<DOC>
[106th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:59652.wais]
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
______
U.S. GOVERNMENT PRINTING OFFICE
59-652 CC WASHINGTON : 1999
COMMITTEE ON GOVERNMENT REFORM
DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut ROBERT E. WISE, Jr., West Virginia
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
STEPHEN HORN, California PAUL E. KANJORSKI, Pennsylvania
JOHN L. MICA, Florida PATSY T. MINK, Hawaii
THOMAS M. DAVIS, Virginia CAROLYN B. MALONEY, New York
DAVID M. McINTOSH, Indiana ELEANOR HOLMES NORTON, Washington,
MARK E. SOUDER, Indiana DC
JOE SCARBOROUGH, Florida CHAKA FATTAH, Pennsylvania
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
MARSHALL ``MARK'' SANFORD, South DENNIS J. KUCINICH, Ohio
Carolina ROD R. BLAGOJEVICH, Illinois
BOB BARR, Georgia DANNY K. DAVIS, Illinois
DAN MILLER, Florida JOHN F. TIERNEY, Massachusetts
ASA HUTCHINSON, Arkansas JIM TURNER, Texas
LEE TERRY, Nebraska THOMAS H. ALLEN, Maine
JUDY BIGGERT, Illinois HAROLD E. FORD, Jr., Tennessee
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
DOUG OSE, California ------
PAUL RYAN, Wisconsin BERNARD SANDERS, Vermont
JOHN T. DOOLITTLE, California (Independent)
HELEN CHENOWETH, Idaho
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 ROD R. BLAGOJEVICH, Illinois
ILEANA ROS-LEHTINEN, Florida TOM LANTOS, California
JOHN M. McHUGH, New York ROBERT E. WISE, Jr., West Virginia
JOHN L. MICA, Florida JOHN F. TIERNEY, Massachusetts
DAVID M. McINTOSH, Indiana THOMAS H. ALLEN, Maine
MARSHALL ``MARK'' SANFORD, South EDOLPHUS TOWNS, New York
Carolina BERNARD SANDERS, Vermont
LEE TERRY, Nebraska (Independent)
JUDY BIGGERT, Illinois JANICE D. SCHAKOWSKY, Illinois
HELEN CHENOWETH, Idaho
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
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
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 epidemiological 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.
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 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:]
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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 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 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.
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 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?
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.
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 initiative 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 veteran 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:]
[GRAPHIC] [TIFF OMITTED] T9652.005
[GRAPHIC] [TIFF OMITTED] T9652.006
[GRAPHIC] [TIFF OMITTED] T9652.007
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.
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.
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, 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 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 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.
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.
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 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 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 hearing 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
community-based 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 accompanying 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 positive 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 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 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-size-fits-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 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 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.
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.
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.
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 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 3\1/2\ 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
treatment 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 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 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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