the return of the medication is an automatic delay of perhaps a week as a minimum, and frequently much longer. A visit to a physician today by a non-veteran patient means medication and therapy being initiated that day, not a week or two in the future. No mail order scheme, no matter how sophisticated, can compete with local community pharmacy service availability. Veterans sometimes travel many miles and are forced to wait in VA hospital halls for hours before they can get prescriptions filled or refilled. Other policy considerations are also relevant. Time and again NARD has told the Congress and the Drug Enforcement Administration that it is ludicrous to permit the continued delivery of prescription containers of controlled drugs by mail in the quantities that are currently known to be in the mails. The volume of drugs that the VA must have in transit in the mails on any given day must be considerable. Today when we are concerned about the theft of government cash benefit checks to Social Security recipients from the mail, we must be equally concerned that the widespread use of the mails to deliver drugs subject to abuse contributes to drug diversion and the nation's drug abuse problems. As enforcement efforts aimed at illicit sources of drugs become more effective, diversion of controlled drugs from legitimate uses becomes a greater hazard. Community pharmacists have been offered several hundred tablets of CSA drugs by veterans who have been oversupplied by VA automatic shipments. Waste and diversion should not continue in a government program. It is not at all difficult to identify prescription medication in transit because of its size, labeling and other factors. Such a package is an "easy mark" for anyone seeking to divert drugs and once a prescription container is so identified, it is a simple matter to open the package and determine whether a controlled drug is present or not. The time is long gone when the mail box could be considered a bastion of safety that few would dare to violate. The desire for controlled substances (CSA drugs) has reached a point where pharmacies face an epidemic of serious and often violent crimes. We have ample evidence of pharmacy walls and roofs proving to be small obstacles for those bent on obtaining controlled drugs, which makes a mail box theft a petty undertaking by comparison. A pharmacy may not employ a person who has a record of CSA violations. But who assures that the general delivery personnel and postal employees meet comparable requirements? The great care and concern of the federal government to account for every tablet of a controlled drug, and the integrity and background of every individual with access to legitimate supplies of controlled drugs from manufacturer to pharmacy, ends at the mail box. VA maintains that all controlled substances mailed to veterans are sent via registered mail, return receipt requested. We doubt that this is an accurate statement of VA practice for it would mean that roughly half of all medication would be sent by registered mail. It is our understanding that only Schedule II substances, mainly narcotics, are sent by registered mail. And to the extent that registered mail is utilized, at $2.10 a package plus 25¢ for return receipt, that cost would be more than 50% of the VA's claimed average cost per prescription. DEA officials admit that VA's controls to stop diversion leave much to be desired. We also understand and continue to receive reports that VA has attempted to alleviate some of the inherent delays in its drugs-by-mail program through periodic and automatic shipments. A prescription written for six months would be shipped monthly on a regular schedule, whether it was needed or not and sometimes after the patient had died. The waste in such a system is incalculable but it is a factor in any cost comparisons with private community pharmacies where such waste would be minimized. Further, there is the problem of what happens to these quantities of unneeded medication. Are they properly disposed of, accumulated, or improperly used without appropriate medical supervision at a later time or by other individuals? There is also the important policy question whether Congress should permit or encourage government to usurp a function that can adequately be provided by private enterprise simply because government can perform the function cheaper. In this case, the VA drugs-by-mail program cannot perform the function at any reasonably adequate level of care expected by the general population, and the claim of economy is presently without any reliable basis. Nearly every elected federal official, the President, the Congress and others, pay lip service to the importance of the small businessman and the concept that the free competitive enterprise system is the backbone of our greatness as a nation and our economy. The VA mail order prescription program is one such issue that directly challenges the profession of that belief. There is no question that independent pharmacies can and have provided veterans with pharmaceutical services. There is no question that our private enterprise system can do the job. And there is no group that is more illustrative of locally owned and operated small businesses than community pharmacies. NARD sincerely hopes that consideration of this important issue will be an example demonstrating that our elected officials truly practice what they profess to be their belief in the role of small business and the free enterprise system. In conclusion, NARD would again urge that H.R. 3349 be