHWAITE. Right. There is no additional money because

the President’s budget did conform to the previously agreed upon

balanced budget agreement.

Mr. SHAYS. It is important for that to be part of the record for

me because I want to stay within the budget agreement if we can,

but you would do a disservice if we don’t acknowledge it up front.

The ball is in our court now how we deal with it.

Mr. SANDERS. I don’t agree that we should stay within the caps.

Mr. SHAYS. But we both agree that this is going to cost a plenty

sum, and the money has to be there. I can’t say that it has to come

from within the budget.

Mr. SANDERS. I don’t think there is any great secret that VA hospitals all over this country are hurting and to take money away

from already underfunded areas to deal with this tragedy, people

are going to be worse off.

Mr. SHAYS. In Connecticut, we combined some hospitals and

made some tough decisions. We didn’t see that same success in

Boston. So we have some disputes within our own district which

says there are some savings to be made but frankly those savings

are needed in a whole host of areas besides this.

Mr. SANDERS. But we don’t want to see VA health care undermined, and we are at that point. Now we have to vote.

Mr. SHAYS. We are going to have to recess. This is the only vote

that we have for about 2 hours. We are just going to walk over and

come back but it will probably take us about 15 minutes.

[Recess.]

Mr. SHAYS. I would like to call this hearing back to order and

Bernie Sanders will begin asking questions and also I recognize Vic

Snyder from Arkansas. It is great to have you here.

Mr. SANDERS. Having come—just one question and again I apologize if this issue has been gone into before. The rate of infection

for veterans of hepatitis C is much higher than in the general population. Can somebody explain briefly why that is the case? Is that

because veterans in general being young males primarily are more

at risk or what is the connection?

Dr. GARTHWAITE. We believe right now we can say that when we

tested veterans who showed up for care and were getting blood

treated, it was at the 8 to 10 percent level. What we can’t tell you

exactly is whether that is a true representation of the entire vetVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 E:\HEARINGS\59652 pfrm09 PsN: 59652
16

eran population since smaller number—only a portion of the total

number of veterans use the VA health care system. I think our

population is skewed in that we take people who are disabled, often

combat disabled, which implies that they were wounded in service

or had transfusions in relation to their disabilities perhaps or we

have patients—one of the other selection criteria is the highest priority for veterans is that they are poor. Often in America people

are poor because they are ill to begin with or in some cases because

they suffer from mental illness or disability, including drug and alcohol use, and we know that drug use is highly correlated as well.

So we think that at least the population that we have tested so far

has some significant risk factors, combat wounds, transfusions,

multiple surgeries with transfusions prior to 1990 when testing

was available. Certainly the theaters of Vietnam in particular

where we see the highest prevalence certainly had risk factors associated with them. These are areas in which medics were often

called upon to treat people who were bleeding so there was a fair

amount of mixture and potential cross infection out in the field.

Mr. SANDERS. You think that service in Vietnam is a significant

cause for—perhaps for the disparity of incidence?

Dr. GARTHWAITE. I am not sure—— Dr. HOLOHAN. There is an increased risk for patients with hepatitis C who have been in country in Vietnam, yes. They have a

higher ratio of being positive than veterans who were not.

Mr. SANDERS. On top of the fact that they may be low income

and may use drugs, just presence in Vietnam, everything being

equal, will give you a higher risk factor?

Dr. HOLOHAN. Yes.

Mr. SANDERS. Thank you.

Mr. SHAYS. Congressman Snyder.

Mr. SNYDER. Thank you. I am sorry I’m late, there was a Veterans Subcommittee meeting on health. I have an opening statement that I ask to be submitted in the record.

Mr. SHAYS. Without objection, so ordered.

[The prepared statement of Hon. Vic Snyder follows:]

17

18

19

20

Mr. SNYDER. I have been grappling with this issue of how a veteran picked up an illness in 1968 and we didn’t test for until 1989

or 1990.

No. 1, do any of you have any comments on this issue of how well

we are doing in the VA system in terms of our accuracy of either

affirming or turning down claims for service connection with regard

to hepatitis C? And No. 2, what do we think at this current state

of knowledge is the percentage of those with hepatitis C that we

don’t have a good guess what the etiology is and we just put them

in the unknown category? I don’t know who to direct those questions to.

Dr. GARTHWAITE. With regards to the accuracy of ratings, no one

here is really an expert on that. We could get you for the record

obviously what a reasonable response is about the rating decisions

that have been made. We are reviewing I believe your bill on presumption and getting comments on that so I think as part of our

analysis of that rating, the rating decisions being made, we would

like to provide that for the record.

Tom, do you have any comment on the other part?

Dr. HOLOHAN. I think the bottom line is that in an individual

case from a medical point of view, not a medical legal necessarily

but from a medical point of view, it is almost impossible to determine what the precise proximate cause of infection with hepatitis

C is. A patient may have one, two or many risk factors and to determine which was in fact the proximate cause of the disease is in

my opinion impossible.

Mr. SNYDER. And that does have some revocations. I like your

phrase almost impossible to determine because in 20 to 30 years

of history, some risk factor may be service connected and some risk

factors may not be service connected. I don’t know if my bill is the

best way to get at this problem. I haven’t seen anything better out

there and I think there really are some challenges, having talked

to some of the people who do the ratings. I am a family doctor and

I would hate to be the one who had to flip that coin and make that

kind of determination on this illness. I think doctors are used to

making evaluations on things that you can evaluate, but this is different. You are talking about a point in time. We are physicians,

not detectives. At what point in time did that virus enter that

bloodstream. I will say any comments, criticisms, suggestions on

H.R. 1020, I would be more than receptive to. We are trying to

solve what I think is a problem for some veterans.

Thank you, Mr. Chairman.

Mr. SHAYS. Thank you very much. I have a few questions before

we go to the next panel that I would just like to get on the record.

The first, what outreach initiatives does the VA have underway to

reach the veteran population considered most at risk? If you just

put it in fairly simple terms, what the outreach initiatives are?

Dr. MITCHELL. I think that we have tried to approach the problem in general by first educating our clinicians because they will

be the front line contact with all veterans and the point of the information letter was to help us in risk stratification, which patients

are at greatest risk and therefore need testing and are more likely

to be eligible for treatment.

21

Second, we have developed a Web site which will be Internet accessible by patients and their families.

Mr. SHAYS. When will that be done by?

Dr. MITCHELL. It is actually up now. It is not terribly sophisticated at this point in time, and we are working on that and plan

on soliciting articles both from veteran service organizations, from

our networks, from the facilities, from the American Liver Foundation, from other Federal agencies to provide further information,

but I will be glad to provide to you later the exact Web address because I have learned quickly that a number of them are Web savvy.

We are working with the American Liver Foundation to develop

specific materials, one of which was the PSA that you just saw;

others are written materials which will be delivered to them. We

also have asked and have been working directly with the networks

to have counselors specifically trained to discuss these issues with

patients and their families. We have also been working with the

networks and the ALF to set up support groups so that when a patient tests positive, whether or not they are eligible for treatment

yet, that support groups will be made available to them so that

they can meet on a regular basis.

So there are a number of activities that are going on, both nationally and at the local level. When there has been a request for

assistance for testing, for instance in New York State, the VA had

asked for our assistance in helping to set up a testing program, and

we participate in those kinds of collaborative outreach kinds of programs as well.

Mr. SHAYS. The testimony so far is that some say 10 percent can

be treated, some 20 and potentially up to 40 percent successfully,

and we still haven’t defined success. We would all agree I am assuming that everyone has a right to know that they have hepatitis

C, not knowing that it would be a tragedy for them not to know

how and to begin to find ways to deal with it, and certainly not to

spread the disease and so on. My first question is even if we didn’t

think that we could successfully treat someone with hepatitis C, we

do feel that it is important that they know that they have it; is that

correct?

Dr. MITCHELL. That is correct.

Dr. GARTHWAITE. One of the criteria is patient requests for

screening.

Mr. SHAYS. Any patient who requests will be tested?

Dr. GARTHWAITE. Yes.

Mr. SHAYS. But you don’t test everyone. Everyone who comes in

is not tested for hepatitis C?

Dr. MITCHELL. As I said, with the information letter the point

was if they have absolutely no risk factors, we would not test them

unless they requested to be tested because, as Dr. Holohan described earlier, the risk of a false positive is fairly high. So if they

have no risk factors we do not test. We say you have none of the

known risk factors and we have been more inclusive than the CDC

in that by adding the Vietnam veteran as one and——

Dr. HOLOHAN. Even alcohol abuse, tattooing, or body piercing,

none of which are considered to be risk factors by CDC we do include.

22

Mr. SHAYS. Mr. Farsetta, you have one of the VA service networks?

Mr. FARSETTA. That is correct.

Mr. SHAYS. Can you describe your area?

Mr. FARSETTA. My area is New York City, Hudson Valley and

most of New Jersey.

Mr. SHAYS. As I recall, we had a hearing in one of your areas.

Mr. FARSETTA. Yes, we had a hearing in Waterville, which is

about 2 miles north.

Mr. SHAYS. I will never forget that hearing as long as I live.

Mr. FARSETTA. Neither will I.

