[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]



                               before the


                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION


                             JUNE 14, 2001


                           Serial No. 107-97


       Printed for the use of the Committee on Government Reform

  Available via the World Wide Web: http://www.gpo.gov/congress/house

                       U. S. GOVERNMENT PRINTING OFFICE
81-591                          WASHINGTON : 2002
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001


                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             PATSY T. MINK, Hawaii
JOHN L. MICA, Florida                CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia            ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
JOE SCARBOROUGH, Florida             ELIJAH E. CUMMINGS, Maryland
BOB BARR, Georgia                    ROD R. BLAGOJEVICH, Illinois
DAN MILLER, Florida                  DANNY K. DAVIS, Illinois
DOUG OSE, California                 JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JIM TURNER, Texas
JO ANN DAVIS, Virginia               THOMAS H. ALLEN, Maine
DAVE WELDON, Florida                 WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   ------ ------
ADAM H. PUTNAM, Florida              ------ ------
C.L. ``BUTCH'' OTTER, Idaho                      ------
EDWARD L. SCHROCK, Virginia          BERNARD SANDERS, Vermont 
JOHN J. DUNCAN, Jr., Tennessee           (Independent)

                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

 Subcommittee on National Security, Veterans Affairs and International 

                CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida              DENNIS J. KUCINICH, Ohio
JOHN M. McHUGH, New York             TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio           JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
DAVE WELDON, Florida                 ------ ------
C.L. ``BUTCH'' OTTER, Idaho          ------ ------

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
              Kristine McElroy, Professional Staff Member
                           Jason Chung, Clerk
                    David Rapallo, Minority Counsel

                            C O N T E N T S

Hearing held on June 14, 2001....................................     1
Statement of:
    Bascetta, Cynthia, Director, Health Care, Veterans' Health 
      and Benefits Issues, General Accounting Office, accompanied 
      by Paul Reynolds, Assistant Director, Veterans' Health Care 
      Issues, General Accounting Office..........................     6
    Murphy, Frances M., M.D., M.P.H., Deputy Under Secretary for 
      Health, Department of Veterans Affairs, accompanied by Dr. 
      Lawrence Deyton, Chief Consultant for Public Health, DVA; 
      Dr. Robert Lynch, Director, Veterans Integrated Service 
      Network 16, DVA; Mary Dowling, Director, VA Medical Center, 
      Northport, NY, DVA; and James Cody, Director, VA Medical 
      Center, Syracuse, NY, DVA..................................    38
Letters, statements, etc., submitted for the record by:
    Baker, Terry, executive director, Veterans Aimed At 
      Awareness, prepared statement of...........................    26
    Bascetta, Cynthia, Director, Health Care, Veterans' Health 
      and Benefits Issues, General Accounting Office, prepared 
      statement of...............................................     8
    Brownstein, Dr. Allen, president, American Liver Foundation, 
      prepared statement of......................................    30
    Garrick, Jacqueline, deputy director, Health Care for the 
      American Legion, prepared statement of.....................    69
    Murphy, Frances M., M.D., M.P.H., Deputy Under Secretary for 
      Health, Department of Veterans Affairs, prepared statement 
      of.........................................................    41
    Shays, Hon. Christoper, a Representative in Congress from the 
      State of Connecticut, prepared statement of................     3



                        THURSDAY, JUNE 14, 2001

                  House of Representatives,
Subcommittee on National Security, Veterans Affairs 
                       and International Relations,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room B-372, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Members present: Representatives Shays, Schrock, Kucinich, 
and Platts.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Robert Newman and Kristine McElroy, professional staff 
members; Jason M. Chung, clerk; Kristin Taylor, intern; David 
Rapallo, minority counsel; and Earley Green, minority assistant 
    Mr. Shays. A quorum being present, the Subcommittee on 
National Security, Veteran Affairs and International Relations, 
hearing entitled, ``Hepatitis C: Screening in the VA Health 
Care System,'' is called to order.
    The Department of Veterans Affairs, VA Medical Network, has 
the potential to function as an indispensable pillar of the 
Nation's public health system. The question we address this 
morning, is that potential being realized in the VA effort to 
screen and test veterans for hepatitis C infection.
    With more than 15,000 providers at 1,100 sites, the 
Veterans Health Administration [VHA], will see and treat almost 
4 million patients this year. Those patients may be 
particularly vulnerable to the silent epidemic of hepatitis C 
because so many veterans, particularly those who served in the 
Vietnam era, may have been exposed to blood transfusions and 
blood derived products before the hepatitis C virus, HCV, could 
be detected.
    In early 1999, the VA launched the HCV initiative, setting 
a goal to screen and offer testing to all veterans passing 
through VHA medical centers and clinics. It was a responsible 
but daunting undertaking in response to a public health crisis 
afflicting veterans at three to five times the rate of 
infection found in the U.S. population as a whole.
    In three previous hearings on the hepatitis C effort, we 
heard of frustratingly slow but measurable progress as the 
decentralized VA health system struggled to implement and fund 
the program consistently across 22 regional networks. We heard 
persistent reports of inconsistent outreach, perfunctory 
screening and limited access to testing and treatment.
    So we asked the General Accounting Office [GAO], to visit a 
cross section of VA facilities to address the reach and 
vitality of this important public health effort. The GAO 
findings indicate the HCV initiative has failed to capture a 
significant number of veterans who carry the hepatitis C virus. 
Those veterans show no symptoms, do not know they are infected, 
but they need medical help to protect their own health and the 
health of those around them.
    After almost 3 years of attempting to implement this high 
priority initiative across the VA system, access to screening 
remains inconsistent and limited. Heavy-handed, invasive 
screening techniques at some VA facilities discourage 
disclosure of HCV risk factors by patients. Many facility 
managers see HCV screening and testing as an unfunded mandate, 
unaware Congress appropriated $340 million this fiscal year for 
the program.
    Due to poor VA communication with regions and facilities, 
inadequate data systems to measure program performance and 
faulty budget estimates, more than half that amount will not be 
spent on HCV related care. Adequately funded, the program still 
appears to lack focus. According to one estimate, fewer than 20 
percent of veterans using VA health care facilities were 
screened or tested for HCV. Data recently obtained by VA 
indicates up to 49 percent of VA patients may have been within 
reach by the HCV initiative over the past 2 years.
    But to redeem the promise of the HCV initiative, GAO 
recommends VA screen 90 percent of regular VHA patients next 
year. Reaching that target will require a far more sustained 
and aggressive approach from VA leadership at all levels than 
has been evident to date. We hope to hear today how the program 
impediments and weaknesses observed by GAO can be addressed, 
and how the VA will miss no further opportunities to improve 
the public health and the health of the Nation's veterans.
    We truly appreciate the skilled work of our oversight 
partners, the General Accounting Office, in this ongoing review 
of the VA's hepatitis C program. We also appreciate all our 
witnesses who bring important perspectives, experience and 
expertise to this discussion. We look forward to their 
    [The prepared statement of Hon. Christopher Shays follows:]
    [GRAPHIC] [TIFF OMITTED] 81591.001
    [GRAPHIC] [TIFF OMITTED] 81591.002
    Mr. Shays. At this time I recognize the ranking member, Mr. 
    Mr. Kucinich. I thank the Chair. Good morning. Let me 
welcome the witnesses from the General Accounting Office and 
the Department of Veterans Affairs. I'm glad all of you could 
be here today. The issue of hepatitis C is an urgent one for 
many veterans in all of our districts. For them, the prospect 
of blood tests, biopsies, pharmacological treatments and in 
some cases liver transplants can be tremendously frightening. 
It's no wonder, therefore, that many veterans and many others 
are hesitant to even get tested.
    And in the case of hepatitis C, symptoms may not arise for 
years, if not decades. So procrastination and avoidance can 
have serious impact.
    But it's for precisely these reasons that the screening 
process, which helps veterans identify their conditions and 
come to terms with them, must be an open process, one that is 
informative, accessible and encouraging. A system that 
arbitrarily restricts screening procedures, or worse, makes 
them embarrassing to endure, will only complicate this process 
    For that reason, I want to thank the Department of Veterans 
Affairs for their public statements and policies, recognizing 
their lead role in this process. I'm confident of the agency's 
commitment to help the veterans in need. However, I remain 
skeptical that we're doing all we can to attack this problem 
head-on. My skepticism is renewed today by the testimony that 
will be presented by GAO.
    I want to thank the chairman for calling this hearing, and 
I appreciate the Chair's continued commitment in this area.
    Mr. Shays. My colleague told me he has three hearings, I 
think most of us do, and he already sounds tired.
    Mr. Schrock.
    Mr. Schrock. Thank you, Mr. Chairman. I too, want to thank 
you for being here. I represent the Second Congressional 
District, which probably has as many retired people and 
veterans in it as any place in the world, and I know that's a 
    And I'm sure you're aware of it, this is National Men's 
Health Week right now, so I think it's appropriate that you're 
here, and I look froward to your testimony. Thank you.
    Mr. Shays. I thank my colleague.
    Let me just get the unanimous consents taken care of, and 
then we will swear in our witnesses. I ask unanimous consent 
that all members of the subcommittee be permitted to place an 
opening statement in the record and that the record remain open 
for 3 days for that purpose. Without objection, so ordered.
    I ask further unanimous consent that all witnesses be 
permitted to include their written statements in the record, 
and without objection, so ordered.
    I'd like to ask if you can hear us in the back of the room. 
Is it OK? OK.
    We have two panels. Our first panel is Ms. Cynthia 
Bascetta, Director, Health Care, Veterans' Health and Benefits 
Issues, General Accounting Office, accompanied by Mr. Paul 
Reynolds, Assistant Director, Veterans Health Care Issues, 
General Accounting Office. I would invite both of you to stand, 
we will swear you in and then we will hear your testimony.
    Raise your right hands, please.
    [Witnesses sworn.]
    Mr. Shays. For the record, our witnesses have responded in 
the affirmative. If you can say anything funny to keep us alive 
and awake here, feel free. It's not required. [Laughter.]
    We welcome your testimony. We'll get to the questions 
afterwards, and then we'll go to our second panel.