adopted, not simply because private enterprise can and should do the job that VA has usurped as a governmental function, not simply because of the important policy reasons which conflict with the continuation of the VA drugs-by-mail program, but because it will provide veterans with the right and opportunity to receive the level of pharmaceutical care afforded to all other citizens and is consistent with other national policies and priorities. The members of this Committee have our full support and our offer for such other assistance as we may provide in assuring that this legislation be favorably considered and adopted. AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, North Chicago, Ill., July 23, 1976. Mr. DAVID E. SATTERFIELD, DEAR MR. SATTERFIELD: I am enclosing a statement made by Local 2107, American Federation of Government Employees, John Reeves, President, with regard to the matter of Veterans Administration land to University of Health Science/Chicago Medical School. The National AFGE concurs with the content of this statement. We would like to have this statement included in the Permanent Record of the Sub-Committee on Hospitals of the House Veterans Affairs Committee. Sincerely yours, Enclosure. JOHN REEVES, President, Local 2107 AFGE. PREPARED STATEMENT BY THE AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, LOCAL 2107 INTRODUCTION The specific issue addressed in this hearing is that of the legal propriety, appropriateness, and desirability of the outright deeding of a large tract of ostensibly "surplus" government (Veterans Administration) owned land to an affiliated private medical school. The land is an important and much used recreational patient care resource in view of the large chronic psychiatric (and therefore location bound) patient population at VAH, North Chicago. It consists of some 83 acres of golf course considered to be prime real estate valued at approximately $35,000 an acre, and thus represents over a million dollars worth of irreplaceable patient care resource. This tract of land is supposed to be transferred gratis to the Chicago Medical School, a private educational institution. SPECIFIC ISSUES 1. Propriety of method used to transfer the land at issue The land in question is proposed to be deeded to the Chicago Medical School by means of a newly introduced piece of legislation. The reason for this legislation is to circumvent existing legislation which addresses the subsidizing of medical and health manpower training programs (namely, PL 92-541) which explicitly states that (a) training of health care professionals will be funded as a separate item distinct from patient care so that resources intended for the care of patients will not be withdrawn to benefit training activities, and that (b) surplus government property can be deeded only to state-run educational institutions whereas such property can only be leased to private educational institu tions. The proposed legislation also circumvents GSA regulations and procedures for declaring government property as surplus and making it available to other governmental agencies and all eligible institutions. Hence, the introduction of new legislation to make a special exception to allow the Chicago Medical School, a private institution, to enjoy a benefit previously reserved for state institutions, namely the gratis receipt of a million dollars worth of federal property labeled "surplus" without even the appearance of GSA's competitive procedures. Without the introduction of new legislation, the outright deeding of this land to CMS would be in direct violation of both the letter and the spirit of PL 91-541 and those GSA regulations pertaining to the distribution of surplus Federal property. 2. Is the land in question really surplus! In view of the present and past use of this tract of land as a recreational patient care resource for a large chronic psychiatric-geriatric (and therefore location bound) patient population, the "surplus" status of this land is highly questionable. Its conversion to building and parking space owned by a private medical school (making it inaccessable to patients) would constitute an irreplaceable loss of a therapeutic resource at a hospital where, due to severe staffing and funding shortages, therapeutic resources are already too scarce. For that reason, the land cannot by any measure be considered surplus. 3. Why not lease, as provided in Public Law 92-541? One can only speculate why the Chicago Medical School insists on owning all 83 acres, rather than leasing a portion of the property for building purposes. The school, due to its present financial status (which is marginal) and its projected expenditures for the creation of a new "campus", is in dire need of additional funds, or in the absence of such, of ample collateral for capital financing. The outright ownership of a million dollar piece of real estate would constitute excellent collateral, especially if acquired at no cost to the school. A lease of the land, on the other hand, would increase the need for outside capitalization for building purposes and constitute another drain on CMS's already strained financial position. For this reason, the lease of the land in question is not considered favorably by CMS officials. 