Mr. SHAYS. I felt like I was a western judge preventing a lynching.

Mr. FARSETTA. Thank you very much.

Mr. SHAYS. And in the process I almost got lynched myself. If the

choice was between you or me at the end I would have made——

Mr. FARSETTA. The right choice. Public service, wonderful. Go

ahead.

Mr. SHAYS. I got out all right, just a few bad articles in the process. Describe how the HCV initiative has been implemented in network 3?

Mr. FARSETTA. First of all, we have the highest prevalence of

HIV in the Nation in my network. We really have been dealing

with HIV and hepatitis C for a number of years. We actually have

had a collaborative effort between the infectious disease physician,

the GI physicians and the chiefs of medicine and we have been

looking at hepatitis C and have been concerned about hepatitis C,

as I say, for a number of years.

We have tested in excess of 14,000 people in the network. This

year alone we have tested from October 1 to the current date over

10,000 veterans.

Mr. SHAYS. You tested 14,000 total?

Mr. FARSETTA. Roughly, and 10,000 since October 1. We have

2,700 who are positive and we have about 250 who are in treatment and we are adding about 50 per month for treatment. We are

actively testing about 800 veterans per month.

Mr. SHAYS. You just answered the next three questions and you

did it the right order.

Are you taking this out of your own budget?

Mr. FARSETTA. Yes, I am.

Mr. SHAYS. Have you put a cost to it?

Mr. FARSETTA. So far probably this year about $4 million. And

in essence every time we engage a veteran in treatment, we will

be incurring over the course of 48 weeks roughly $15,000. So I am

incurring costs of perhaps $750,000 each month and it doesn’t work

out to be each month but I am essentially using a credit card and

saying whatever it costs to treat you, we will treat you. While this

year is not problematic, with what we are hearing about the budget

for next year it will be terribly problematic and I don’t know how

I will be able to continue to do that.

Mr. SHAYS. I think it is important that the VA know that alarm

bells are going off and putting Congress on notice. We will be debating the VA–HUD bill and it has less money total than last time,

23

and we really have to come to grips with this and you should not

allow me or anyone else to escape the reality of that.

We have been joined by Judy Biggert. I don’t know if you have

any questions.

Mrs. BIGGERT. I have one question. I understand that there really is no cure, but there is the antiviral treatment. And if somebody

is not a good candidate for that and you find out that they have

this, what happens to them?

Dr. SIMBERKOFF. The risk factors that preclude treatment are

often things like alcohol, drug abuse and depression. One of the

things that we are doing is to try to counsel patients about the fact

that either alcohol or drug abuse perpetuates the problem and

often makes it much worse so we are trying to get the patients into

treatment programs so that they can—can deal with those problems. Certainly depression itself is a treatable medical problem. So

again, we are trying to get patients into treatment for those things

which for the most part are keeping them from being candidates,

individuals who are not candidates for treatment.

Mrs. BIGGERT. Is something like depression as a result of having

this or is it a cause?

Dr. SIMBERKOFF. In some cases the medical illness may lead to

the depression. If it doesn’t respond, we will try to deal as best we

can with the medical illness. But in many instances there are other

medical problems. PTSE is another, and these are illnesses that

the VVA has a great experience in trying to deal with. So I think

we are hoping that many of these patients who are not candidates

for treatment today will be better candidates for treatment in days

or weeks to come.

Mrs. BIGGERT. Thank you.

Dr. MITCHELL. I would like to add, if they need other supportive

therapy, in other words they are cirrhotic and that is the reason

that they have advanced liver disease, the reason they are not eligible for treatment, we would continue to provide all of that ongoing supportive medical care to which they would normally be provided. So we do not stop or not do any of the other things simply

because they are hepatitis C positive.

Mrs. BIGGERT. Thank you. Thank you, Mr. Chairman.

Mr. SHAYS. Mr. Sanders.

Mr. SANDERS. Let me get back to dealing with the financial situation of the VA. My understanding, I think, Mr. Farsetta, you indicated that or somebody had mentioned to me in the past if I understand correctly, the VA treats more HIV patients than any other

institution in the world; is that correct?

Mr. FARSETTA. Yes.

Dr. SIMBERKOFF. Yes.

Mr. SANDERS. And that is pretty expensive?

Dr. SIMBERKOFF. Yes.

Mr. SANDERS. Is that also true with hepatitis C?

Dr. GARTHWAITE. I don’t know that we have the data on that.

Mr. SANDERS. I ask that question for the following reason. Treatment of AIDS is obviously very expensive. Treatment of hepatitis

C is very expensive and you asked a moment ago about outreach.

He who has an institution struggling with inadequate financial resources, if in fact somebody said to them we want you to be very

24

aggressive and do the right thing for this country and for the people involved, reach out, bring all of those people in who are veterans and who have AIDS, bring all of those people who are suffering with hepatitis C, and it is going to cost you $10,000 or

$15,000 to treat hepatitis C, of course we are cutting the budget

in the process but we want you to be very aggressive and do the

right thing. I think we are sending you a rather mixed signal, and

I think if I were an administrator, I would probably turn my back.

Or if I were aggressive, I would have to cut back on the World War

II veterans that we are not treating with the respect that they are

due. What am I missing here?

Try to be as honest as you can. I think because ultimately we

are going to have to deal with this issue, if we want these people

to do the right things, we are going to have to fund them or else

we say don’t do the right things.

Mr. SHAYS. I know he is going to be more honest because he

hasn’t been in Washington long enough to know he has to be careful.

Mr. SANDERS. Yes. Be honest. I think it is important that the

U.S. Congress hear the truth, because it is not acceptable because

we want to help the veterans, we are deeply concerned about the

veterans but we are going to cut them and, by the way, we are critical of you for not doing the right thing.

Mr. FARSETTA. I am not sure you have missed anything. I think

it is as we approach 2000, it is really problematic. I think it is

something that from an ethical perspective—I had a conference call

with many of my treating clinicians yesterday on this very issue.

And they are troubled not by today, but by the uncertainty about

tomorrow, that when you engage in screening and make a diagnosis and treatment, then you are really ethically committed to

provide that treatment. And do we want to engage a population

that we are not quite certain that we are going to have the wherewithal to treat 6 months from today when we know the treatment

is 48 weeks. So it is really problematic.

Mr. SANDERS. In other words, something is coming in, we have

bad news for you, hepatitis C, but we can’t treat you.

Mr. FARSETTA. Well, I think what we are doing is we are saying,

we have bad news, you have hepatitis C, we are going to treat. The

clinicians right now are not saying, but in 6 months we are not

going to have the money, but they are saying to me, based upon

the dialog we have had about based upon what the budget looks

like for next year, do you have the resources to provide the wherewithal that is necessary for next year, and my response is A, I

don’t know; and if I don’t, then something else will have to go, because we are really committed to doing this.

Mr. SANDERS. But in the back of your mind—you were asked

about outreach. I would assume if I were sitting in your chair, I

would not be all that aggressive. I mean you don’t have to tell me

whether you are or not and I know there are ethical concerns here,

but in the real world, how are you going to launch a major outreach campaign if you are going to have to tell folks that you can’t

treat them? Anyone else want to comment on that?

Dr. GARTHWAITE. I think you raise very valid concerns. We have

had internal discussions where we have really talked about what

25

are some alternatives if the money doesn’t stretch, to provide all

benefits to all comers, does that mean we then stop seeing priority

7 veterans. The reality is with the third-party insurance payments

we get from priority 7 veterans and the fact that on average they

cost less, it appears that they do not cost the VA a lot of money;

i.e., if we stop seeing priority 7 veterans, we wouldn’t save a lot of

money.

So that I think was at least an initial concern about how to make

all, you know, balanced budget numbers work was, in part, if you

really get tight for money, you don’t have to see the higher income

veterans. The reality is they don’t necessarily—by stopping seeing

them, you don’t necessarily save a lot of money. So then you are

really talking about, since there aren’t really that many priority 6

veterans, you are really talking about priority 5 veterans who do

meet a means test for poverty.

My guess is if you had a hepatitis C-positive priority 5 veteran

who meets a means test for poverty, that they are likely going to

seek public resources for the treatment of their hepatitis C. You

know, if the VA is not seeing them, I don’t think that means that

the taxpayer isn’t going to help out here, and I think that we do

a good job and would like to see us be able to do that.

So I think we just have to work our way through how many we

can see within the budget we are given, but I think it is probably

good public policy to let the VA treat a fair number of hepatitis C

patients. We learn a lot, I think we do a lot of research at the same

time, and I think we do it compassionately as well, over the years

that we have seen these patients, and I think it makes a lot of

sense.

Mr. SANDERS. Let me just conclude by making a request. I think,

and Chris or anybody else can disagree with me, but I am not sure

that the average Member of Congress is fully aware of the financial

stress that the VA system is under, given the load that they have

to deal with, and I don’t know that the VA has done—and I know

that you are not able to lobby also, but I think you could do a better job in saying to the Members of Congress, just explaining.

I talked to Dr. Kizer about this as well, but to say, look, with

this amount of money, this is what we can’t do. Congress ultimately has to make that choice and they should make that choice

with their eyes open, and I would hope that you would give us

those facts.