    Ms. Bascetta. Mr. Chairman, and members of the 
subcommittee, thank you for inviting us to discuss the VA's 
efforts to identify veterans with hepatitis C.
    Three years ago, VA set out to screen all patients for risk 
factors and test those who had at least one. In its budget 
justifications, VA made a compelling case that it needed more 
money to identify veterans with hepatitis C and provide anti-
viral drug therapy where appropriate. In response, the Congress 
provided over $500 million.
    Today, we should be commending VA for a model public health 
initiative, but instead, we're discussing why most veterans 
still have not been screened. Two months ago, VA estimated that 
as many as 800,000 veterans had been screened during fiscal 
years 1999 and 2000, just 20 percent of those using VA health 
    Yesterday, VA told us about a new source of data that had 
just become available. It focuses on veterans who visited VA 
facilities during March and April of this year, and it suggests 
that many more veterans have been screened. This is consistent 
with our impression that in fact the pace of screening has been 
improving over the last few months.
    However, VA's new data also suggests that significant 
performance problems remain. Most notably, it reveals that 
thousands of veterans visited VA facilities during those 2 
months and left without hepatitis C screenings. Equally 
disturbing, VA told us that the data suggests that about 50 
percent of veterans screened nationwide were never tested, even 
though they had known hepatitis C risk factors, results that 
are consistent with our reviews of medical records at four 
facilities we visited.
    The sobering consequences are that the majority of VA's 
enrolled veterans with hepatitis C likely remain undiagnosed, 
potentially as many as 200,000 veterans. These veterans could 
unknowingly spread the virus to others and miss important 
opportunities to safeguard their health.
    A most notable contributor to VA's disappointing 
performance was the failure to act in accordance with the high 
priority set in its budget submissions. Until early this year, 
headquarters communicated its policy objectives through an 
information letter that allowed room for interpretation instead 
of using directives with clear expectations.
    And managers and providers at local facilities told us that 
they were unaware of the ability of funding for screening and 
testing. As a result, they used their own discretion to 
restrict screening. For example, by screening only on certain 
days of the week or by letting individual providers use their 
own judgment regarding who to screen.
    Besides these restrictions, we found flawed procedures when 
screening did occur. As you can see on the chart on my left, 
many of the risk factors address sensitive topics. Yet at some 
sites, providers required veterans to identify their risk 
behavior, rather than allowing them to acknowledge that at 
least one risk factor applied to them. At other sites, these 
questions were asked in areas that lacked sufficient privacy.
    As I mentioned earlier, many providers did not order blood 
tests, even for patients with known risk factors. Often, these 
tests were not ordered because a provider thought that a 
patient's age, psychiatric illness or substance abuse would 
make them ineligible for treatment.
    Mr. Chairman, VA has operated its hepatitis C for almost 3 
years without performance targets or adequate oversight. As the 
chart on my right shows, the new program director is dependent 
on the line authority of the Under Secretary, which extends 
through the 22 networks and facility managers to more than 
15,000 providers. This management structure suggests to us that 
a more systematic approach may be warranted to screen veterans 
appropriately and expeditiously.
    This could include three key components. First, making 
early detection of hepatitis C, a standard for care could 
convey the higher priority that headquarters would expect local 
managers to place on screening and testing. Second, performance 
targets are essential to hold managers accountable. And from 
our perspective, these should be results oriented and time 
sensitive. And finally, clearer communication regarding 
available funding could eliminate misperceptions that the 
program is not adequately funded.
    In summary, VA has the resources and the know-how to make 
up lost ground very quickly. In our view, additional delays, 
including this relatively straightforward initiative, are 
unnecessary and inexcusable. Mr. Chairman, this completes my 
statement, and we'd be happy to answer any questions that you 
or other members of the subcommittee might have.
    [The prepared statement of Ms. Bascetta follows:]
    [GRAPHIC] [TIFF OMITTED] 81591.003
    [GRAPHIC] [TIFF OMITTED] 81591.004
    [GRAPHIC] [TIFF OMITTED] 81591.005
    [GRAPHIC] [TIFF OMITTED] 81591.006
    [GRAPHIC] [TIFF OMITTED] 81591.007
    [GRAPHIC] [TIFF OMITTED] 81591.008
    [GRAPHIC] [TIFF OMITTED] 81591.009
    [GRAPHIC] [TIFF OMITTED] 81591.010
    [GRAPHIC] [TIFF OMITTED] 81591.011
    [GRAPHIC] [TIFF OMITTED] 81591.012
    [GRAPHIC] [TIFF OMITTED] 81591.013
    Mr. Shays. Thank you. I'd like to get your response to a 
few questions, and then we'll get into the next panel. Why 
weren't network budget officers, facility managers and 
providers aware that VA had received funding for hepatitis C 
screening and testing?
    Ms. Bascetta. Mr. Chairman, that's a question that brings 
to my mind business as usual at the VA. They see their 
appropriation as available for any medical care regardless of 
how the budget request was developed. They in turn allocate the 
money to the networks, and the networks in turn to the 
facilities. They expect managers to understand the priorities 
that have been set, and to manage to those priorities.
    In this case, hepatitis C obviously was not set clearly 
enough as an unambiguous priority.
    Mr. Shays. So the bottom line is, and let me just say, I 
believe that we have to allow flexibility in anyone who has to 
manage a Government agency. Sometimes we request nine things 
and we only fund for eight. But this was clearly a priority of 
Congress and I thought as well the VA. You basically have 
literally millions of people who may not know they have this 
disease. And ultimately, they get pretty hard, and it's life-
    But your testimony is that you one, don't think it's a 
priority, and two, you think there is the incentive to be using 
these funds for other reasons?
    Ms. Bascetta. Yes, clearly the funds were used for other 
reasons. The problem appears to be a disconnect between the 
high priority in the budget justifications and the way the 
money was allocated. We agree that the networks and the 
facilities need flexibility. And we're not suggesting that the 
money be earmarked. We're suggesting instead that the 
facilities be made aware of the fact that extra money was 
provided for this program, and that the clear expectation of 
headquarters is that is a top priority and funds will be 
expended to achieve the hepatitis C program goals.
    Mr. Shays. Basically, we're talking about 4 million 
patients, not 4 million visits?
    Ms. Bascetta. Four million patients, correct.
    Mr. Shays. We're talking about 22 network directors, 145 
facility directors and 15,000 health care providers. They all 
need to be into the loop.
    Did you determine where the system was breaking down? Did 
it get as far as the network directors and the facility 
directors? Did the network directors have different goals? You 
didn't go into every network, obviously.
    Ms. Bascetta. Correct.
    Mr. Shays. But can you kind of describe to me where you 
think it broke down? And I'm talking about the lack of 
communication through the VA's management structure, and how it 
affected the screening.
    Ms. Bascetta. Right. I think that the first and most 
important breakdown is in the vehicle that they chose to 
communicate their goal, or their policy objective to screen and 
test all veterans. What they did was they issued, in June 1998, 
an information letter which is a vehicle that isn't used to 
convey mandatory policy. In other words, although the 
information letter stated that all patients will be evaluated 
for hepatitis C and tested if a risk factor indicates that it's 
warranted, so they used an information letter, which is a less 
formal vehicle for communication.
    What happened was, local managers, in reading this 
information letter, didn't feel that it was a requirement or, I 
should say, it was ambiguous whether or not there was a 
requirement to screen all veterans. In addition, there was no 
timeframe in the information letter. So it wasn't, the 
information letter didn't convey a sense of urgency about when 
headquarters would expect it.
    Mr. Shays. So that leads to what recommendations you would 
    Ms. Bascetta. Well, first of all, if in fact they intend it 
to be a high priority----
    Mr. Shays. You know what? I'm going to actually ask this 
question first. Why hasn't the VA completed a performance 
standard? In other words, you're talking about, it all relates, 
there should be certain goals set out, given to the various 
directors, filtered all the way down to the various health care 
providers. And I want to know why those standards haven't been 
put in place and then your recommendations.
    Ms. Bascetta. Unfortunately, I don't have a good answer to 
that question. The last two budget submissions have indicated 
those performance standards are TBD, to be developed.
    Mr. Shays. Say it again?
    Ms. Bascetta. TBD----
    Mr. Shays. No, I understand to be developed, but the last 
    Ms. Bascetta. Budget submissions indicated that they 
intended to set performance standards.
    Mr. Shays. But this is an issue that, it didn't happen in 
the last budget and it hasn't happened in this budget?
    Ms. Bascetta. Correct. And they're promising that they will 
have them for 2003. What we find----
    Mr. Shays. Let me understand. What's involved with 
getting--I'm not quite sure why it has to wait until 2003.
    Ms. Bascetta. Well, we're not either. It's clearly not 
rocket science, and they use performance measures in many of 
their other programs. It seems to us to be as simple as saying 
you'll screen 80, 90, 100 percent of your population within 12 
months, whatever the timeframe might be.
    Mr. Shays. So at any rate, what's your recommendation?
    Ms. Bascetta. With regard to performance standards?
    Mr. Shays. Yes. And how they can communicate better.
    Ms. Bascetta. First of all, they obviously need to set 
those performance targets. They need to be quantifiable and 
measurable and results oriented, not process oriented. As I 
just said, pick a high percentage, 80, 90 or 100 percent of the 
population to be screened, and to be screened within a 
specified time limit, say 1 year from the date of the 
    Another way to emphasize the urgency of screening this 
population as expeditiously as possible is to write into the 
directive that veterans are to be screened at their next visit.
    In addition, with regard to performance measures that would 
convey the urgency of the testing portion of the program, we 
think that they need to minimize the gap between assessing a 
risk factor and ordering the blood test. And certainly, they 
need to order the blood test. As we said, 50 percent of the 
tests aren't ordered, even when there is a risk factor.
    Mr. Shays. Describe a risk factor.
    Ms. Bascetta. The risk factors are the 11 on the chart.
    Mr. Shays. So a veteran who comes in, they want to ask 
questions about, were you a Vietnam veteran, did you have a 
blood transfusion, were you a drug user, that's when it gets a 
little more intrusive, some people may not want to admit to 
    Ms. Bascetta. Right.
    Mr. Shays. But they need to be told that if they were, they 
could have this disease, and they need to have someone describe 
the impact of this disease on them and their loved ones.
    Ms. Bascetta. That's correct.
    Mr. Shays. A tatoo, body piecing, all those are issues that 
you would ask.
    Ms. Bascetta. Right.
    Mr. Shays. And should be asked. Now, are those questions 
out to everyone? All the health care providers, they have that 
    Ms. Bascetta. They are now. Recently, the first one, 
Vietnam-era vet, was added to their guidance. In our visits, we 
noticed that some of the sites did not include Vietnam-era vet 
as one of the risk factors. And of course, as you can see, 
