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i 

50–823 2010

[H.A.S.C. No. 111–26] 

MEDICAL INFRASTRUCTURE: ARE 

HEALTH AFFAIRS/TRICARE 

MANAGEMENT ACTIVITY PRIORITIES 

ALIGNED WITH SERVICE REQUIREMENTS? 

JOINT HEARING 

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE 

MEETING JOINTLY WITH

READINESS SUBCOMMITTEE 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

HEARING HELD 

MARCH 18, 2009 
(II) 

MILITARY PERSONNEL SUBCOMMITTEE 

SUSAN A. DAVIS, California, Chairwoman 

VIC SNYDER, Arkansas 

LORETTA SANCHEZ, California 

MADELEINE Z. BORDALLO, Guam 

PATRICK J. MURPHY, Pennsylvania 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

JOE WILSON, South Carolina 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

THOMAS J. ROONEY, Florida 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

DAVID KILDEE, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 

ROSELLEN KIM, Staff Assistant 

READINESS SUBCOMMITTEE 

SOLOMON P. ORTIZ, Texas, Chairman 

GENE TAYLOR, Mississippi 

NEIL ABERCROMBIE, Hawaii 

SILVESTRE REYES, Texas 

JIM MARSHALL, Georgia 

MADELEINE Z. BORDALLO, Guam 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

JOE COURTNEY, Connecticut 

DAVID LOEBSACK, Iowa 

GABRIELLE GIFFORDS, Arizona 

GLENN NYE, Virginia 

LARRY KISSELL, North Carolina 

MARTIN HEINRICH, New Mexico 

FRANK M. KRATOVIL, Jr., Maryland 

BOBBY BRIGHT, Alabama 

J. RANDY FORBES, Virginia 

ROB BISHOP, Utah 

MIKE ROGERS, Alabama 

TRENT FRANKS, Arizona 

BILL SHUSTER, Pennsylvania 

K. MICHAEL CONAWAY, Texas 

DOUG LAMBORN, Colorado 

ROB WITTMAN, Virginia 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

FRANK A. LOBIONDO, New Jersey 

MICHAEL TURNER, Ohio 

DAVID SIENICKI, Professional Staff Member 

THOMAS HAWLEY, Professional Staff Member 

MEGAN PUTNAM, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2009 

Page 

HEARING: 

Wednesday, March 18, 2009, Medical Infrastructure: Are Health Affairs/ 

TRICARE Management Activity Priorities Aligned with Service Requirements? ................................................................................................................... 1 

APPENDIX: 

Wednesday, March 18, 2009 ................................................................................... 23 

WEDNESDAY, MARCH 18, 2009 

MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/TRICARE MANAGEMENT ACTIVITY PRIORITIES ALIGNED WITH SERVICE REQUIREMENTS? 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 2 

Ortiz, Hon. Solomon P., a Representative from Texas, Chairman, Readiness 

Subcommittee ....................................................................................................... 1 

Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, 

Military Personnel Subcommittee ...................................................................... 3 

WITNESSES 

Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for Health 

Affairs .................................................................................................................... 4 

Potochney, Peter, Director, Basing, Office of the Deputy Under Secretary 

of Defense, Installations and Environment ....................................................... 7 

Robinson, Vice Adm. Adam, USN, Surgeon General, U.S. Navy ......................... 10 

Roudebush, Lt. Gen. James G., USAF, Surgeon General, U.S. Air Force .......... 9 

Schoomaker, Lt. Gen. Eric, USA, Commanding General, U.S. Army Medical 

Command, Surgeon General, U.S. Army ........................................................... 12 

APPENDIX 

PREPARED STATEMENTS: 

Casscells, Hon. S. Ward ................................................................................... 32 

Davis, Hon. Susan A. ....................................................................................... 28 

Forbes, Hon. J. Randy, a Representative from Virginia, Ranking Member, 

Readiness Subcommittee .............................................................................. 30 

Ortiz, Hon. Solomon P. ..................................................................................... 27 

Potochney, Peter ............................................................................................... 47 

Robinson, Vice Adm. Adam .............................................................................. 63 

Roudebush, Lt. Gen. James G. ........................................................................ 58 

Schoomaker, Lt. Gen. Eric ............................................................................... 68 

Wilson, Hon. Joe ............................................................................................... 31 
Page

IV 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Mr. Kline ........................................................................................................... 77 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Ms. Bordallo ...................................................................................................... 88 

Mr. Kissell ......................................................................................................... 87 

Mr. Wilson ......................................................................................................... 81 
(1) 

MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/ 

TRICARE MANAGEMENT ACTIVITY PRIORITIES 

ALIGNED WITH SERVICE REQUIREMENTS? 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED

SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, 

MEETING JOINTLY WITH READINESS SUBCOMMITTEE, 

Washington, DC, Wednesday, March 18, 2009. 