What does it mean if your budget is cut? Tell us the honest

truth. Is that something you think you could perhaps work on a little bit?

Dr. GARTHWAITE. In fact, we are in the process, fairly far along

in the process of looking at scenarios of the exact President’s budget and at several increments as to what that would mean in terms

of what we could or couldn’t do at a local level and at a national

level.

Mr. SANDERS. I know there are political ramifications to it, but

I think you are not doing your job well unless you tell Congress

what the truth is; and I would appreciate it. We are going to have

to make those decisions very shortly, so the quicker you could get

us that information, the better.

26

Mr. SHAYS. It makes it more awkward if the administration

hasn’t honored a request, because then you are in the administration having to speak out about something that wasn’t put in your

budget. But I do think that there really is almost a moral necessity

that happens. I think one way we can help your cause is to ask the

GAO to step in and try to look at the cost of some of your big ticket

items. I would assume HIV is one; another is hepatitis C potentially, and another is the costs dealing with Gulf war veterans

based on our hope that we will make presumptions, and that will

certainly increase costs a lot.

Let me do this. There are other questions that if we need to, we

will put them to you in writing, and we will get to our next panel.

Thank you very much.

Our next panel is Mr. Terry Baker, Vietnam Veterans of America

and president of Veterans Aiming Towards Awareness; Mr. George

C. Duggins, president, Vietnam Veterans of America, accompanied

by Mr. Rick Weidman, director of Government Relations, Vietnam

Veterans of America; and Dr. Adrian DiBisceglie, professor, Department of Internal Medicine, St. Louis University, and medical

director of the American Liver Foundation; and finally, Dr. Alan

Brownstein, president of the American Liver Foundation.

It is very good to have all of you here. The first thing we do is,

as you know, we swear in all of our witnesses, and I would ask you

all to stand and I will give you the oath.

[Witnesses sworn.]

Mr. SHAYS. For the record, all have responded in the affirmative.

We will use our clock, but let me explain how we will proceed. You

have 5 minutes, and then I will tip it over again, and if you didn’t

finish in the first 5 minutes, if you would certainly finish within

that 5 to 10 minutes, that would be helpful.

So we will start with you, Mr. Baker.

STATEMENTS OF TERRY BAKER, VIETNAM VETERANS OF

AMERICA AND PRESIDENT OF VETERANS AIMING TOWARDS

AWARENESS; GEORGE C. DUGGINS, PRESIDENT, VIETNAM

VETERANS OF AMERICA, ACCOMPANIED BY RICK WEIDMAN,

DIRECTOR OF GOVERNMENT RELATIONS, VIETNAM VETERANS OF AMERICA; DR. ADRIAN DIBISCEGLIE, PROFESSOR,

DEPARTMENT OF INTERNAL MEDICINE, ST. LOUIS UNIVERSITY, AND MEDICAL DIRECTOR OF THE AMERICAN LIVER

FOUNDATION; AND DR. ALAN BROWNSTEIN, PRESIDENT,

AMERICAN LIVER FOUNDATION

Mr. BAKER. Mr. Chairman and members of the subcommittee,

my name is Terry Baker. As the executive director of Veterans

Aiming Towards Awareness, a support group for veterans with

hepatitis C, and national service officer for the Vietnam Veterans

of America, I am honored to be here today to present my views on

the Department of Veterans Affairs’ handling of the hepatitis C

epidemic.

I want to thank you for your leadership and for holding this

hearing on the VA’s responsibility to help the men and women who

risk their lives for their country and who now face an even greater

risk. I am particularly pleased that the committee is focusing on

if the national VA initiative is being carried out.

27

As a veteran with hepatitis C, I want to begin by saying thank

you to Dr. Kenneth Kizer and the Department of Veterans Affairs

for recognizing the seriousness of this disease and for launching a

major initiative to address it.

In June 1998, the Department of Veterans Affairs issued guidelines to the VA health system regarding the proactive testing of

veterans with any of 10 risk factors for hepatitis C. Beginning last

June, every patient visiting a VA facility should have been evaluated for HCV. The results should have been entered into the patient’s chart and an antibody test should have been performed on

any veteran presenting with one or more risks.

In January of this year, Dr. Kenneth Kizer announced further

initiatives to deal with the hepatitis C virus. Among these was the

creation of two hepatitis C Centers of Excellence where medical

professionals and research scientists could coordinate treatment

and research efforts, as well as develop education for patients and

their families, health care providers and counselors. When Dr.

Kizer established these centers he stated that, ‘‘VA’s goal is that

every patient who needs and wants treatment will receive it.’’ Mr. Chairman, Dr. Kizer’s initiative and his leadership on this

issue are appreciated. However, the Department’s ineffectiveness at

the service delivery level in actually providing screening, counseling and treatment to hepatitis C infected veterans is most disconcerting. The VA hepatitis C initiative has been in place for 1

year now. During this time, the Department has not succeeded in

communicating the objectives of this initiative to hospital personnel. I know of numerous cases of veterans who are not being assessed for hepatitis C risks, not being offered testing in a systematic fashion, and not being evaluated routinely for the suitability

for treatment.

In fact, many veterans have gotten just the opposite from the

VA, the old runaround, by VA personnel and roadblock after roadblock in their pursuit to be treated for HCV, a disease they most

probably contracted while defending their country.

For example, I know a veteran in Idaho who was wounded in

combat in Vietnam. I suggested he request a test for hepatitis C

the next time he visited the VA hospital in Spokane, WA. When he

did ask to be tested the staff at that facility gave the impression

they had no idea of what he was talking about, and claimed that

they were not aware of any such test. To date, the service-connected veteran has yet to be tested for hepatitis C even though he

specifically and proactively went out and asked to be tested.

Another veteran, this one from Montana, was actually diagnosed

with hepatitis C during a nonVA-sponsored HCV testing last year.

After discovering he was positive, he attempted to have the test

confirmed at his local VA clinic, but they refused to test him. He

then visited an Arizona VA clinic and the diagnosis was confirmed.

Even though the VA doctor from Arizona contacted the Montana

clinic and recommended followup, the VA clinic has continued to

refuse the vet treatment for his hepatitis C.

My final example comes from a hepatitis C-infected veteran in

Newark, NJ. This veteran served with the 173rd Airborne Brigade

in Vietnam where he was twice awarded the Bronze Star for Valor

for coming to the aid of wounded soldiers on the battlefield. His

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military service records contained clear evidence that he was directly exposed to blood during combat in Vietnam. Even so, the VA

denied his claim for service connections stating that he met none

of the risk factors for hepatitis C, and that his records contained

zero evidence of having hepatitis C. This statement completely contradicts VA’s public acknowledgment that HCV symptoms often do

not manifest for 10 to 30 years after the victim is infected. So right

now, there is a Vietnam veteran who has been forced to seek out

private medical attention at his own expense, because now he is in

the last stages of liver disease.

Members of the committee, I must stress that while I applaud

VA’s plan for dealing with hepatitis C, it is not enough to have a

plan. This war against a deadly disease will require a fully deployed assault by all of us. The VA must act swiftly to educate its

physicians, staff and all rating officers all about this disease. While

training one physician and one nurse from each of the 172 medical

centers may seem ambitious, it is not adequate.

Mr. SHAYS. Excuse me. Mr. Baker, this is a little unusual. But

ma’am, how many students do we have? Because they could sit up

here if we don’t have too many. How many students do you have?

They can just sit on the side. You don’t mind, do you?

Mr. BAKER. No.

Mr. SHAYS. I find any time—you young people can sit right up

along this side here.

Mr. TOWNS. They come from my district, Mr. Chairman.

Mr. SHAYS. I figured as much.

Any way we can get Mr. Towns here, we will take it, because he

has been such a wonderful member of this committee. How many

other students do you have? You can sit right up over here if you

want. You can sit on the floor up front. If you don’t mind sitting

on the floor, you can do that. You young people, if you don’t mind,

we are running out of seats up here, but you can sit up front here

if you don’t mind sitting on the floor. You can come in, and sit this

way. Thank you for letting me do this.

For the benefit of our guests, we are having a hearing on our veterans who have been affected with hepatitis C and ways that we

can help them. There is some more room over here. The gentleman

speaking now is a veteran.

Mr. Baker, you are coming close to finishing and then we will get

to the next speaker. Thank you.

Mr. BAKER. Members of this committee, I must stress that while

I applaud the VA’s plan for dealing with hepatitis C, it is not

enough to have a plan. This war against a deadly disease will require a fully deployed assault by all of us. The VA must act swiftly

to educate its physicians, staff and all rating officers all about this

disease. While training one physician and one nurse from each of

the 172 medical centers may seem ambitious, it is not adequate.

The Portland VA Medical Center sent a computer specialist to the

HCV training session held last week here in Washington. This does

not seem to indicate a clear commitment from the Portland VA

Medical Center.