that's one of the ones that would be easiest to answer, because 
there isn't a stigma.
    Mr. Shays. All Vietnam-era veterans should be asked some 
very significant questions.
    Ms. Bascetta. Right.
    Mr. Shays. OK. In terms of, we have two different 
statistics. We have the statistic that basically your feeling 
is 20 percent were screened, and we have the VA saying their 
new data, since you've done the report, indicates that up to 40 
percent may be screened, 49, I'm sorry. Have you had a chance 
to look at that data and see--we just received it yesterday. 
Were you notified of that?
    Ms. Bascetta. Yes, we received it yesterday as well, and we 
did spend a number of hours trying to do some very quick 
    Mr. Shays. I'd love to just have your sense of it. I 
realize, and this is not a criticism of the VA, but this is new 
information. Depending on its accuracy, and I'm assuming that 
it obviously points us in the right direction, we should be 
happy to see that level. But I'd love to just have a sense of 
how comfortable you can be with it. If you can't tell me your 
comfort level, I understand.
    Ms. Bascetta. Well, I can tell you that the external peer 
review program is very rigorous, methodologically sound data. 
The frustrating part about this whole analysis has been that, 
of course, the VA doesn't have a management information system 
that can give us timely and accurate tracking of how well 
they're doing.
    So just as with their external peer review program 
providing some results yesterday, the system wasn't designed to 
track and monitor how many veterans have been screened and how 
many are positive. The timeframes are different than the 
timeframes that we used to do our analysis and that VA in fact 
used to do its estimates that it provided for the appropriators 
a couple of months ago.
    So it seems to me that all the data have basic limitations. 
The uncertainty revolves around three key numbers: the number 
yet to be screened, the number screened for the risk factor but 
not tested; and the overall prevalence. Our conclusion at this 
point is that our numbers and our analysis are conservative, 
and that there still need to be about 3 million veterans 
    So if in fact the conservative prevalence of 6.6 percent is 
accurate, that leave potentially 200,000 veterans with this 
    Mr. Shays. I'm going to invite counsel to ask questions.
    Mr. Halloran. So say that again, the prevalence indication 
from this new data is 6.6? Or is that what you found?
    Ms. Bascetta. No, 6.6 is the number that VA used to develop 
its budget estimates, based on its 1 day survey.
    Mr. Halloran. What's the prevalence indicated by the 
internal review data? None.
    Ms. Bascetta. I don't know.
    Mr. Shays. When we're talking prevalence--speak my 
    Mr. Halloran. How many people were found to have the 
    Ms. Bascetta. We don't know the answer to that.
    Mr. Halloran. It doesn't show that?
    Mr. Reynolds. If it does show it, they didn't share it with 
us yesterday.
    Mr. Halloran. I see. In your work, did you come across any 
indication, in the places you visited, come across any 
indications of any other outreach or lookback efforts that VA 
was feeling the impact of, a local hospital blood center had 
sent back a lookback notice and did a veteran present 
themselves to say, hey, I got this letter, I don't quite 
understand it, they think I have hepatitis C, did you come 
across any trace of anybody else beating the bushes and driving 
the veterans toward the VA system on hepatitis C?
    Ms. Bascetta. I believe that in Spokane, there was an 
outreach letter that went out to all veterans. But I don't know 
that we have information on the impact at that facility at that 
    Mr. Halloran. Was it a VA letter, or some externally 
derived letter?
    Ms. Bascetta. I think it was a VA letter, from the 
    Mr. Reynolds. That was a VA letter that they sent out to 
everyone in that network. But as we did go around, quite often 
concerns were expressed that when other private providers or 
insurers would find people that had hepatitis C, and they found 
that they were a veteran, that they would strongly encourage 
them to go to VA.
    Mr. Halloran. On the screening for risk factors, what did 
you find in terms of the consistency of the process and the 
procedure for presenting information about the risk factors, 
and in particular, the need to get the patient to identify one 
particular risk factor versus being susceptible to one of those 
in a less specific fashion? Why one versus the other?
    Ms. Bascetta. Well, in the sites that we visited, a couple 
of them did require that the veteran admit to a specific risk 
factor. In one location, the form was presented to the veteran 
to fill out essentially in the waiting room. And in that case, 
the disadvantage was that the kind of counseling that you'd 
like to see happen wasn't happening. But I suppose an advantage 
was that the veteran didn't have to specify a particular risk 
    Mr. Halloran. What is the standard that is recommended and 
the VA guidance that you saw in terms of them administering it?
    Ms. Bascetta. Well, the guidance isn't as clear as we would 
like it to be. It presents the questions and then says, 
document the risk factor, but it doesn't say document a 
specific risk factor, or document that the veteran acknowledged 
one of them. The guidance is unclear.
    Mr. Halloran. And in your written testimony, you suggested 
that it would be a reasonable target for VA to look to be able 
to screen 90 percent of the patients passing through the VHA 
system in the next 12 months. Given the resources and the 
current state of play as you found it, do you think that's 
still possible?
    Ms. Bascetta. Yes, we do.
    Mr. Halloran. Thank you.
    Mr. Reynolds. It's especially possible, if I could add, 
because the veterans come many times during the year. I think 
that most come four or five times or more. So there's several 
opportunities to screen them during the 12 months.
    Mr. Shays. Thank you. I want to ask one last question. You 
looked at seven facilities, correct?
    Ms. Bascetta. Correct.
    Mr. Shays. And only one of those facilities used the 
clinical reminder system. Explain what the clinical reminder 
system is and why only one used it.
    Ms. Bascetta. The clinical reminder system is a very 
powerful tool. When a patient is in a physician's office, the 
computer screen actually displays that the patient needs to be 
screened for hepatitis. It's essentially a flag that process 
needs to happen.
    And we actually found that at one site, they had tremendous 
success in using the clinical reminder system. In April 2000, 
they were at 13 percent screened. They began publishing the 
results by clinic of the numbers, the percentages that were 
screened. By September they were up to 50 percent screened, and 
by the end of the year, they were actually at 89 percent 
screened, because the peers actually saw one another's data and 
they did better to perform on that particular clinical 
    Mr. Shays. And this clinical reminder reminds them to ask 
questions, not just as it relates to hepatitis C but other 
issues as well?
    Ms. Bascetta. Correct, yes.
    Mr. Shays. What was that facility? Congratulations to them.
    Ms. Bascetta. That was the Bronx.
    Mr. Shays. The Bronx, OK.
    Mr. Reynolds. If I may, what we're talking about, I think, 
with the one facility, was using that system as a management 
tool for the managers to look and see how well the providers 
were doing screening veterans. All of the facilities we went to 
used, it was turned on and the providers were getting the 
message on their screens, although some of them only turned it 
on a week or two or three before our visit.
    So the system, from last July through now, has been slowing 
been implemented in the system. It's possible that to this day, 
there are a couple that don't have it turned on.
    Mr. Shays. One of the values of having GAO inspector 
general look at issues is that it sometimes encourages people 
to look at what they're doing and say, are we meeting the 
standards and are we doing what we should do. We got into the 
whole issue of hepatitis C in a hearing we had, a monumental 
hearing on the safety of the blood supply. We learned that HHS 
was not using their review panel to come up with new 
recommendations as this Congress had mandated.
    But instead of being critical of the agency, the 
Department, for not doing it, we just were grateful that they 
started. But in the process of looking at the safety of the 
blood supply, we invited hemophiliacs, 10,000 of whom had died 
during the infection of AIDS. We were told about this kind of 
silent killer, and it was called hepatitis C. It was new to us, 
and we learned that in the process of the taint of HIV, there 
was also hepatitis C.
    And this really kind of opened up this understanding to the 
committee and I think also to the various departments that it 
needed to. It's just sad that we haven't made as much progress 
as I think we all have wanted to make. We're just trying to see 
that come to conclusion.
    Let me ask you, is there any question you feel we should 
have asked?
    Mr. Platts, welcome. I understand you may have questions 
for the next panel, but not this panel.
    Is there any question you would like to ask yourself and 
then answer?
    Ms. Bascetta. No, but I don't think I answered the second 
part of your question, which is why aren't more facilities 
using the clinical reminder system. The answer is that, there's 
very complex software, actually that needs to be installed. And 
the computer systems at most of the facilities vary. So it's 
almost as though the reminder system needs to be customized, 
there has to be custom programming, which requires a high level 
of expertise to not only install it but have it produce 
reliable information.
    There were some initial startup difficulties for both 
hardware and software. In some cases, if the hardware was 
inadequate, the entire CPRS system, the computerized patient 
records system, could be running slowly, which of course would 
frustrate providers and cause them not to use it. As well as, 
there's always a learning curve with any new technology and 
some initial resistance. Frankly, the managers in those 
facilities need to tell providers that this is a way that will 
dramatically improve quality of care in the long run, and that 
they need to get used to the new system.
    But we think that one of the most important things that VA 
can do is get that clinical reminder system and the 
computerized records running everywhere.
    Mr. Shays. Individuals who have other jobs but then have to 
deal with technology sometimes postpone. I have a computer 
that's been sitting on my desk for the last few weeks, and it 
is still a mystery to me, but it won't be hopefully for long.
    Ms. Bascetta. Once you get used to it, you'll never go 
    Mr. Shays. I know. But you've got to make that initial 
step. So I have to cancel a hearing so I can have the 
opportunity. [Laughter.]
    Let me thank you. Is there any question, Mr. Reynolds, that 
you want to respond to? Anything we should have asked you that 
we didn't?
    Ms. Bascetta. I don't think so.
    Mr. Shays. OK. Thank you very much.
    I'll call our next panel. Let me invite our panel to come. 
We have Dr. Frances Murphy, Deputy Under Secretary for Health, 
Department of Veterans Affairs, accompanied by Dr. Lawrence 
Deyton, Chief Consultant for Public Health, Department of 
Veterans Affairs, Dr. Robert Lynch, Director of Veterans 
Integrated Service Network 16, Department of Veterans Affairs. 
Everyone is from the Department of Veterans Affairs. Ms. Mary 
Dowling, Director of the VA Medical Center, Northport, NY, and 
Mr. James Cody, Director, VA Medical Center, Syracuse, NY.
    I was trying to read quickly so I could keep you standing, 
but if you would all rise and raise your right hands, please.
    [Witnesses sworn.]
    Mr. Shays. Note for the record that we have one statement 
which would be you, Dr. Murphy, but all will be invited, in 
fact, encouraged to respond. Let me ask unanimous consent to 
include in the record statements submitted for the record by 
Terry Baker, executive director, Veterans Aimed At Awareness. 
Without objection, so ordered. And Dr. Allen Brownstein, 
president of the American Liver Foundation. Their statements 
will be in the record.
    [The prepared statements of Mr. Baker and Dr. Brownstein 