4. Is there a solution to the lease versus deed quandary? Possible solutions acceptable to the VA hospital employee's union can only be addressed in light of the broader issue of the necessity of locating the school campus on VA grounds, and the even more crucial issue of the desirability of an affiliation between the Chicago Medical School and the North Chicago Veterans Administration Hospital. BROADER ISSUES 1. Is it necessary and beneficial to locate CMS on the VA Hospital grounds? A. Does the physical proximity resulting from CMS's relocation on VA Hospital grounds increase the benefits of the affiliation to the VA patient beyond benefits normally resulting from an affiliation without this relocation? Given the conflicting philosophies and missions of the VA hospital (primary and secondary patient care) and CMS (tertiary care, research and education) it is highly unlikely that veteran patients at the hospital (chronic psychiatric and geriatric population, +73% over 40 years of age) will benefit more from an affiliation with relocation of CMS onto the hospital grounds than they would from an affiliation without relocation, even if the relocation did not involve the loss of 83 acres of patient therapeutic recreation resources. Since CMS proposes to pursue only tertiary care goals, their physical proximity is not likely to increase the amount of primary and secondary care to veteran patients. B. Does the affiliation result in improved abilities of the VA hospital to perform its mission in view of conflicting roles and philosophies? An external review report (SERP report) prepared by a team of VA Central Office representatives in January, 1976 clearly states that the affiliation with CMS: does not substantially change the overall role of the hospital in the district as well as the system, nor does it change the individual mission of this hospital. The five-year plan clearly depicts that this hospital will continue to be a resource for chronic care, a resource for treatment of alcoholics, a resource for blind rehabilitation, a resource for gerontologic care" (SERP report p. 22). In other words, primary and secondary care. The same report (p. 3) quotes the school's perception of its role at the VA hospital as developing “a tertiary care center". To do so "would require a massive infusion of funds" (page 52). VA Hospital employees are extremely concerned with the hospital's primary and secondary care mission, a mission which is in danger of becoming impossible to fulfill given existing staffing and funding shortages. As the SERP report states it: "Without question, the major concern of all members of the Fiscal staff is the scarcity of funding from Central Office. At the present time, more than $10 million in project requests are awaiting Central Office action, projects which would do no more than meet JCAH accreditation mandates. Radiology Service has not yet been able to meet even the basic needs. The only hopeful area of possible support appears to be in educational projects." If 10 million dollars will barely suffice to bring the hospital's primary and secondary care resources up to JCAH accreditation standards, it is apparent that the development of tertiary care capabilities of the type desired by CMS will compete with and probably occur at the cost of the hospital's primary mission! In view of existing tertiary care capabilities at other VA hospitals in the area, and the shortage of primary care funds at the VAH, North Chicago, VA employees view the move towards funding of tertiary care capabilities for CMS as wasteful and not in keeping with the hospital's needs and priorities as acknowledged by VA Central Office in the SERP report. Since CMS itself does not bring any funding assets to the affiliation, the financial liabilities resulting from the affiliation are incurred by the VA in addition to existing liabilities and shortages in primary care areas. The philosophical conflict between CMS, the VA and VAH, North Chicago, with regard to roles and funding priorities is best exemplified in the following passage from the SERP report: "One of the operational impacts of these diametrically opposing points of view is that the Director is rebuffed in attempts to motivate the clinical service chiefs into identifying funding priorities for established programs. Instead of submitting recommendations on how to finance existing levels of care, committees such as the Clinical Executive Board and the Joint Planning Committee are promoting the need for a Computerized Axial Tomography Unit, a Cardiac Surgical Program, a Cancer Center and a Gerontology Research, Education and Clinical Center. The fact still remains, however, that undistributed funds available for the 3rd and 4th quarters of Fiscal Year 1976 total $151,164 and projected additional costs above the original budget plan total $213,030. The decision by the Clinical Executive Board, after being appraised of the current fiscal situation, to recommend the commitment of $116,000 of the $151,164 to the acquisition of the equipment and supplies needed to open the newly constructed ICU-CCU appears to represent a clear disdain in matters pertaining to fiscal solvency. A far more serious consequence of the basic conflict is that the Hospital Director appears to have been circumvented or uninformed about the appointment of a therapeutic radiologist as the Chief of Radiology Service and the expenditure of operating funds for supplies, equipment and renovations necessary to support open heart surgery." (p. 3) VACO's view of CMS's insistence on using VA primary care funds to enhance their own tertiary care and teaching resources (at the cost of patient care) is also exemplified in the following passage from the SERP report: "It is inappropriate to develop a cardio-vascular program at the expense of the development of the medical and