If VA’s efforts must be limited, these efforts must also be focused,

focused on persons most likely to interact with people affected by

HCV. Something as simple as large posters at every VA medical

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center enumerating the risk factors for HCV and encouraging veterans to get tested have not been posted in VA facilities. These

posters do not even exist. The VA said it would aggressively fight

this disease, and yet few, if any, VA medical centers advertise hepatitis C testing. It was even brought to our attention that the VA

Excellence Center in Miami was not receiving the proper funding

to combat this disease. Dr. Mitchell herself had to personally address that problem. This approach seems inappropriate when a systematic plan has already been outlined. Or has it? Therefore, VA

must ensure that every directive about hepatitis C is taken seriously and carried out completely by every VA medical center.

I respectfully request, myself a veteran and on behalf of all veterans, that you hold the VA 100 percent accountable for its plans

to fight this battle. If necessary, Congress must give Dr. Kizer the

authority for centralized activities against hepatitis C. You alone

have the authority to make sure the VA does precisely what it says

it will do. Please aggressively pursue answers and results from the

VA. I assure you all of America’s veterans are counting on you.

Please don’t let them down.

Thank you.

[The prepared statement of Mr. Baker follows:]

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Mr. SHAYS. Thank you, Mr. Baker. What we will do, I want to

acknowledge that the first panel who spoke has stayed to hear your

presentation, and that is really appreciated; second, that the particular cases that you have presented should be shared with the

VA, and it would be instructive for us to have, Dr. Garthwaite, just

follow them up and then just see what the story is of breakdown

or where there are other factors involved, and that would be instructive to helping you and helping us understand the system.

Thank you for your testimony.

Mr. Duggins, you are here to give testimony and then you are accompanied by Mr. Weidman who will respond to questions afterwards, is that correct?

Mr. DUGGINS. We both will respond.

Mr. SHAYS. I just meant that Mr. Weidman, you are not here to

give testimony, but you will be responding along with Mr. Duggins

and the others, as an equal member responding afterward, but Mr.

Duggins, if you would give your testimony.

Mr. DUGGINS. Mr. Chairman, my name is George Duggins and

I serve as national president of Vietnam Veterans of America. On

behalf of Vietnam Veterans of America [VVA], I wish to congratulate and thank you and your distinguished colleagues for your leadership in holding this hearing this morning on the subject of the

hepatitis C virus and the efforts of the Vietnam Veterans Health

Administration at the U.S. Department of Veterans Affairs to effectively deal with this epidemic that is disproportionately affecting

veterans.

Of particular interest to VVA is the apparently high prevalence

among Vietnam veterans, particularly those veterans who served

‘‘in country;’’ i.e., the Vietnam theater of operations. Because of

combat wounds, exposure to blood on the battlefield and other factors that attend to the most basic and messy nature of warfare, a

large number of veterans were exposed and unaware that they

should have been tested.

VHA response is: The Veterans Health Administration has responded admirably following the outstanding report issued by this

subcommittee in October 1998. The policy directive issued to all

VHA facilities on June 11, 1998 is a very reasonable plan for a

starting place to begin the process of testing and treatment. The

treatment protocol issued by the VHA to all clinical coordinators at

the end of December 1998 is a reasonable approach and a good

starting basis for each medical facility to move forward with treatment. While we would hope that each of these policy statements

and guidance documents will eventually be strengthened, they

would be a reasonable start toward dealing with the veterans’ aspect of this epidemic, if there is a means of ensuring relative uniform implementation.

Earlier this year, many of the VVA local leaders in virtually

every part of the Nation told us that VHA officials in their area

were saying that the test would be given and that VHA had the

resources and the means to set up their system to properly treat

those who are tested and are shown to have hepatitis C virus.

Today, it is our belief that most of the facilities are still doing an

inadequate job of actually testing for hepatitis C virus in a systematic manner and are slow to treat in many cases. We are still hearVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00040 Fmt 6633 Sfmt 6601 E:\HEARINGS\59652 pfrm09 PsN: 59652
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ing of Pharmacy Chiefs and VAMC directors who are reluctant to

order enough of the relatively expensive medication necessary to

begin treatment in sufficient quantities to begin early treatment of

suitable candidates for this very arduous process.

This lack of a concerted and highly visible outreach and rigorous

testing campaign could have potential devastating effects on the

veterans involved, as well as on the VA health care system that

will have to deal with the aftermath of this not so benign neglect

in the future. If left untreated, many of those veterans will develop

symptoms of the virus, leading to very serious and debilitating diseases that may result in liver transplant as their only option.

The extreme pressures of the VHA over 3 years of a flat line

budget and the disastrous and woefully inadequate requests from

the President for the fiscal year 2000 budget for VHA has cast a

chilling effect on the motivations of the administrators in the field

to move ahead with doing their jobs properly for veterans potentially affected with hepatitis C. Finally, while it is unacceptable

and unconscionable for medical personnel to act this way, it is inexcusable for the President and the Congress to put these people in

a situation of extreme and needless scarcity.

We ask your help, Mr. Chairman, and that of your distinguished

colleagues in helping secure a more reasonable budget for VHA for

fiscal year 2000. While VVA believes that $3 billion more than the

President’s budget request is truly needed, obviously the $1.7 billion more being currently discussed in Congress would help keep

the system from diminishing any further.

VHA should work with the veteran service organizations and

American Liver Foundation and other public and private entities to

mount a comprehensive, significant, extended and prolonged public

service campaign to give veterans who may have been exposed to

come into the VA, enroll, and be tested. Most veterans do not use

the regular VHA facilities for their health care needs and since the

virus is silent, most do not know that they are affected or even potentially at risk. This would perhaps be most effectively done as a

part of an overall coordinated Federal response to hepatitis C epidemic, while it is still in a relatively early stage.

VVA stands ready to do our part in such an outreach effort to

spur testing of veterans and encouraging individuals to get tested

now. It is our belief that many private groups as well as public entities and the media will be responsible for such a concrete and organized effort. However, VHA must take steps to assure that the

key personnel at the local level stand ready to work with the veterans groups and the rest of the community in a meaningful and

sustained manner.

VVA would also note that such efforts must be designed and implemented in such a manner that all subgroups in the veterans

population are effectively reached. Ensuring that the communitybased groups that serve homeless veterans and others under several populations in greatest need is very important in this matter.

VHA should begin to rigorously ensure that all veterans currently registered for the VHA services who meet the at-risk profile

have their blood tested for signs of the hepatitis C virus. This is

not happening at many of the medical facilities we are aware of at

this moment. Many veterans at risk, such as the former medic acVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00041 Fmt 6633 Sfmt 6601 E:\HEARINGS\59652 pfrm09 PsN: 59652
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companying me today, have been trying to get tested for hepatitis

C at a VHA facility, but on their own initiative, not that of the VA.

It is our belief at VVA that this can be set up as a regular part

of intake and yearly physicals by the VHA by making it part of a

computer program to indicate certain tests must be given to veterans based on his or her full military medical history that is

logged in as a matter of course. This is something that VVA believes should be done for many sound medical reasons in a veterans health care system. VVA has engaged in discussions with top

VHA leaders on this subject for several months and VHA has

agreed this week to proceed with setting up a task group to begin

the process of framing the design and implementation of the basic

process.

VHA must also take steps to ensure that much more effective accountability mechanisms are put in place that would enable the

key national managers to monitor what is happening in the field.

VVA has consistently called for much better and more effective

modern accountability mechanisms within the VHA. The problem

is one of the top officials in VHA not knowing what is going on at

the service delivery level, except by anecdotes told to them by others. There is no mechanism for systematic quality assurance review

in regards to hepatitis C or for other vital measures. This is simply

no way to manage a system that is as large and complex as the

VA Health Administration.

VHA should closely work with the Surgeon General, the National

Institutes of Health, and the Congress, to ensure that additional

research is undertaken into more effective cures for eradicating the

hepatitis C virus. While VVA is appreciative of the approximately

$5 million in research funds which will be made available this

year, the sum is inadequate in the face of the potential danger of

the medical epidemic. Our Nation can do better in pursuit of a

more effective cure for this virus.

VVA would urge that the Department of Defense be involved in

this effort and that you and your distinguished colleagues help

DOD keep a positive attitude that is open to the virus being a potentially serious problem as opposed to denying beforehand that

there could possibly be any substantial risk.

Mr. Chairman, this concludes my remarks. I will be pleased to

answer any questions you may have. Thank you again for allowing

us to present our views here today and for your strong and vigorous leadership on so many vital issues that confront our Nation’s

veterans.

[The prepared statement of Mr. Duggins follows:]

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Mr. SHAYS. Thank you very much.

At this time we are going to do the video for the 3 Members that

weren’t here, and then we will go to you, Mr. DiBisceglie, and then

we will go to Mr. Brownstein.

[Video shown.]

Mr. SHAYS. Dr. DiBisceglie, if you would give us your testimony.

Mr. DIBISCEGLIE. Thank you, Mr. Chairman and other members

of this committee. I have submitted written testimony.

First, I will say that I am a physician, a hepatologist, that is a

liver doctor, and I have been involved in the care of patients with

hepatitis and researching viral hepatitis for more than 15 years

now. Part of that was while I was at NIH and when I left there

I was chief of the liver diseases section. I am currently at St. Louis

University and medical director of the American Liver Foundation.

I was asked to comment specifically on some aspects of hepatitis

C, including appropriate standards for diagnosis. I think Dr.