    Mr. Shays. I think what we'll do is we'll get your 
statement on the record and then I'll come back for questions.


    Dr. Murphy. Thank you, Mr. Chairman and members of the 
subcommittee. I appreciate this opportunity to discuss VA's 
hepatitis C screening, testing, treatment and prevention 
programs. With me today are Dr. Lawrence Deyton, Chief 
Consultant for Public Health, who coordinates VA's hepatitis C 
programs; Dr. Robert Lynch, who is the Network Director in 
Network 16, in the southern part of the United States; Mr. 
James Cody, the Director at the VA Medical Center in Syracuse, 
NY; and Ms. Mary Dowling, who's the Director at the Northport 
VA Medical Center in New York.
    Hepatitis C, as you know, is a major public health program 
for the VA and the United States as a whole. VA has responded 
vigorously to the challenges by creating the largest hepatitis 
C screening testing and treatment program in the world.
    Let me briefly mention just a few of our activities. VA has 
issued three directives for information letters outlining 
hepatitis C screening and testing guidelines. Over 800 front 
line clinicians have participated in VA national education 
programs for hepatitis C screening, testing and treatment.
    In July 2000, the National Clinical Reminder System was 
initiated to alert clinicians about the need for hepatitis C 
screening at the time of each patient visit. Even though it is 
new, the clinical reminder system shows VA has screened over 
734,000 veterans for hepatitis C infection during the last 2 
fiscal years, plus the first quarter of this fiscal year, 2001.
    We believe that is an underestimate. From fiscal year 1999 
through the second quarter of fiscal year 2001, VA performed 
over 800,000 hepatitis C tests and identified over 77,000 
veterans who currently are under care for hepatitis C.
    As you previously acknowledged, I'm pleased to report to 
you today on hepatitis C specific aspects of our external 
performance review program that reported results to us for the 
first time last Friday. The EPRP reviewed nearly 18,000 medical 
records of veterans using VHA facilities. In that review, they 
found that 49 percent of those veterans had either been 
screened or tested for hepatitis C.
    Since this is a random review of a very large number of 
records, this we believe is a more reliable number than other 
data that can currently be derived from our clinical reminder 
system, since it has not uniformly been implemented in every 
medical center, due to software and computer compatibility 
    These data from our external peer review program 
demonstrate the VA providers have responded vigorously to 
screen and test veterans for hepatitis C. Nearly 2 million 
veterans have likely been screened or tested for hepatitis C in 
the last 2 years. We are increasing our efforts to ensure that 
all VHA users are screened for hepatitis C. I believe these 
data also demonstrate that the problem we have is primarily 
with our data system and our recording of our efforts. We 
depended on these to report on screening and also for budget 
estimates. But it appears we have underestimated the screening 
activities that have already gone on.
    However, despite our successes, we intend to do even more 
for hepatitis C screening and testing. We're improving the use 
of the clinical reminder system for hepatitis C screening to 
make it uniformly available and used across the VHA system. 
We've initiated an epidemiologic study, so that we can 
determine the actual prevalence of hepatitis C among VA health 
care users, and to identify the risk factors in this veteran 
population. This will allow us to better target veterans who 
are at greatest risks.
    We have learned from front line providers and 
administrators that we can do a much better job of 
communicating our hepatitis C program priorities and the 
resources that are available. We have therefore initiated a 
number of activities that will improve communications with 
front line providers. The National Hepatitis C program office 
and VHA's chief information officer are working to establish a 
new national hepatitis C registry. This registry will assist us 
in accurately tracking veterans with hepatitis C and managing 
the resources that VA devotes to helping them.
    VA's hepatitis C clinicians are among the most experienced 
and well trained in the world. We have hepatitis C lead 
clinicians at each VA facility where hepatitis C care takes 
place. These clinicians are extraordinarily capable and 
experienced in the treatment of this disease. They have 
averaged 14 years experience in the care of hepatitis C and 
chronic liver disease. These clinicians average 11 years 
serving in VA health care. Ninety-four percent of these 
physicians have specialty or sub-specialty board certification 
in gastroenterology, internal medicine, family practice or 
infectious disease. Sixty-two percent of these have academic 
affiliations at the level of full professor or associate 
professor of medicine, and 44 percent have treated over 500 
patients with hepatitis C or chronic liver disease, and 84 
percent have treated over 100 patients.
    VA makes available all licensed drugs to treat hepatitis C. 
We've added to our national formulary the new form of alpha 
interferon and made that available as soon as it was licensed 
by FDA. Our National Hepatitis C program office informs all of 
our clinicians and pharmacists treating hepatitis C patients of 
the availability of new treatments upon licensure by the FDA.
    The treatment for hepatitis C, as you know, changes rapidly 
as new drugs and new information is developed. Thus, the 
National Hepatitis C program office is now updating VA's 
hepatitis C treatment guidelines and will distribute them to 
the field shortly.
    Before I close my statement, I would like to address issues 
that we have concerning VA's projections about the utilization 
of hepatitis C----
    Mr. Shays. Maybe I need to ask you, how much time would 
that take?
    Dr. Murphy. Another minute.
    Mr. Shays. I think we can do that. I don't want to rush 
you, I'm happy to come back, but if it's a minute, we'll do it 
    Dr. Murphy. We recently submitted a report to Congress that 
articulates the reasons for the differences between our 
projections and VA's budget formulation requests. Hepatitis C 
is a new disease, the hepatitis C virus was only identified in 
1988, the blood test in 1992 and the first treatments approved 
in 1997. The previous budget estimates were based on 
assumptions that were not informed by reliable data, because 
there was no experience on which to base these projections. Our 
estimates of the numbers tested, the prevalence and the 
treatment acceptance were larger than proved to be the actual 
    At the same time, our ability to accurately capture 
hepatitis C treatment related costs likely missed significant 
costs to the VA health care system. Today, based on actual 
experience in testing and treating hepatitis C, we feel we 
better understand where early assumptions were inaccurate, and 
intend to continue to improve the projections for the future.
    Because of the magnitude of difference between previous 
models and our actual experience, VA revised its projections 
for hepatitis C expenditure in fiscal year 2002 to $171 
million. The budget planning for 2003 will include use of 
improved data.
    With that, also, the National Hepatitis C registry will 
allow much more accurate reporting and tracking. So we believe 
that we'll be able to perform better in the future.
    Mr. Chairman, my colleagues and I will be happy to answer 
    [The prepared statement of Dr. Murphy follows:]
    [GRAPHIC] [TIFF OMITTED] 81591.026
    [GRAPHIC] [TIFF OMITTED] 81591.027
    [GRAPHIC] [TIFF OMITTED] 81591.028
    [GRAPHIC] [TIFF OMITTED] 81591.029
    [GRAPHIC] [TIFF OMITTED] 81591.030
    [GRAPHIC] [TIFF OMITTED] 81591.031
    [GRAPHIC] [TIFF OMITTED] 81591.032
    [GRAPHIC] [TIFF OMITTED] 81591.033
    [GRAPHIC] [TIFF OMITTED] 81591.034
    [GRAPHIC] [TIFF OMITTED] 81591.035
    [GRAPHIC] [TIFF OMITTED] 81591.036
    [GRAPHIC] [TIFF OMITTED] 81591.037
    Mr. Shays. Let me just say, if you felt a little rushed, we 
can have you make any other statement you want. I'll come back. 
I have two votes, so it may take a while. We stand in recess.
    Mr. Shays. We were in recess, and we are back in session. I 
just want to make sure, just to make sure we get back into 
this, if there's any comment that any of you want to make 
before we start the questions.
    Let me start the process by asking you, we have GAO coming 
in and obviously doing a sample study, and then you have a peer 
review study. Tell me why you think the numbers differ, and 
tell me what you think the peer review study really tells us.
    Dr. Murphy. The peer review study was done on a random 
selection of charts during a 2-month period in VA. It's part of 
our routine peer review quality assessment program. With the 
larger number of charts over a broader range of medical 
centers, we believe that the data is more accurate than doing a 
small number of charts.
    That's not a criticism of the GAO methodology. It's simply 
a difference in the screening technique that was used and the 
depth of the analysis that was done by EPRP.
    Mr. Shays. What is the timeframe used in that study?
    Dr. Murphy. The charts were pulled from patients who were 
seen during March and April. But the analysis was actually 
whether risk factor screening was done during the 2-year period 
prior to that.
    Mr. Shays. How was it conducted?
    Dr. Murphy. By actual medical record review. So the way the 
information was gathered was that a random number of charts 
were selected, 18,000 medical records were reviewed, and in 
those medical records, the health care provider would have had 
to record risk factor screening for hepatitis C or a positive 
test for that chart to be included in the 49 percent positive 
for screen.
    Dr. Deyton. Positive or negative test, juste any testing.
    Mr. Shays. I'm sorry?
    Dr. Deyton. The review looked for risk factor screening or 
a test for hepatitis C. So the test could be either positive or 
    Mr. Shays. OK. By the way, I welcome anyone else jumping in 
here. We'll get out into the field and just question. Tell me 
how the sample was drawn?
    Dr. Murphy. We have a standard sampling methodology that 
EPRP uses. What they do is they randomly select from among the 
veterans charts who are seen at our facilities nationwide over 
a 1-month period. The EPRP reviewers will send a list of charts 
to the medical center just prior to their visit to pull, so 
that they can be reviewed for a number of quality measures.
    Mr. Shays. I was going to ask, and am going to ask, but I 
get the inference that it wasn't just one network, it was all 
the networks?
    Dr. Murphy. Yes.
    Mr. Shays. It was random throughout the system. And what is 
the margin of error when we do this?
    Dr. Deyton. I believe I heard yesterday when we were 
discussing this with GAO, I think I recall the EPRP programs 
testing, the margin of error is very small, like 97 to 98 
percent accuracy. And I should point out, sir, that this is 
performed by an external contractor group. They're 
professionals in going in and monitoring medical records. So 
this is a contract that VA has external to us to review the 
quality of the work we're doing in specific areas.
    Dr. Lynch. It's in fact a State peer review organization 
that does Medicare work for the State of West Virginia. So 