surgical service, and truly it is inappropriate to develop this program at the expense of the internal integrity of the overall program of the hospital, including the psychiatric service." (p. 40) The appropriateness of developing a cardiovascular (open heart surgery) tertiary care capability is in itself open to question since the VA is currently being required by the Government Accounting Office to decrease the number of cardiac centers within the Veterans' Administration due to their lack of cost effectivness and cost benefit. Because the affiliation has been unconscionably underfinanced, funds which would have been used for primary and secondary care of chronically ill VA patients have been diverted to CMS controlled tertiary care programs. Levels of patient care for our chronically ill psychiatric and geriatric patients have declined since the affiliation with CMS. C. Do the philosophical differences unduly influence federal employee's careers and VA administration policy! Philosophical differences between the VA hospital and CMS extend into other areas of great concern to the AFGE and VA employees. OMS staff and faculty have increasingly made it clear that they feel entitled to make or influence administrative/management decisions directly affecting VA employees' careers. As a result, many VA employees feel that their careers previously secure under VA federal administrative and management policies-are now vulnerable to manipulation by CMS officials, who are not subject to federal regulations. The school's influence over federal employees' careers is evident in the following statement from the SERP report (p. 6): "With regard to more immediate desires, an interview with the Dean established that the school feels that the Chief of Staff should be retained in his current position and that the school supports the clinical faculty fully in their almost unanimous opinion that the Director must be replaced. It was also eminently clear that the Dean feels that over the 'long haul' the Chief of Staff will have to be replaced with a more dynamic individual who will fit in as a full partner with the developing Chicago Medical School. This apparent incongruity may best reflect the inability of the school to attract the type of individual they are looking for in a Chief of Staff." Given the fact that the Director and the Chief of Staff (both federal career employees) mentioned in the above passage were subsequently removed from their positions, it is evident that the CMS can and does influence VA internal affairs to an unwarranted extent and in total disregard of the career security of individual employees who might not agree with CMS policy or philosophies. In addition to the above instance the issue of "who runs the VA Hospital-VA or CMS" is further exemplified by the practice at VAH, North Chicago of appointing CMS department chairmen to VA service Chief positions. This practice is inappropriate and contrary to VA guidelines. It results in a division of loyalties and blatant conflicts of interest in which the chronically ill VA patients' interests take a back seat to medical school interests. Patient care service chiefs in the VA employees and the AFGE have reason to be concerned over their career academic and faculty positions as their primary allegiance often at the cost of their clinical loyalties to the patient care mission. To quote from the SERP report: "Unfortunately, in discussing this (the Surgical Service) with members of the staff, with allied health people, with other services, there tends to be a considerable amount of friction between the Chief of the (surgical) service and other individuals within the hospital. Since the chief of the (surgical) service is also concomitantly the Chairman of the Department of Surgery (at CMS), there is a lack of faith in his ability to carry out both roles without taking part in an obviously overt conflict of interest." (p. 36). It is evident, if SERP reviewers from VA Central Office can perceive dual (VA-CMS) appointments as cases of "obviously overt conflict of interest", that VA employees and the AFGE have reason to be concerned over their career security vis a vis the demonstrated fact that since the affiliation, many VA patient care service chief positions have been subsumed by CMS graduates, selectees or appointees (namely Surgical, Rehabilitation Medicine, Radiology, Laboratory, Psychiatry and Medical Services). The AFGE feels warranted in expressing extreme concern about this growing and undue influence of the management of a private medical school over the career security and lives of federal (VA) employees. In view of the above, the affiliation (initially welcomed by VA employees as a chance to cooperatively improve patient care) is viewed by many employees as a proven danger to federal career security. As a result, many professional employees have resigned their positions or are actively considering transfer or resignation. D. Does CMS itself feel that relocation on VA hospital grounds is a necessary prerequisite for the affiliation or, for that matter for their move to the northern suburbs? As stated by Mr. Herman Finch, Board of Trustees, Chairman of CMS in their "Manifesto" of May 28, 1976, Decision Based on Deliberation : "This impels us to emphasize that our move to this area (Lake County, North and Northwest Greater Chicago) is firm and irrevocable. The decision to move... was made several years before the then Downey VA hospital invited us to relocate on a site adjacent to this hospital. We had explored available sites |