Holohan in panel I covered those points adequately enough; nothing to add, really.

Next was appropriate standards for treatment. Here I would say

that the standards I think were set by the NIH consensus conference which was held in 1997. It laid out criteria for selecting patients for treatment. For example, they needed to have raised liver

enzymes, positive hepatitis C RNA, a liver biopsy showing significant liver disease, and then they said also that patients who already have advanced liver disease, cirrhosis, or those where the

liver disease was very mild could still be treated, but on an individual basis. Then they laid out conditions for categories of patients

who should not be treated outside of clinical trials or with extreme

caution, those who have normal liver enzymes, decompensated or

very advanced cirrhosis, or the contraindications that we have

heard about already this morning, active alcohol or drug abuse or

a history of severe depression. I believe that these standards still

are appropriate today.

What has changed since that NIH consensus conference is the

development of an expanded array of therapies to treat patients.

There are now 4 forms of interferons available and approved by the

FDA. In addition, we have the use of ribavirin, which is used as

an adjunct to interferon. To give you some numbers on that, because this came up with panel I, the data on developing a sustained response to the combination treatment overall is about 36

percent versus 16 percent using interferon alone.

I was also asked to comment on my view of the status of the VA

program to test and treat veterans, and I am certainly aware of the

designated VA Centers of Excellence and the information reported

by panel I, and their achievements in such a short time have been

remarkable and I commend them for that. But in order to find out

what was happening at the local level, I sought information from

the director of the division of gastroenterology at my local VA, the

St. Louis VA Medical Center, to find out what was actually happening on the ground. This is an unusual VA because it is affiliated

with two major medical schools, both of which have a strong interest in viral hepatitis, great expertise. They in fact had established

a hepatitis C clinic about 2 years ago. So far in this clinic they

have evaluated and counseled more than 200 patients testing posiVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00048 Fmt 6633 Sfmt 6601 E:\HEARINGS\59652 pfrm09 PsN: 59652
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tive for hepatitis C. They found that only about 1 in 10 of the patients in their specific clinic met the criteria for treatment and they

are currently treating about 20 such patients.

This director of gastroenterology pointed out to me several problems that they have identified. Although they have been successful

on the service, they have several problems. The first was the waiting list. To be seen in this clinic is about 6 months, so a patient

diagnosed with hepatitis C to be evaluated by an expert would

need to wait 6 months to be seen by these specialists.

Second, he felt that he was receiving insufficient support by pathology and laboratory services, and this concern relates to the limitations put on the use of HCV RNA testing, the blood test, and

lack of formal training and experience in liver pathology by people

seeing the liver biopsies done in these patients. Third, really insufficient knowledge about hepatitis C by their referring sources.

Thus, many patients are referred inappropriately to the hepatitis

C clinic or may not have had an adequate workup before they are

referred then.

So I suspect that these issues at the St. Louis VA represent a

microcosm of the situation nationally with some local variability.

Moving on from there, I would make a couple of additional

points. Most of the focus so far has been on getting the veterans

tested and evaluated for antiviral therapy now, but I think thought

needs to be given to the future, to the expected rise in the incidence of liver failure and liver cancer or a hepatocellular carcinoma

that will occur over these veterans over the next 2 decades and the

resources for the wave of morbidity and mortality need to be developed.

Another important element of the VA program that I believe

could be strengthened is research. Although there is already considerable VA-funded research, not much of it appears to be VA-specific. That is, there are many important questions to be addressed

that could best be answered in the VA system.

For example, what exactly is the role of combat exposure in the

transmission of hepatitis C? What are the mechanisms of resistance to therapy in some patients and how does this apply to the

VA?

Finally, an issue key to the success of the VA program I believe

is that it not be required or seem to require taking away resources

from other VA programs. This is an element of discussion earlier

with panel I.

Mr. Chairman, I will conclude my remarks there.

[The prepared statement of Mr. DiBisceglie follows:]

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Mr. SHAYS. Thank you very much.

Mr. Brownstein, we will go with you and then I will have Mr.

Towns ask questions, Mr. Sanders, and then I will ask questions.

Mr. BROWNSTEIN. Mr. Chairman and members of this subcommittee, my name is Alan Brownstein, and I am the president

and CEO of the American Liver Foundation. I thank you for giving

us an opportunity to have our organization present our views to

you today concerning the risk of hepatitis C infection to veterans.

As a national voluntary health agency, our mission is to prevent,

treat and cure hepatitis and other liver diseases through research

and education. We are made up of chapters throughout the country, and we provide information to over 400,000 patients and families and over 70,000 physicians in America.

The prevalence of hepatitis C in the United States is staggering.

We have 4 million Americans who have hepatitis C, 10,000 with

hepatitis C die every year, and as you heard before, hepatitis C is

the leading cause of liver transplantation. Overall, 1.8 percent of

all Americans have hepatitis C. What is shocking for this meeting

here, as if that isn’t shocking enough, is that 8 to 10 percent of all

veterans have hepatitis C.

Clearly, hepatitis C is a major health challenge for America, and

in fact, will be the most significant infectious disease challenge as

we enter the 21st century for us, but it is also an incredible challenge for U.S. veterans. Because hepatitis C is a quiet, a silent

kind of virus, the vast majority of veterans with hepatitis C are not

aware that they have it, because they do not have symptoms. We

have heard a lot about treatment and that somewhat less than 40

percent of those who are eligible for treatment to receive it have

a sustained response. It is also important to identify all veterans

who have hepatitis C because there are other interventions that

can help.

Concretely, it is incredibly important that people with hepatitis

C not drink. Drinking is like throwing gasoline onto a fire, so it is

very important that this kind of message is given to those with

hepatitis C. Also, it is of great importance that those with hepatitis

C be vaccinated to protect them against hepatitis A and hepatitis

B. While that is important for all Americans in many important

areas, it is especially important for those who are infected with

hepatitis C so that they are protected against additional liver damage.

I would like to thank this committee and the chairman of this

committee, because we appreciate the leadership that you have

provided to focus America on hepatitis C. In your October 1998 report, Hepatitis C: Silent Epidemic, Mute Public Health Response,

that is incredible, because I think the humor in that title really underscores how serious the problem is. You have really opened our

eyes, so I thank you for that. It says indeed, your input has paved

the way for this veterans initiative, as the report pointed out, to

the problem in U.S. veterans where you said that the Department

of Veterans Affairs should conduct additional studies of the prevalence of hepatitis C in veterans’ populations.

As the chairman knows, on March 17, 1999, the VHA conducted

a very significant national blood test of 26,000 veterans for hepatitis C antibody and found a prevalence rate of 8 to 10 percent as

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I mentioned before. This is more than 5 times the national rate.

And we also—the committee’s foresight in calling for this test has

confirmed the need and has paved the way for the $250 million

that we hear has been requested by the Department of Veterans

Affairs for fiscal year 2000.

Our view of what the Veterans Health Administration has done

is, others say that we are really very impressed with the mobilization that they have put forward in launching an attack against

hepatitis C among veterans, and that the mobilization has been put

into place. Now we are looking at implementation, full implementation in the year, in the years ahead. We believe that this implementation presents several critically important challenges.

First of all, the $250 million of treatment that has been committed will not happen, it will not occur unless the infrastructure

is developed. You cannot just have money for treatment without

having the mechanisms to deliver the care. So the worst thing that

could possibly happen is you reconvening this body next year and

finding out that only $30 million, $50 million or $75 million was

spent in the year 2000. That would indeed be a tragedy, because

that would not signify that there isn’t a need, it would signify that

we haven’t effectively translated that need into an effective demand that can be responded to.

So that is the first challenge, and we believe that this is an important challenge to the Department of Veterans Affairs; it is also

an important challenge to Congress and also to the private sector

and the American Liver Foundation is prepared to assist in whatever way we can from the private side, as I know other organizations are willing to do as well.

The second challenge is that $250 million of treatment will not

happen unless providers, the health care providers, the primary

care providers within the VA are well—and all of those who are associated with the VA are well educated, well educated about hepatitis C. It is interesting because the American Liver Foundation

has done many consumer awareness campaigns and our hotline

gets about 15,000 calls a month. After we do campaigns, what we

have learned is that people call us and they tell us we followed

your advice, we went to the doctor and the doctor said it wasn’t

necessary to get tested, or we were tested and the doctor told us

that it wasn’t necessary to pursue treatment or not to worry about

it. So while we are doing this campaign, we have an incumbent responsibility to make sure that the providers who are associated

with treating veterans are well educated about hepatitis C.

The third challenge is that the $250 million of treatment will not

occur unless there is an effective awareness campaign directed at

U.S. veterans. In other words, most are not aware they have it;

most don’t have the—the overwhelming majority don’t have symptoms. Often, when you have symptoms, it is too late. So it is very

important that we spark public awareness. And this again, public

and private sector partnerships offer a great potential for us to

really attack hepatitis C among veterans. One example is the public service announcement that you see here, but a heck of a lot

more is needed to get that message across. So we have to use

health education techniques, but also commercial techniques at

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selling hepatitis C, explaining what hepatitis C is all about to veterans in the broadest sense.