they're already an existing group in the State of West Virginia 
that does Medicare peer review. And we contracted so we kept it 
outside of VA. The sample sizes are designed to be 
statistically significant at the network level, so they make 
sure they extract enough charts.
    Mr. Shays. And how is it determined that a veteran had been 
screened and tested for hepatitis C? How did they determine 
    Dr. Murphy. They actually looked at the medical records, 
went back through the progress notes for a 2-year period. And 
in one of those progress notes or in a discharge summary, there 
needed to be evidence that the veteran was screened for 
hepatitis C, and specifically screening for the risk factors 
that are on your chart, or that there was a test for hepatitis 
C ordered.
    Dr. Deyton. I'd be glad to provide to your or your staff, 
sir, the specific questions that the reviewers do go and look 
in the charts for over the last 2 years. Because they're very 
specific instructions, and the reviewers are certified on doing 
this in a very accurate way.
    Dr. Lynch. They're in fact required to be medical record 
technicians or registered record technicians. This is their 
    Mr. Halloran. And hepatitis C questions were just added t 
the external review process?
    Dr. Deyton. Yes, sir. Back in I think it was February or 
March, when the EPRP staff were developing the questions to go 
out in the latest cycle, we were able to insert six specific 
questions about hepatitis C for the reviewers to go and look 
    Mr. Halloran. How often is this done?
    Dr. Deyton. Constantly.
    Mr. Halloran. The EPRP process?
    Dr. Deyton. It's a constant, ongoing process. There are new 
questions added every cycle.
    Mr. Halloran. A cycle being--my question is, when can we 
expect to see another set of data with hepatitis C questions in 
    Dr. Deyton. We don't have a set time plan, obviously. When 
Dr. Garthwaite gave us responsibility for this program, we 
wanted to immediately insert in the EPRP some of these 
questions to just get a baseline. So obviously we will be going 
back to EPRP in the near future to followup on some of these 
and other issues that we'll need to for better management of 
the program. But I don't have a specific time date in mind.
    Mr. Halloran. Let's go down the data and get from it what 
we can, and I know it's preliminary and there will be 
subsequent analysis. But just to decode some of the data 
elements here, the 49 percent is derived from the sample six, 
the 17,994, that's the charts reviewed, right?
    Dr. Deyton. Yes.
    Mr. Halloran. And they found in those 17,994 charts 8,846 
showed indications of screening and/or a test, is that correct?
    Dr. Deyton. Yes, sir.
    Mr. Halloran. Positive or negative. Moving down the rest of 
the data, tell me what they represent, if you would.
    Dr. Deyton. What I get from these data, and again, we just 
got these data the other day, and staff hasn't even had a 
chance to do all the analysis and the final sort of summary of 
it. But what I get from these data, the important messages, 
that first message that of the nearly 18,000 charts that were 
reviewed, there was evidence of screening for hepatitis C or a 
test in a 49 percent.
    The other very important factor to me is that of those who 
tested, or who had a risk factor, only 49 percent of those 
people actually went on to get a hepatitis C blood test. So 
there's another 50 percent that had identifiable risk factors 
and were not tested for some reason. I don't know what those 
reasons are.
    Mr. Halloran. That's the differential the GAO was talking 
    Dr. Deyton. That's exactly what GAO found as well, yes. So 
I think that's a very important lesson here, that there's risk 
being identified in the screening, and there is about half who 
are not going on to get a blood test for some reason.
    Mr. Halloran. What are the possible reasons? I mean, maybe 
a veteran says no?
    Dr. Deyton. Yes, the veteran says no, or it may be a 
situation where the veteran is at incredibly low risk for a 
problem, that is, a 90 year old veteran who is in the hospital 
with dementia, you might not want to get tested there. Other 
reasons may be that the screening itself may be again, I think 
GAO found some evidence of this, screening may be going on in a 
way where it's happening in a clinic, a waiting room setting or 
something like that where the information actually doesn't get 
to the doctor or nurse to order the test.
    So those are all issues which we need to identify and 
figure out how to correct that problem, so that in fact, 
testing of all 100 percent who do have a risk factor does 
    Ms. Dowling. I would add something to that, just to share 
my experience. In the way we rolled out the program, we started 
in our primary care area, one team, and then rolled it out 
across the team. Over a 12 month period, if you look at our 
average of patients who were tested, those who had a risk 
factor and were tested, it was 48 percent.
    But if you look at how it was rolled out in the beginning, 
it was 23 percent, and at the end, it was 90 percent. So it's 
really progressed remarkably well in terms of improvement.
    Mr. Halloran. I'm glad you raised that. My next question 
was to ask the other facility directors here if this data 
comports with your experience in the field. Is there any other 
surprise besides the 49 percent?
    Mr. Cody. I'm from Syracuse. I wasn't surprised at the 
data. I thought we were screening much more than the 20 percent 
than was being quoted before. I was surprised at that figure. 
And at Syracuse, I could show that 20 percent was not the 
figure. It's in excess of at least 30 percent that I know have 
been screened and given the blood test, at this point, just 
over the last year.
    What I am finding though, I am a little bit surprised that 
of the one that we do the actual questioning or screening on, 
most of them are getting the blood test at our place. I'm not 
finding that half of them are not getting it. I can't explain 
    Mr. Halloran. So most who have an identified risk factor--
    Mr. Cody. Right, just to throw out some numbers, just in 
the last 6 months, 6,011 were screened, 41 percent of them 
presented some risks. And of those, 98 percent of them got the 
blood test.
    Mr. Shays. And then what happened?
    Mr. Cody. Out of those, then about 15 percent came out 
    Mr. Shays. Fifteen of the 41 percent?
    Mr. Cody. Yes. Excuse me, 15 percent of the people had the 
blood test, which is essentially all the 41 percent that you 
just mentioned. So about 15 percent were positive, then they 
have the confirmatory test. Of those, it varied between 25 and 
40 percent were again positive.
    So the numbers diminish very quickly as to who should go on 
for treatment. Then I have numbers after that who have actually 
gone on for treatment. But that varies significantly. A lot of 
people don't go on for treatment for very many reasons.
    Mr. Halloran. Right. But that raises the question I think 
GAO came across, I think it was your facility or one of them 
here, that there was a concern at the provider level about the 
implications of the screening and testing, that care was 
expensive, or that, why would we test somebody who may be, the 
risk factors are so pronounced that they're likely to be 
ineligible or not tolerate the care? Is that----
    Mr. Cody. I'm not finding that at Syracuse, if I understand 
the question. From the whole process, we start with a process 
of the patient filling out the screening. That is done in 
private with a nurse. The nurse presents it to the provider at 
the time in the primary care visit. The provider and the 
patient then discuss the results of it. There is a decision 
made as to whether the patient wants to get a subsequent blood 
test on that.
    Once the blood test results come back, then there is 
specific counseling with people trained to do the counseling to 
tell them what the implications are, what the possible 
treatments are, there are contraindications for getting the 
treatments. But those are discussed, a decision is made between 
provider and the patient to go on or not. And some patients 
don't come back.
    Mr. Halloran. What is or was your understanding of the 
fiscal implications of this program in terms of the facilities, 
resources to undertake the screening and testing?
    Mr. Cody. The preliminary indications were that this was 
going to be very, very expensive. As we've slowly, continuously 
progressed and we're actually seeing and actually having to 
treat those figures are not coming out as high as we thought 
they were going to be. It's still very significant. But I think 
originally it was 18 percent of the veteran population was 
going to need to treatment at $10,000 apiece. Well, that's not 
going to happen, because we're not finding that's going on. Is 
that your question?
    Mr. Halloran. Yes, exactly.
    Dr. Lynch. I think you asked two questions. The first is on 
the issue of why this 49 percent is not getting, why we have 
this large group of patients who are screened, appear to have 
these factors and don't get tested. I don't have the perfect 
answer for that, either, but we do have data on people who have 
a positive hepatitis C blood test who don't get treated. We've 
been able to analyze why they don't get treated, and I suspect 
some of that also speaks to this group, why they don't get 
    For example, we can go in and look at codes for things that 
are objectively codeable that, or laboratory tests, for 
example, that would exclude patients from treatment, a low 
blood count, which is a contraindication to treatment. We find 
that about two-thirds of the patients who have a positive blood 
test have a codeable contraindication to treatment.
    And I suspect that's also true in this screening group. 
Because I suspect, as Dr. Deyton pointed out, we have non-
physicians doing some of the screening, then when it gets to 
the physician, they apply a little cognitive input and they can 
discriminate and make a decision that probably would not agree 
with, but that's probably what's happening.
    Mr. Halloran. A codeable diagnosis or condition that would 
exclude somebody from treatment is not an exclusionary factor 
from testing, is it?
    Dr. Lynch. I think in some cases you're right. I think Dr. 
Deyton pointed out a case where we'd say it is exclusionary. 
For example, I don't think there's much benefit to testing 
someone, say, who's institutionalized with advanced dementia. 
They won't change their behaviors and we won't change ours. 
Somebody who is still functional and has a lot of years to 
live, we want them to modify their risk factors, and that 
person we should test. So it depends who you're asking the 
question about.
    The issue of resources, in our network, when the Under 
Secretary pulled money out of the reserve to fund, we sent a 
specific disbursement agreement through a methodology we used 
in the network to our facilities. In fact, I think that was 
shared with the GAO site visitors when they visited in Gulfport 
and Biloxi. Since that time, we've made it very clear to our 
managers how our budget is generated in terms of how hepatitis 
C has gone to the that formulation.
    Our policies, we've had a policy since March 1999 which is 
developed by a committee that consists of our associate 
directors, chiefs of staff and nurse executives. That policy is 
confirmed and voted on by our PLC, which is our directors, 
which basically has to do with how we're going to do these 