But again, the broadest sense is not enough. The attention of veterans is captured. Once that happens, we will not succeed unless

we meet the challenge of veteran education and outreach. It is extremely important that we reach those who are affected in culturally appropriate ways. We need to address the different subgroups within the veterans population. It is no longer a one-sizefits-all world. We must have targeted messages at veterans from

different cultural, racial and ethnic backgrounds. There need to be

different literacy levels to make sure those messages reach those

veterans, and there needs to be a system of support groups so that

the veterans have that background of support as they are struggling through the difficulties that many experience in their treatment, as well as the difficulties that will be faced by many who will

not respond well to the treatments.

The next challenge is that if we are going to commit $250 million

to fighting this disease among veterans, it is extremely important

that we put accountability mechanisms in place so that we can figure out and we can look in the mirror and say, are we succeeding

in this enterprise, and if we are not, how can we develop the corrective strategies to better do what we need to do to reach the veterans who are affected by hepatitis C, and to us, we believe accountability includes performance measures for testing, diagnosis

and treatment; performance measures for outreach and education,

establishing a data base to measure performance, and also having

an annual report of results so that we can constructively move forward.

And then the last challenge that I would like to present in closing is that we need to maintain the momentum. As Dr. DiBisceglie

and others have pointed out, it is extremely important that we understand this is not going to be a 1-year solution. We have to be

in this for the long haul. And from the private sector side, the

American Liver Foundation has formed its own veterans hepatitis

C and liver disease council that will include members from leadership from the top veterans service organizations and top medical

and scientific people in and out of the VA. So we are prepared to

work with you, and we need to have that kind of a partnership.

We really need to look at this headline that was in yesterday’s

USA Today. It says millions hit hepatitis C deadline. What it

means is that unlike HIV, which moves pretty quickly, hepatitis C

is a slow burn in its natural history progression for most people.

However, even though it progresses slowly, we now have veterans

who have been exposed to hepatitis C for 10, 20 and even 30 years.

So now we are in a race against time for those where there is inexorable damage that is being done to their livers. So that really now

is the time to act and we need to have the urgency.

I thank you, Mr. Chairman and the members of this subcommittee, for creating this sense of urgency about this very serious public health challenge that we face today. Thank you.

[The prepared statement of Mr. Brownstein follows:]

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Mr. SHAYS. Thank you. Mr. Brownstein, Mr. Towns and I were

very involved, as well as Mr. Sanders, in this when we were looking at HIV, and it was that silent epidemic, just kind of that shadow epidemic, and it really hit us all that we needed to deal with

it. So we thank you for your nice words, but it just kind of hit us

in the face and slapped us around. We needed to deal with it. We

appreciate all that you are doing and others on the panel that you

are doing, and we also appreciate what the VA is doing to try to

get a good handle on this. We have a ways to go, though.

Mr. Towns.

Mr. TOWNS. Thank you very much, Mr. Chairman. Let me begin

by thanking you for really sticking with this and working on it.

You have put a lot of time on this, and of course it is a very serious

problem and I want to congratulate you on the kind of effort that

you have put forth. Also Mr. Sanders, who has also been involved

in this issue for quite some time, and I want to salute both of you

before I raise any questions.

The first question I have, why do you think that it is much higher among veterans? I saw the video, but is there anything else that

we need to know as to why it is so much higher among veterans

than the general population?

Mr. DUGGINS. Well, I think one of the reasons is it is the exposure to blood products in the combat environment. The general

population do not have that effect. We might be seeing it in the cities now, but what I am saying in a combat situation, if your friend

is wounded or you may have a scratch or something and you are

dealing with his blood products, you don’t have time to put on rubber gloves or take the necessary precautions to make the environment safe for you to deal with blood products. For us who are Vietnam veterans, at the time we were getting blood transfusions and

blood products, the testing for hepatitis C or the testing of the

blood products wasn’t anywhere near where it is now.

So we got bad blood. That is just the bottom line. I think more

veterans were exposed to that. I don’t think our conduct and behavior is any different than any other portion of our society.

Mr. BAKER. I also believe that in the veteran community, even

though combat is definitely one of the biggest risk factors, veterans,

they acclimate back into their own communities, they acclimate

back into the armed forces, they are still with veterans, they are

still amongst each other, and there are possibilities of transmitting

other ways. As we said, possibly tattooing and other ways like that.

So as they acclimate back in with other veterans and even when

they come into the civilian world, veteran communities seem to

stay together. So there is that process that we are more of a community and we are interacting more together, so the possibilities

and the risk factors are higher for us as well, from point of service

to being in the world again, and still to this day we interact with

each other. We are always with each other.

Mr. TOWNS. You just said something there that raises another

question in my mind. You mentioned tattoos. All the young people

today are going out and getting tattoos.

Mr. BAKER. Correct.

Mr. TOWNS. It is a big thing among the young people. Nobody

seems to be making the statement that this might be a connection

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here and nobody is saying it. So I am concerned about the education and prevention part of all of this. I would like to hear you

on that.

Mr. DIBISCEGLIE. Let me comment specifically on tattoos, Mr.

Towns. I think that the CDC has not been able to identify tattoos

as a risk factor, but I think what they are thinking of is the kind

of tatoo that is what is done commonly these days, in a tatoo parlor

where there is awareness of the risk of transmitting blood borne

viruses. I think what is of more concern is tattoos that are done

perhaps in other countries while somebody was in the service, for

example, in a back street or by a friend or something like that,

where we are uncertain about the sanitary conditions. That does

pose a potential risk. The usual kind of tatoo that is done commonly these days I don’t believe represents a big risk.

Mr. BROWNSTEIN. I agree completely with what Dr. DiBisceglie

has said, because tatoo parlors now by and large are aware of it.

But I would just say, for any young person who is considering getting a tatoo, you ought to think twice and make sure you check out

whether there are the sterilization techniques. Ask to be shown

what techniques are being used, and it should not be done in any

casual way. So tattoos themselves do not spread it, it is when unsanitary conditions exist, if I might add that.

Mr. TOWNS. The other thing that—do you want to add something?

Mr. WEIDMAN. I did want to mention just one other thing, Mr.

Towns. Things that President Duggin pointed out having to do with

the very nature of the combat situation itself and exposure to blood

for those of us who served in Vietnam on the ground was one of

the factors, as well as the other known risk factors. But there is

something else that began that everybody went through, whether

you served in country or not, that we have raised as an issue continuously with the CDC just recently, again with a long letter to

them, and that is the air guns. The Department of Defense earlier

this year has discontinued any use of the air gun whatsoever of

any manufactured variety. You talk to any veteran in your district,

Mr. Towns, or anywhere who went through, particularly the Vietnam era, they can tell you stories about long lines of hundreds of

folks lined up with the air gun moving person to person with the

blood running down their arm and dripping off the air gun. So because we know from the work of Dr. Siev at NIC and others that

as early as 1948 the hepatitis C virus was present in the United

States, you had transmission before people even got into basic

training.

Mr. TOWNS. I am concerned about the fact that the education

prevention part is not stressed enough for me. Why, doctor, do we

not deal with the education prevention? There are some things,

based on what people are saying, that if people do it is possible for

them to avoid it.

Mr. DIBISCEGLIE. We are coming along. I think one needs to recognize that is a fairly recently discovered virus. This was only discovered in 1989, 1990. It is only 8 or 9 years old. So it took 3 or

4 years after that to recognize how big of a problem, how widespread of a problem it was in the United States. So with that now,

we have seen more and more. In the last 3 years I would say we

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have seen an acceleration of awareness among both physicians and

the general medical public, and I think that education is coming

along. However, I think more is clearly needed, as we have heard

from the testimony today. Even among physicians who are not involved in treating these patients, their awareness may be somewhat limited, and I think we need more efforts in this area.

Mr. TOWNS. What would you say to the veterans? What recommendations would you have to the VA regarding the nationwide

implementation of the hepatitis C testing treatment initiative? I

am listening to Mr. Duggin and Mr. Baker, and I am hearing that

people are having difficulty getting tested. What suggestions do you

have or recommendations do you have to the Veterans Administration?

Mr. DUGGINS. I think one of the recommendations I would have

to the Veterans Administration is that they have to do more outreach. I heard them say that they had a web page, but I also heard

them say that the people at the most who would be affected are

the underemployed and the unemployed. You can’t convince me

that these guys are going to sit there in front of a computer.

Mr. TOWNS. And a lot of them don’t have computers.

Mr. DUGGINS. Right. So the outreach effort has to be rethought.

One of the things that I have seen here recently is that in the State

of Virginia, and I am from the Virginia Beach area, is that the

Commonwealth of Virginia is dealing with the problem of convicts

who are HCV positive. And they say well, I don’t have the resources to treat these guys. So I am saying, how many of these

guys are veterans and who should be treating them. Should the

commonwealth be treating them if they are service connected? I

can see 50 governments coming to Congress and saying look, guys,

this is your problem, clean it up. Therefore, the outreach is limited.

I found out about hepatitis C at a leadership conference that we

were having and Terry and I both were tested at the same time.