things. So there should be no ignorance in our facilities about 
where the moneys come from, that it's out there and what our 
expectations are.
    Now, when you get down to the end clinician, I will be the 
first to admit we don't always get the perfect information out 
to them and a lot of stuff is being thrown out there and things 
get confused and there's a lot of competing agendas.
    Mr. Shays. I have a few interests. One obviously is that we 
have a study that says approximately 20 percent are being 
tested, and another study that we received last night, 
yesterday, 49 percent. When did you get the results of that 
    Dr. Deyton. We heard about the results of the EPRP, first 
news that we might be able to get an analysis out was Friday 
night. I actually was able to see the data and talk to staff 
about it Monday morning, this week. We took Monday to 
understand it more and shared it immediately then with GAO and 
your staff.
    Mr. Shays. And immediately is when?
    Dr. Deyton. I sent an e-mail to GAO Tuesday, and we talked 
Wednesday morning.
    Mr. Shays. When did we get this study?
    Dr. Deyton. Yesterday.
    Mr. Shays. So why do you use the word immediately? Today is 
Thursday. And you got the study Friday of last week, and now 
you wanted to analyze it before you shared it with the 
    Dr. Deyton. I actually was able to talk to staff about the 
data Monday morning.
    Mr. Shays. Our staff?
    Dr. Deyton. No, the staff at the EPRP program at VA.
    Mr. Shays. So you knew about the study last Friday, you had 
the information on Monday?
    Dr. Deyton. Yes.
    Mr. Shays. With all due respect, why would we get it 
Wednesday afternoon?
    Dr. Deyton. I needed to understand if it was real. I was 
not as familiar with the EPRP program on Monday morning as I am 
now. It was really just a, this has been my education about 
that program.
    Mr. Shays. Well, I'll tell you how I would have, you had a 
study, it's relevant, even whatever it says, there's something 
relevant to it. We appreciate getting it before the hearing, 
but last night is not very helpful, because then we have a 
difficult time making our assessment. So your team immediately, 
I just want to take issue with, you didn't do it immediately.
    Dr. Murphy. Congressman Shays, I apologize for that. And we 
won't let it happen again. We really, at the time that Dr. 
Deyton got this information on Monday, needed to verify in fact 
what it meant.
    Mr. Shays. No, I understand, but I'm just saying to you, 
and given the way we interact with each other and the long term 
relationship we have, you could have said, by the way, we got 
this on Friday, we started to ask questions about it on Monday, 
we don't know if it will help or hurt our understanding, but we 
want you to be aware it's there, and here's what we know, and 
we haven't figured out what it actually says yet, and we'll 
invite you to do some questions yourself. I think it would have 
been helpful.
    Dr. Murphy. It was an error in judgment on our part, and 
we'll work more closely with your staff in the future.
    Mr. Shays. Yes, there's no reason not to.
    When I look at the questions, what I wanted to say is that 
whether it's 29 percent or 20 percent or 49 percent, I'm struck 
with the fact that it's been over a decade since we've known 
about hepatitis C. Now, there's not a cure, and there wasn't 
always a way to always identify it. But we knew there was a 
problem there. One of the things that we've had a problem with 
HHS and with VA is that we weren't getting the word out to 
people that they may in fact have hepatitis C.
    Now, what I'm struck with is, we're debating 20 or 49 
percent, and you gave us a statistic that says 41 percent of 
the people who came in were at risk, and of the 41 percent, 15 
percent. So we're talking about at least 5 percent of the total 
population. If it was 15 of the 41, not 15 of your total. So 
we're talking approximately 5 percent.
    That's a huge number of people if I projected it out to 4 
million. Did you want to say something?
    Dr. Murphy. I believe it's 5 percent of those who have risk 
    Mr. Shays. Right, and the risk factor was 41 percent. No, 
it was 15 percent, I thought you said?
    Mr. Halloran. That were positive.
    Mr. Shays. What were the numbers, Dr. Lynch? I wrote them 
down. I wrote 15, if I wrote incorrectly and I even asked you.
    Mr. Cody. I believe you're talking about numbers that I was 
    Mr. Shays. I'm sorry, Mr. Cody, you said 41, then said 15 
percent of those proved positive.
    Mr. Cody. Over the last 16 months, yes.
    Mr. Shays. Of the 41, yes. So of the 100 percent, 41 
percent were at risk, and you had almost 41 percent take the 
test. And of that, 15 percent showed positive, correct?
    Mr. Cody. Yes, and then there's one more going down from 
that. Of the 15 percent, then you do a confirmatory test, and 
about 25 percent of those were confirmed.
    Mr. Shays. OK, so 15 percent said, we need to do another 
test, in other words. I just want to make sure we agree on 
these numbers, my question still stands.
    Dr. Lynch. I apologize for the confusion, I think I 
understand it now. But I have similar numbers, and it does make 
a somewhat different point. We've seen the prevalence, this is 
the number of tests, the number of positive tests as a 
percentage of patients tested. This is the first time a patient 
has been tested, not repeat testing, decline significantly 
since we've tracked this now for the last 4\1/2\ years, while 
the number of tests have gone up significantly.
    For example, this year we're on track to do about four 
times as many hepatitis C screening and blood tests as we did 
in fiscal year 1996, 1997.
    Mr. Shays. You're telling me a point you want me to know, 
but I at least want to get an answer to the point I've asked. 
Is that all right?
    Dr. Lynch. Sure.
    Mr. Shays. We had 41 percent who basically showed up as 
risks. We had 15 percent of those who, in the initial test, 
said we'd better test further to nail it down. Of that 15 
percent, 25 percent of the 15 percent proved to have hepatitis 
C, correct?
    Dr. Lynch. That's correct.
    Dr. Murphy. Yes.
    Mr. Shays. Which is basically one quarter of the 15 
    Dr. Lynch. It's a prevalence rate of about 3 to 4 percent.
    Mr. Shays. Yes. Now, 3 to 4 percent of 4 million people is 
a large number.
    Dr. Murphy. Note those numbers are from one medical center 
with a different population and shouldn't be translated to the 
    Mr. Shays. Fair enough. It could be larger or it could be 
    Dr. Murphy. Right.
    Mr. Shays. But those are the numbers we've got, and I 
appreciate your qualifying that, because we're going to qualify 
the 49 percent, too.
    Dr. Lynch. The point I was trying to make was relevant to 
that, I didn't mean to interrupt.
    Mr. Shays. OK. I just want to nail down that number. We're 
making one point, now you make your point.
    Dr. Lynch. Well, it's just that these figure change through 
time. And I think it has to do with the fact that when you go 
and you screen by risk factors, you're trying to narrow down on 
a population that has a higher prevalence than the general 
population. If you go toward the highest risk factors, you'll 
obviously find more patients positive than if you go to a low 
risk population. In fact, when we tested in 1997, 27 percent of 
the people who had a blood test were positive. This year it's 
only 9.84 percent, and it's fallen every year.
    In other words, what we're finding is, since we've started 
aggressively screening, using risk factors as a screening----
    Mr. Shays. But that tells me we should speed up the 
    Dr. Lynch. Well, I'm not disagreeing with that----
    Mr. Shays. No, numbers, let's leave that as the point.
    Dr. Lynch. It's just that the prevalence is going to 
decline, or the positive are going to decline----
    Mr. Shays. The more we test and the more we identify, the 
more the numbers are going to decline. So let's get on with it. 
The one, I think, problem I have with the VA, almost more than 
anything else, and it's a culture that exists, I feel like I 
could ask my interns over to the left of me to design a system 
that would ensure that every veteran was asked this question, 
and they don't have the mind set that we have in the VA, they 
wouldn't think that they're allowed a margin of error. I mean, 
if I had traffic controllers here, they wouldn't tell me, it's 
20 percent or its 49 percent, they don't have those margins of 
    We're talking about people's lives, and I don't want to 
sound like I'm talking and preaching to you, but we are. And I 
need to know this question. I need to know why a simple, now, 
I'm looking at the questions you ask, or recommend, this is 
Center of Excellence in Hepatitis C Research and Education. 
That is VA?
    Dr. Lynch. Yes.
    Mr. Shays. Now, some of these questions, why did you come 
to be tested for hepatitis C, have you ever been tested for 
hepatitis C, have you ever received a blood transfusion, have 
you ever injected drugs, gets a little more sensitive, if yes, 
do you currently inject drugs, have you ever snorted cocaine, 
people are probably going to respond not as honestly. Asks 
about condoms, it asks about, have you ever been tested for 
HIV, how many sex partners have you had, it gets on, have you 
ever been tattooed, have you ever had a body piecing, have you 
ever been in drug treatment, have you ever felt that you should 
cut down on your drinking, have people annoyed you by 
criticizing your drinking, have you ever felt bad or guilty 
about your drinking.
    So these get a little more sensitive with people, but we're 
still talking about their lives. And I want to know why every 
health care provider isn't required to ask these questions of 
the veterans who come in. I need to know why there would be one 
person, why even one would escape these questions. I just need 
to know. It's like, it's almost like, I'll just make this point 
to you, it's like, my gosh, if it's not 20, it's 49, case 
closed, let's get on with it. Tell me why there should even be 
one person that comes to a VA facility who is not asked this. 
And tell me why it wouldn't be the mandate and directive of the 
Director of the VA, the Secretary of the VA, to basically say, 
this will be done.
    Dr. Deyton. Mr. Chairman, we certainly agree that these are 
questions that the hepatitis C screening needs to happen much 
more. We've got many veterans that need to be screened. There 
are occasional examples where it's not appropriate. I have a 
clinic at the VA medical center here. And if I have a patient 
who comes in with a 104 fever and evidence of bacteria running 
through his or her system, I think it's more appropriate for me 
to handle that medical situation that's an emergency and then 
get to the hepatitis C question later.
    Mr. Shays. Right, OK, later means before they leave the 
    Dr. Deyton. Probably, yes.
    Mr. Shays. My dad, at one time I told my dad I forgot 
something. He said, if I gave you $1 million, would you have 
forgotten? I wouldn't have. It just wasn't important to me. And 
the question, I almost find it irrelevant what you said to me, 
with no disrespect, you're making a point you wouldn't ask them 
in the beginning, but now let me ask you why you wouldn't ask 
them before they leave.
    Dr. Deyton. I would.
    Mr. Shays. OK, then why aren't 100 people, why isn't it 100 
    Dr. Murphy. Our hepatitis C policy is in directive. And we 
have put a clinical reminder system in place in the 