Hadn’t heard about hepatitis C from the VA system up to that

point. It wasn’t the VA system that was doing the testing, it was

an independent concern who was doing the testing. I ask veterans

in my every day walk of life, have you heard of hepatitis C, have

you been tested for it, and they look at me like what are you talking about? What is hepatitis C? So the VA can reach people in the

system, but they are not reaching the people outside of the system

who are veterans. I think that outreach has to be broadened.

Mr. BROWNSTEIN. I think that you had mentioned your involvement with HIV earlier. I think we have a lot of lessons we could

learn about HIV. I would venture to say that probably every one

of these young people here knows about AIDS, knows something

about AIDS. I bet a whole lot of them didn’t know too much about

hepatitis C until today. I think that we need to get that word out

so that it is on the street. It needs to be on the street, because 400

percent more people are infected with hepatitis C than with AIDS.

So just looking at the order of magnitude, we have a heck of a lot

of work ahead of us.

And the same applies to veterans. The average veteran has no

idea about hepatitis C until you were tested just about a year or

so ago.

Mr. DUGGINS. Right.

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Mr. BROWNSTEIN. I think that what we need—I don’t think every

veteran should be tested, but I do think every veteran should be

screened with some sort of a health risk assessment that doesn’t

have—put the burden on them to acknowledge what risks they are

acknowledging, but just to say, if any of these eight areas apply to

you, you ought to be tested, and those in that health risk assessment should be directed at the known risk associated, both on the

battlefield as well as other risks that the veterans may have. Dr.

DiBisceglie can speak to those risks.

Mr. TOWNS. I have to go vote. That is the reason I am jumping

up.

Mr. SHAYS. Kind of weird talking to somebody who asks a question and he gets up and leaves.

Mr. BROWNSTEIN. Maybe it is because of what I said before.

Mr. DUGGINS. I also think that veterans who have third-party insurance, if they knew about the hepatitis C virus, they would go

to their own PCP for testing. I don’t think they would overburden

the system any. But I do think it is up to the system to get the

word out to veterans. I know I would have gone to my own PCP

to be tested, and I came to the VA system to be tested. I think all

veterans who have that insurance would do that versus burdening

down the system.

Mr. SHAYS. Let me ask you about the intake process. What could

be done, and I will start with you, Mr. Baker. What could be done

to follow a process where we guarantee that there is some uniformity, and that we are making sure that no one is—we are missing anyone. If you put the mic a little closer to you.

Mr. BAKER. I think the first thing that could be done is the VA

has a data base of all of their veterans within their system, and

if the VA can send out form letters for issues about how much

money on a cost of living allowance that a veteran gets every year,

they could send out a form letter to every veteran within the system and explain to get tested for hepatitis C at your local VA clinic

or your local VA hospital. That is an easy step to send out that

form letter there.

Second is when veterans come into the system or come into a VA

hospital and request to be tested or also when veterans are there

to explicitly make it a point that these veterans be tested, to talk

to their directors of VA medical centers and directors of VISNs who

have their own priorities on how they want to run their VISN or

their hospitals and what they feel is important to bring it down

from the top that this is the No. 1 priority issue that all people,

all veterans be tested and we do our outreach to make sure that

everybody finds out about it.

Mr. SHAYS. Before I go to the other panelists, when you say all

veterans, some veterans don’t need to be tested, correct?

Mr. BAKER. That is a—I tend to disagree. I think because we

have an epidemic on our hands and because it is within our veteran community that sometimes is spread to our spouses and to

other family members, that maybe we should aggressively just test

all veterans and get a real idea of what is going on here instead

of testing 141 veterans at one hospital when you have 15,000 at

that one hospital.

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Mr. SHAYS. Let me throw it out to the others. The first part of

the question, do you recommend a particular procedure that should

be followed to guarantee that there is some uniformity.

Mr. DUGGINS. I think what they should do is to clone the director

of division 3. I mean as I travel around the country, VISN 3 seems

to be the poster child and others should adopt the procedure that

they are using in VISN 3. That is the problem that veterans have.

They hear good things that are going on in one division, and then

they get denied these kinds of services and then they wonder why.

Mr. SHAYS. Mr. Duggins, if we cloned and had more than one Mr.

Farsetta in this world, this would be a dangerous world.

Mr. DUGGINS. Right. And truly VISN 3 is the poster child of

VISNs. I always hear good things about that VISN. But some of

them don’t seem to be getting in the ballpark.

Mr. SHAYS. They have gotten in it early and we should be seeing

their successes and failures and so on.

Mr. Weidman.

Mr. WEIDMAN. Incidentally, I am from New York, and Jim

Farsetta loves to come to Washington because sometimes he is

more popular here than he is up there. But he is an excellent VISN

director.

You will notice that a question was skirted earlier today. There

is no rigorous plan for taking the entire catchment of each hospital

of folks already enrolled for treatment, matching that up against

the 10 risk factors and then making sure that everybody who

meets the 10 risk factors is tested, it is not happening. It is not

happening in any facility that we are aware of. I met one of those

risk factors by having been a medic in I Corps in 1969. I asked

about testing at the Washington VA Medical Center last July. I

was put off and asked again in October and was put off. I have

been put off several times and then I started pressing the matter

beginning in March. I am due to be—scheduled to be tested this

Friday. I am a fairly tenacious guy, and it took that long to get the

test even though I had requested it, even though I met one of the

risk factors.

The one thing that is missing from the plan, and we would agree

at VVA that VA has done a good job in putting together a plan,

but putting together a plan is not the action part, No. 1. No. 2,

within the actual procedures of testing, it is just simply not there

at the local hospital nor is it in the protocol that they should go

through as part of their normal physical and make sure that this

test happens.

The other thing is when people initially enroll in reaching outside of the VA, as George Duggins just commented on, to draw people in, people can enroll and if they can go through a battery of

tests having to do with what happens to folks, what branch of service did they serve, what years did they serve, what was their military occupational specialty, where did they do service and what actually happened to them, and that is not just hepatitis C, that is

lots of other things, ranging from exposure to dioxin to exposure to

cortisol, exposure to DU, all kinds of things that would be reasonable for folks to screen for if in fact it is a veterans health care system, and that is not currently happening.

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We have had discussions with VHA on this and have what we

believe is agreement to move forward to put together a task force

of veterans service organizations, VA officials and DOD officials to

move in that direction so when you go into the VA hospital in my

instance automatically because of when and where I served, I

would have gotten a hepatitis C screen.

Mr. SHAYS. Let me do this. We are probably going to have a 2-

minute recess to enable our young people who are probably a little

awkward sitting down all this time to leave if they want. That

would probably be helpful. So we will just take a 1-minute recess

to allow our students—is that good?

Mr. DUGGINS. That is great. Thank you.

Mr. SHAYS. We welcome you to our hearing and thank you for

coming.

[Brief recess.]

Mr. SHAYS. Let me call the hearing back to order.

What I really think is on the table is the first panel is obviously

having to wrestle with the fact that there are limited resources and

we are starting to find ways to get the word out and then the question is who gets tested and who doesn’t get tested. It is such a gigantic network some VISNs are going to do a good job and some

are not. The VA has to find a way to get a handle on that. What

I want to do is ask what recommendations would you make to the

VA regarding the nationwide implementation of the testing and

treatment? One, should we agree that all of the ones at risk should

be the ones first and foremost? Second, is there a protocol that you

are aware of that is there that you are certain that the right questions are being asked to determine the people at risk, and are you

convinced that there is the proper follow on. And I would be happy

to have VA respond to this question as well.

Mr. DIBISCEGLIE. Well, I think certainly the CDC has considered

the question should we be screening the general population, and

they have discarded that option. They feel it is not cost effective.

Along those lines I would say the same for the VA, but it depends

on what the definition of screening is. Everybody should be

screened by a health risk assessment questionnaire. If everyone

has the 9 or 10 risk factors, if there is any one that is positive, that

should move you to the next step of getting a blood test, which is

very doable, I think.

Mr. DUGGINS. I think that the main thing that the VA has to do

is make certain that the VISN directors buy into the program. If

they don’t, the implementation is going to fail in their area and the

veterans are not going to be tested. I agree that the at risk categories should be the first ones tested and, if dollars allow, any

other veterans who seeks this test should have it. I know some of

the at risk factors but I think we should put all of the at risk factors out there and then those veterans will know whether they

should bother being tested for this.

Mr. SHAYS. Anyone else?

Mr. BROWNSTEIN. I think that—your part of the question about

getting the word out, the American Liver Foundation last week

conducted a market research survey of 700 veterans across America, Bruskin survey research firm and I will share this data with

you in the next week or two. We are basically trying to find out

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what the veterans know and don’t know about hepatitis C. Also

what their behaviors would be if they thought they might be at risk

for hepatitis C as well as what they see as perceived provider responses. So based on that data we are going to try to target messages that are directed at veterans to try to capture, to best educate people about that. And toward that end we are preparing a

brochure that we are prepared to distribute to 31⁄2 million veterans

associated with the VA and we are already talking with VA officials, and we are going to get their involvement.

But the first step is entry into the system. In other words, it has

to be stimulating that unmet need into and effective demand based

on knowledge from those veterans.

Mr. SHAYS. I am going to be asking one last question on research, Dr. DiBisceglie, probably directed toward you but let me

ask if Mr. Sanders has any other questions.

Mr. SANDERS. I do have questions.

Mr. SHAYS. Why don’t we go to your questions.

Mr. SANDERS. I thought this was an excellent panel and I think

all of your presentations were important. What I am hearing, and

correct me if I’m wrong, and maybe, Mr. Brownstein, you want to

start off and others can pipe in, is that there are large numbers

of veterans who are sitting out there with hepatitis C who don’t

know it. Are we all agreed on that?

Dr. DIBISCEGLIE. That is correct.

Mr. SANDERS. The other panel was indicating that perhaps the

numbers that they had seen were perhaps disproportionately high

or we don’t know the answer to that but I gather that we are looking at—how many folks are sitting out there with hepatitis C who

are veterans who don’t know it now? Does anyone have a wager or

guess?

Dr. DIBISCEGLIE. I think we are lacking the data, but those who

tested positive in that 1 day sample is 8 to 10 percent. Extrapolating from the general population, 80 to 90 percent of the population with hepatitis C do not know it; 8 to 10 percent would make

350,000, and 80 to 90 percent do not know it. This is a silent disease. It either has no symptoms or they are so vague and nonspecific that would not lead you to think of hepatitis as being the likely cause.

Mr. WEIDMAN. Our estimate is 8 to 10 as a minimum and it may

be greater, 8 to 10 percent.

Mr. SANDERS. You think that is the low end?

Mr. WEIDMAN. Yes. And you asked the question before having to

do with resources of the panel, if we don’t test now and start to

deal with—first of all, I think it is unconscionable not to test. And

second, it flies in the face of the wellness model and we are going

to pay a heck of a lot more down the line if we don’t catch people

before they start to show symptoms. It is just not reasonable for—

don’t ask, don’t tell. Don’t ask, don’t treat is not a policy that we

should be pursuing in this, and so rigorous testing and outreach of

people already in the catchment who are doing blood work anyway

is simply not reasonable to move forward in a methodical manner.

Mr. SANDERS. I agree. If VA tomorrow did all of the right things,

you are talking about a mammoth outreach and beginning treatVerDate 11-MAY-2000 09:49 Mar 22, 2001 Jkt 066348 PO 00000 Frm 00082 Fmt 6633 Sfmt 6601 E:\HEARINGS\59652 pfrm09 PsN: 59652
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ment for these hundreds of thousands of people. That is a monumental effort, is it not?

Dr. DIBISCEGLIE. Yes.

Mr. SANDERS. The only other question I would ask is have we

tested for incidence of hepatitis C in Korean veterans? Is there

anything particular about Vietnam as opposed to World War II or

Korea?

Dr. DIBISCEGLIE. I think it is 4 percent of Korean veterans have

hepatitis C?

Mr. BROWNSTEIN. I don’t know. I did see data presented last

Thursday that showed it was somewhat of a bimodal distribution.

It was real heavy on Vietnam and then there was some data that

showed that Korean and I think even World War II, and I would

defer to anyone from the VA who is more familiar with that data.

Mr. SANDERS. Should there be any difference of incidence?

Should there be differences between Vietnam and Korea?

Dr. DIBISCEGLIE. I think hepatitis C was a disease that was

emerging in the general population after Korea and that explains

it in good part.

Mr. SANDERS. Thank you.

Mr. SHAYS. Thank you. Just to end the hearing, tell me is there

any value in having research that is focused directly on veterans’ populations?

Dr. DIBISCEGLIE. I think there definitely is. Clearly just getting

patients tested and evaluated for therapy is just the beginning

step. There will be some who don’t meet the criteria for treatment

now or do not clear the virus therapy, and so those individuals will

remain within the system and some will have their liver disease

progressing or require medical care there. And there are some I

think veteran specific questions that can be answered related to

perhaps the demographic variation of the veterans versus the general population. I think we need to look toward the future as well

in terms of new treatments. I think the VA needs to stay at the

forefront of new treatments as they become available to be able to

test and develop them or ways of minimizing the liver disease to

avoid it progressing. I think all of these are very valid areas for research.

The VA has a large infrastructure and there is now this large cohort of patients, a couple hundred thousand, I think that represents a wonderful research opportunity.

Mr. SHAYS. Yes, sir.

Mr. BAKER. I think the other thing, and Mr. Sanders talked

about it before with the other panel, is their funding. I didn’t hear

anyone actually say out of that panel but they are underfunded,

and they know that they are. Their employees are overworked,

understaffed at most facilities and now they have this tremendous

new incident that has come upon them.

Sure, directives will come down, and I even talked to a director

at an RO, and he said directives will come down. But how are we

supposed to take care of it. They are losing people every day. Kizer

has to make more cuts but we are asking that patients with hepatitis C and veterans be taken care of. And the issue is really

money. The VA is trying to do a job at the top to the bottom and

their facilities don’t have the resources, don’t have the people to

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even try to take, like I said, from Portland. They had a computer

specialist more than likely because there was nobody else that they

could spare.

The other issue is they need funding real bad.

Mr. DUGGINS. We have heard the rob Peter to pay Paul scenario,

but Peter doesn’t have any money. You are robbing somebody who

is already broke.

Mr. WEIDMAN. There was talk of the caps and how we need to

squeeze in under the caps. Let me say that veterans health care

was the only health care for a discrete group of Americans that was

flat lined in 1997. Had that been done to African-Americans, to

women or to any other discrete group of people that you were going

to take over the next 5 years a 50 percent cut in your health care

because we are going to flat line you, all the dickens would have

broken loose, and we did it to veterans in that kind of a discriminatory way and it slid on through.

The cap was wrong to begin with. Let the Congress not be like

George Armstrong Custer. Let’s go back on this Custer decision

and set it right by raising the cap on veterans health care.

Mr. SHAYS. Let me ask you, though, as related to the cap on veterans, there was no determination that we would flat fund it for

5 years. It was a determination that the overall budget would have

a slight growth. So I am not quite comfortable with your description.

Mr. WEIDMAN. If we went back to 1990 and we charted out medical inflation, we charted out Medicaid, the Federal portion of it

and Medicare——

Mr. SHAYS. So is your point that more money is being spent but

less than the required need?

Mr. WEIDMAN. And when you factor in inflation.

Mr. SHAYS. So you are basically saying that we are losing ground

on inflation.

Mr. SANDERS. I would just add to what Mr. Weidman says, and

correct me if I’m wrong, if the VA does the right thing and they

reach out to all of the veterans, the 10 percent who are infected are

treated, you must be talking about astronomical numbers that

there is no way on God’s green Earth you can deal with within the

budget.

Mr. Brownstein or Dr. DiBisceglie, is that correct?

Dr. DIBISCEGLIE. That is correct.

Mr. SANDERS. If they do the right thing and respond to hepatitis

C——

Mr. SHAYS. I think the record will demonstrate that we are putting tremendous demands on the VA and someone like myself, who

does believe that we need to find a way to honor this agreement

as best we can, we either have to find the money from some other

area, not within VA, or we have to break the cap. Those would be

my two options.

Let me do this. Since I said responding to the cloning of Mr.

Farsetta would make the world a more dangerous place, he is

clearly allowed to come back and make any comment he would like.

I would like to dismiss this panel and thank them and just invite

the VA. If they have any closing comments I am happy to have

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them make any comments, Dr. Garthwaite, or anyone that accompanied you.

Dr. GARTHWAITE. Thank you, Mr. Chairman. I would just echo

your comment for any specific cases, we would very much like to

fix the individual case and understand why it happened.

Mr. SHAYS. Mr. Baker, we are hearing that request. Given that

you have come forward with some individual cases, it is important

that you share them with the VA and share them with our office

as well. Let’s followup. There is no attempt to blame anyone, but

let’s say why is this not working and what can be done. And if

there are other factors, we would like to know that.

Dr. GARTHWAITE. We have already fixed some specific communication issues. It helps us get uniformity. I am very much interested in how we can use posters and letters to veterans and other

things to improve our outreach and to make sure that we let veterans know what else we can do. I think the panel did an outstanding job and we are basically in agreement.

Mr. SHAYS. The only other thing, and I am happy to have you

do this in communication with my staff, is how do you provide

some uniformity so that everybody is getting that message and it

is not just going to a few, and I do think that a lot can be learned

from your VISN where you are actually finding that they are already into it, and by reexamining what they are doing well and see

how you can use it in other facilities.

Dr. GARTHWAITE. Certainly. One of the concerns people have had

about some decentralization of control is the nonuniformity. The

good news is that allows creativity which often identifies much better ways of doing business. It is our challenge to find that creativity and the better ways and export that to the other networks.

Mr. SHAYS. I happen to agree that I will take creativity over uniformity, so I have a lot of license in that.

In other words, you don’t want to hold anyone down who is able

to do some things, but to at least make sure that there is a minimum standard of communication, a minimum standard that guarantees you that this word is getting out.

Dr. GARTHWAITE. I agree.

Mr. SHAYS. Thank you very much. With this we will call the

hearing adjourned.

[Whereupon, at 12:45 p.m., the subcommittee was adjourned.]

[Additional information submitted for the hearing record follows:]

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