computerized patient records system. This year we will require 
that clinical reminder system be loaded in every medical center 
around the country.
    That will allow us to not only require the screening, but 
also remind our clinicians on an ongoing basis that if a 
patient has not been screened, that they will be.
    In addition to that, we've done a number of things to try 
to ensure that all of our clinicians are informed about 
hepatitis C and the need for screening in the veteran 
population. We're going to be doing more education of 
clinicians. We've set up a system so that there is a lead 
hepatitis C clinician at every facility that does the screening 
and testing for hepatitis C.
    Mr. Shays. Explain that one. I was going to ask earlier, we 
have 11,000 facilities, but that can just be even a small, 
intake, outpatient facility. But you say in a place that does, 
you said screening? Why wouldn't every place that a veteran 
comes in, why wouldn't we be asking these questions?
    Dr. Murphy. We should be asking the questions. In some 
cases, the lead clinician may be at the parent VA medical 
center, rather than out in the contract VA facility. We believe 
that if we have a point of contact, so that we can constantly 
and continuously feed information to that clinician, and 
continue to share information about changes in treatments and 
policy, that they can then work within their system to get the 
information out to every front line health care provider.
    Mr. Shays. Why haven't performance targets been developed 
    Dr. Murphy. Performance targets are under development for 
fiscal year 2002. They will be in place during the next fiscal 
    Mr. Shays. We're in fiscal year 2001. So why wouldn't they 
be ready for fiscal year 2002? Why not get it ready now? I 
don't understand.
    Dr. Murphy. They will be in place in October 1st at the 
beginning of the next fiscal year.
    Mr. Shays. And then what does that mean?
    Dr. Murphy. That means that starting in that fiscal year, 
on October 1st, we will begin monitoring the performance of 
every facility and every network based on the measures that 
have been agreed upon.
    Mr. Shays. In all facilities?
    Dr. Murphy. Yes.
    Mr. Shays. OK, so why do we say 2003? That's 2002.
    Dr. Murphy. GAO reported to you that it was 2003, sir, but 
in fact, we will have them in place in 2002.
    Mr. Shays. OK, and that's a certainty, no reason not to?
    Dr. Murphy. No reason not to.
    Mr. Shays. Technically, there's no reason, tell me why they 
couldn't be done in a month? There has to be a reason, I just 
don't understand why.
    Dr. Murphy. By July, we'll have them developed and then 
we'll negotiate the performance agreements for every network 
director and they'll be in place----
    Mr. Shays. Do they need to be negotiated?
    Dr. Lynch. I don't think negotiation is the issue, it's 
that our performance contracts run on the fiscal year basis. We 
also need to have a system in place to measure the performance. 
That's one of the most challenging aspects of this, how do you 
tell whether I did what you asked me to do.
    Dr. Murphy. That's the reason, in fact, that they're not in 
place currently. Because without the clinical reminder system 
in place, so that we can track the performance at the facility 
level and at the network level, it's difficult for us to set a 
measure that was objective and reasonable. The only way to do 
that is to have a data system in place to collect the 
information and to track it over time.
    Mr. Shays. So right now, there is not an incentive for the 
managers to be moving forward with asking these questions, at 
least in terms of an evaluation. But they're not evaluated 
based on their success in this area?
    Dr. Deyton. Right now, that's correct. And that will be in 
place as Dr. Murphy has said, immediately, and negotiated in 
the contracts of the network managers.
    Mr. Shays. I'm showing my ignorance here, obviously, but I 
guess, it again still sounds a little bureaucratic. It's saying 
to me that because of a contract with our managers, we're not 
going to do something that would be beneficial to our veterans. 
I'm wondering, if you were a competitive business, whether we 
would think that way.
    Dr. Murphy. No, I think that we've been very clear what our 
expectation is of our managers, in terms of implementing the 
screening, testing and treatment of hepatitis C in the veteran 
populations. We've also improved our prevention and education 
efforts. The program has been very aggressive.
    What we haven't been able to do is to develop an objective 
performance measure to put in the contract, because of the lack 
of an adequate data base.
    Mr. Shays. See, when you say very aggressive, I'm reacting 
the same way that I reacted when you said you gave us the 
material immediately, which you didn't. Very aggressive would 
mean 100 percent. Why is it very aggressive? We have two people 
who are from the district, out in the district who, when GAO 
met with them, they did not have aggressive programs. And they 
had different reasons for that.
    I mean, Mr. Cody, would it be fair to say, Ms. Dowling, 
that you have aggressive programs in your facilities?
    Ms. Dowling. Through this time period, I would say at this 
point I'm working toward that. I would not say that when the 
GAO came that I had an aggressive program.
    Mr. Shays. OK. And it's not to throw stones, because I'm 
sure that your facility does some great things in other areas. 
But this is an area that needs improvement. And you could come 
to my office and you could point out areas in my own office 
that we need improvement.
    But let me ask you, why was this an area that was not 
getting as much attention as some of the other things that you 
were handling?
    Ms. Dowling. I think the program was far more complicated 
than I initially understood. It took a great deal of time, for 
example, to make sure that the education took place across all 
of, not just the physicians, but our nurses, we have an 
interdisciplinary team in the areas. We had to plan how we 
would roll it out. Perhaps this approach other people would not 
agree with, but most of our patients go through our primary 
care area.
    It took some time to plan how we would phase in and test 
and make sure things were working and then roll it out across 
all of the primary care areas. We're continuing to build on 
that. As we measure how we're doing in the progress, we are 
improving. But clearly, we're not where you and I think where 
we need to be in terms of the 100 percent screening.
    Mr. Shays. Is there any reason why on your level you 
couldn't make it 100 percent, forget what they did elsewhere, 
but in your own facility?
    Ms. Dowling. At this point, I absolutely can make it 100 
    Mr. Shays. And it shouldn't have to wait until 2 years from 
    Ms. Dowling. Oh, no, it will not take 2 years.
    Mr. Shays. Mr. Cody.
    Mr. Cody. To add to what Mary is saying, at Syracuse, we 
developed this progressively as well. There was a lot of things 
that needed to occur, education, setting it up, tracking it, 
making it happen, using the clinical reminders and then 
actually gaining the experience from the original estimates of 
how significant it was going to be to how it looks like it's 
something that is more manageable in that sense.
    On July 1st, we're going to be at 100 percent, all our 
primary care clinics will be screening the patients in all our 
community based outpatient clinics at the medical center, 100 
percent is going to be happening just in a couple of weeks.
    Mr. Shays. In your facilities?
    Mr. Cody. Yes.
    Mr. Shays. How is that going to happen?
    Mr. Cody. By the use of the clinical reminder system, when 
the patient comes in, it comes up actually on the screen. 
There's a lot of other things in there, other than hep C, but 
that will be up there and the provider will know that the 
screening tool needs to be used at that time, and our whole 
process will start from there. That will generate need for 
blood tests.
    Mr. Shays. How much additional time does this add? Is this 
a factor in discouraging, in other words, you are understaffed, 
I make that assumption, probably pretty accurate, so you're 
understaffed, you have people waiting in line, so that 
discourages asking a lot more questions. How much time does 
this add?
    Mr. Cody. I don't treat the patients, so I don't know how 
many minutes it's going to take. But it's part of a lot of 
other things that we do that have been showing, because of our 
preventive approach to care, we've been making a tremendous 
difference in the veterans that are coming to us. Hep C is one 
of them, but diabetes screening, which helps in reduction in 
the number of amputations, pneumonia vaccination. We have 
studies showing a number of patients that were caught because 
of what we're doing on a preventive nature. These are a lot of 
things. Yes, they do take time. I couldn't tell you what 
    Mr. Shays. Mr. Deyton.
    Dr. Deyton. Mr. Chairman, in my experience with my 
patients, this is not a simple procedure at all. You see the 
kinds of questions we have to get into. So on an average, 
depending on the patient's receptivity, it probably adds 15 
minutes to half an hour to every visit.
    Mr. Shays. Why would it have to add 15 minutes?
    Dr. Deyton. Oh, Mr. Chairman, you don't just launch into 
these questions if you want to get an honest response. You need 
to explain, I need to ask you some questions about a blood-
borne infection called hepatitis C. And talk about what that is 
and why that might be important to them. You are a Vietnam-era 
vet, therefore you might have been exposed to this virus, and 
what it means. So I talk to them about the disease, that the 
    Mr. Shays. So if I started out and said to you, Dr. Deyton, 
we are extraordinarily grateful for your service, but we are 
very concerned about the health of you and your colleagues 
because of this incredible silent killer called hepatitis C, I 
need to ask you some questions that could help extend your 
life, and some of them may be very intrusive, but I need to ask 
them and you need to give me honest answers in order for us to 
make sure that we are doing everything we can for you. You're a 
Vietnam veteran, did you have a blood transfusion, and go 
through this. I would think that fairly quickly you could ask 
    Dr. Deyton. Maybe I'm a slow clinician, but I find that 
when I ask these questions patients bring up other issues that 
are medically germane.
    Mr. Shays. Fair enough. So is this a factor in discouraging 
these tests? Aside from the fact that you all weren't aware 
that some of the money was available out in the field, is 
there, we did not appropriate money for the extended--this is a 
mandate, in a sense. We require more work to process. Did the 
money we appropriate go in part for this? It did?
    Dr. Deyton. Yes, it did. And I think GAO found in their 
other investigation that there certainly has been sufficient 
money to support this screening, testing and treatment.
    Mr. Shays. Let me do this. It's 12 o'clock, and this is an 
ongoing process. I welcome any of you--did you have a question?
    Mr. Halloran. Yes. Two quick ones.
    Mr. Shays. Dr. Murphy, I'm very content to have you and Dr. 
Deyton leave, with no problem at all. We'll just finish up, Dr. 
Lynch and Mr. Cody and Ms. Dowling, if you could stay. We'll 
let you get on your way.
    Dr. Murphy. We'll be happy to stay until we're finished, 
    Mr. Shays. We'll just be a little longer, but I'm happy to 
have you leave, no problem.
    Dr. Murphy. Thank you.
    Mr. Halloran. I just want to ask two quick questions, and 
one I asked GAO, which is, and for the facility directors, have 
you come across evidence of other outreach or lookback efforts 
that your facilities feel the impact of? Has a local blood 
center or hospital done anything, or the Liver Foundation done 
some letter writing or advertising, have you seen the effects 
of other attempts to identify potential hepatitis C infection?
    Dr. Lynch. There's a couple things. One is a national 
lookback at the blood supply, which every entity that gives 
blood participated in. Obviously we did that as a system, and 
there were a fair number there. We've seen a number of 
independent outreach groups in places like Houston and what 
have you. I cannot quantify what that's meant, but yes, it's 
been in----
    Mr. Halloran. You felt some impact of it?
    Dr. Lynch. Yes.
    Mr. Cody. I'm not aware of any specific impact on the 
Syracuse area. I couldn't comment on that.
    Ms. Dowling. There was, to my knowledge, the same as Jim 
Cody, I'm not aware of specific efforts of these external 
groups that you mentioned.
    Dr. Deyton. Could I add to that? I think there have been 
some really extraordinary efforts made by several organizations 
and as some in collaboration with us. For example, as you may 
know, we're working in collaboration with the American Liver 
Foundation to distribute 3.4 million brochures to veterans who 
use the VHA system, just education brochures on hepatitis C. 
Because we recognize that not everybody accesses the system all 
the time, and they may have risk factors.
    Also the American Legion and Veterans Aimed Toward 
Awareness, which is a hepatitis C specific veterans group, have 
put together really, I think, helpful education programs for 
veterans and their members to learn about hepatitis C that we 
are totally supportive of, and glad to see is happening. 
Because getting the word out there is how we're going to get 
these folks to get screened.
    Mr. Cody. As Dr. Deyton just added that, I have to qualify 
or add something to my answer before. Through the efforts of 
some of the service organizations, like DAV and American 
Legion, yes, they have been educating their members. People do 
come into our clinics saying, I've read this, I'd like to hear 
about it.
    Ms. Dowling. I would agree with that, too, Vietnam Veterans 
of America.
    Mr. Halloran. There was, you mentioned the availability of 
the screening of primary care facilities. There was some 
indication that GAO worked that in specialty care facilities, 
is this more of a challenge there? In a heart clinic or a 
diabetes clinic, I presume you have them, other more 
specialized care facilities, is this a tougher sell there?
    Dr. Lynch. I would answer definitely. Not sell. I think 
it's much harder to do it there for a couple of reasons. As you 
are probably aware, we do have performance measures we're 
trying to improve, the time it takes for a veteran to get into 
certain clinics, you named some of them. And I would be loathe 
to put an additional burden on those if I felt I could do it 
someplace else.
    Mr. Halloran. Might those not be some of the only entrance 
points for a veteran in the VA system?
    Dr. Lynch. That is becoming less and less the case. We are 
approaching rather high percentage, at least in our network, I 
don't have a figure at hand, of all of our patients who see us 
on an ongoing basis who are now enrolled in primary care. Our 
goal is to have anybody who's enrolled on an ongoing basis in 
primary care.
    But also, if you listened to what Dr. Deyton had to say, 
I'm less confident that some of these subspecialists would 
spend the amount of time necessary and would have the 
background and the interest to do what we've asked them to do. 
In addition, we've got tight timeframes where we are asking 
them to do it.
    Dr. Deyton. And in those specific situations, there are 
multiple approaches that we can take and that some VAs are 
already doing, to do the proper screening in a way that will be 
successful and not, say, take a super-subspecialist's time and 
energy away. For example, we have great examples of teams of 
providers, a nurse, nurse practitioner, somebody even trained 
in the testing and counseling area, who can service those areas 
to in fact do the screening in all clinics.
    So one of the things that we're learning are some of the 
best practices that have been put in place in many facilities 
and beginning to promulgate those throughout the rest of the 
    Mr. Halloran. And finally, among the things you gave us 
yesterday was a copy of the solicitation for applications for 
additional, not centers of excellence, I forget what you called 
them, they were field resource centers or something. Why?
    Dr. Deyton. Why?
    Mr. Halloran. Yes, why?
    Dr. Deyton. Why do we need them?
    Mr. Halloran. Yes. What's the point? Why are we identifying 
more kind of nodes of----
    Dr. Deyton. Because what we've learned in talking to the 
front line providers in various settings is that they have a 
need for some specific products and resources to in fact do 
this job. So we are investing in four hepatitis C field based 
resource centers to in fact develop those materials to be used 
across the system. Those resource centers will focus in four 
different areas. One is in patient and patient's family 
education, so that we get the proper kinds of materials 
together to educate the patient, who's either in screening, or 
has tested positive.
    The second area is in clinician education and preparedness. 
The third area is in prevention and risk reduction, 
particularly for those veterans who test positive. What can 
they do to modify their lifestyle to keep their livers as 
healthy as possible. And the fourth area is in what we were 
just talking about, models of care and best practices, and how 
to promulgate those across the system.
    We believe that these four centers will serve the whole VA, 
so that we can have the best practices possible.
    Mr. Halloran. And the relationship of these centers to the 
existing centers of excellence?
    Dr. Deyton. It's the same program. It's just being 
redefined and recompeted.
    Mr. Halloran. OK.
    Dr. Deyton. I'm pleased to say that even as the early word 
has leaked out to the VA that these resources will be 
available, the competition is going to be very stiff. There's a 
lot of interest that has been developed around the hepatitis C 
treatment areas by all the work that you've heard has happened. 
So we're going to have some excellent centers.
    Mr. Halloran. And I didn't notice any particular 
application or qualifying criteria to be one of these centers 
that you actually treat or have been successful so far in 
screening. One hopes that these lessons learned would be 
derived from places that have been doing it.
    Dr. Deyton. That is certainly the criteria, so I'm sorry 
you missed that. But in the application process, the criteria 
that each applicant will be judged on is what experience do 
they have in the area that they want to work, what successes 
have they had, what resources are they going to put to it.
    Mr. Shays. I think Mr. Halloran may have asked this 
question. Before I go, I want to be clear on this, because I'm 
intrigued by the comment that it could take a half hour. I have 
15 minute meetings and sometimes they go to 20 or 30, and they 
may be interesting, but I then know everything is backed up and 
I get anxious and it discourages me from asking questions. But 
Mr. Rapallo was asking the same question as well, on minority 
    Why can't you, first off, I assume most of our veterans 
know how to read. But if they didn't, we could just ask them 
orally. Why can't you just give them the questions, say, do any 
of the above apply, without having to say which ones?
    Dr. Deyton. That certainly is an approach which some places 
do, and I think it's one of the best practices that we want to 
promulgate around the system.
    Mr. Shays. It wouldn't have to take 15 or 20 minutes. After 
they say yes, it might. And it puts a little bit of risk on 
their part. It may be that if you asked more questions directly 
and looked into their eyes, are you sure you're right, you 
could, but at least this way you could start to cover more 
    Dr. Deyton. I think there's certainly benefit in that. Let 
me tell you the risk of it, too. In many years of experience of 
handing out questionnaires to patients in waiting rooms, they 
sometimes don't fill those out either or don't fill them out--
    Mr. Shays. Even if you tell them they could die if they 
    Dr. Deyton. Congressman, I think people are worried about 
putting something down on paper. And some of these behaviors 
are behaviors which have great ramifications to their 
eligibility for certain care. And that was drilled into them in 
the service. So that gets translated to us as well.
    In the HIV arena, sir, I have certainly found that people 
don't want to put down on any piece of paper what risk factor 
they might have, because they're afraid----
    Mr. Shays. Am I reading that if one was a little more so-
called innocent, they wouldn't want to say yes, because someone 
might assume it's something worse?
    Dr. Deyton. Yes.
    Mr. Shays. Well, let me say this. You all are coming back 
next year to deal with the treatment side. We are going to ask 
you questions about what we asked here. We're going to make an 
assumption that you're going to be screening everyone, and that 
when we meet next year, we're going to see that it's in place 
and that you're screening everyone. Is that a false assumption?
    Dr. Murphy. Our goal will be to screen everyone, or at 
least offer the opportunity for the screening questionnaire. I 
think in any public health program, it is very difficult to 
reach 90 percent or 95 percent. So I would have to say 
honestly, sir, that I don't think we're going to be able to 
come back and tell you that we've screened 100 percent of 
patients, no matter how hard we try. We're going to make every 
effort to.
    Mr. Shays. We're going to be able to know that the 
evaluation process will be in place, and I would like to think 
it will, maybe the process will be in place, even if you don't 
evaluate until the start of the next fiscal year, but you can 
give your managers some practice with it. That will be 100 
percent. And then you're telling me there are going to be some 
that fall through the cracks. But I would like to think that it 
would be a very small percent.
    Is there any comment that anyone wants to make, 
particularly those of you that are out in the field doing this 
    We'll let you get on your way. Thank you for your time, and 
this time when I say the hearing is adjourned--no, it's not 
adjourned yet. We have a statement from Jacqueline Garrick, who 
is the Deputy Director of Health Care for the American Legion. 
I ask unanimous consent that it be submitted into the record, 
and it will be.
    [The prepared statement of Ms. Garrick follows:]
    [GRAPHIC] [TIFF OMITTED] 81591.038
    [GRAPHIC] [TIFF OMITTED] 81591.039
    [GRAPHIC] [TIFF OMITTED] 81591.040
    [GRAPHIC] [TIFF OMITTED] 81591.041
    [GRAPHIC] [TIFF OMITTED] 81591.042
    Mr. Shays. We are not recessed, we are in fact adjourned, 
and you can get on your way. Thank you very much.
    [Whereupon, at 12:12 p.m., the subcommittee was adjourned, 
to reconvene at the call of the Chair.]