The subcommittees met, pursuant to call, at 2:06 p.m., in room 

2118, Rayburn House Office Building, Hon. Solomon P. Ortiz 

(chairman of the Readiness Subcommittee) presiding. 

OPENING STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE FROM TEXAS, CHAIRMAN, READINESS SUBCOMMITTEE 

Mr. ORTIZ. The subcommittee will come to order. 

Today, the Readiness Subcommittee and the Military Personnel 

Subcommittee will meet in a joint session to receive a briefing on 

how the Department is managing their medical military construction program. 

As our Nation responds to different threats, we adapt and change 

our strategy and the force structure of our military, and one of the 

most recent decisions to change our force structure has been to expand the Army and Marine Corps and add 74,000 soldiers and 

27,000 Marines. 

The services have been steadily applying facility funds to accommodate this growth, but some areas are significantly lacking, including medical facilities to support the growing force. 

It is imperative that the men and women that join our Armed 

Forces are provided the best medical care possible. 

To this end, I am glad that we provided almost $1.3 billion to 

support medical facilities deficiencies in the stimulus bill. 

I hope that the witnesses will take the opportunity to address 

the Department’s investment priorities on how they are managing 

to address medical facilities needs for all of our growing installations. 

On a related point, our subcommittees had the opportunity to 

visit Bethesda yesterday and we were amazed at the resilience of 

the wounded warriors, their high spirits, their bravery, their dedication to our country. 

And to receive men and women at Bethesda within 48 hours of 

a casualty from anywhere in the world is an amazing feat, and I 

was very, very impressed to know that. 
2 

This capability that exists today will be particularly challenged 

when the Walter Reed complex is realigned to Bethesda and Fort 

Belvoir. 

We were briefed that the majority of care will be moved from the 

Walter Reed campus in August of 2011. With the construction of 

almost $2 billion in the National Capital Region (NCR), in addition 

to commissioning the facilities and installing complex equipment, 

there is no question that this will be a very difficult task. 

A seamless transition from Walter Reed to Bethesda and Fort 

Belvoir is essential to provide the quality of care for our wounded 

warriors. 

[The prepared statement of Mr. Ortiz can be found in the Appendix on page 27.] 

The chair now recognizes the distinguished chairwoman from 

California, Mrs. Davis, for any remarks that she would like to 

make. 

Mrs. Davis. 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL 

SUBCOMMITTEE 

Mrs. DAVIS. Thank you. Thank you, Chairman Ortiz, Mr. Forbes 

and Mr. Wilson, for this joint hearing of the Readiness and Military Personnel Subcommittees. 

The Military Personnel Subcommittee is tasked with oversight of 

the defense health program and the Readiness Subcommittee with 

the oversight of military construction. 

While our staffs have already spent lots of quality time together 

on this topic, it is good that we are meeting jointly to receive testimony and explore the issue of medical military construction. 

As Chairman Ortiz mentioned, it is vital that we program and 

build the infrastructure required to support the expansion of the 

Army and the Marine Corps. It is our responsibility to ensure that 

our service members and their families, specifically, their families, 

too, have the facilities they need from the outset and not be forced 

to wait years before these facilities are even programmed, let alone 

built. 

We must also ensure that the recommendations of the Base Realignment and Closure Commission are implemented. 

Yet another reason to have this hearing is the fact that medical 

military construction is handled differently by the Department of 

Defense and all other military construction (MILCONs). That is not 

to say that it is bad different or good different, just different. 

Consequently, it is both appropriate and responsible oversight for 

our two subcommittees to examine this process so that we may understand exactly how the Department analyzes, prioritizes, budgets 

and then builds medical facilities. 

We must also keep in mind the long-term enduring costs of maintaining these facilities once they are completed. 

Today, we will hear from all of the relevant parties within the 

Department of Defense (DOD). Dr. Ward Casscells, the Assistant 

Secretary of Defense for Health Affairs, will describe how Health 

Affairs/TRICARE Management Activity (TMA) prioritizes projects. 
3 

Mr. Peter Potochney, director of basing for the office of the deputy under secretary of defense for installations and environment, 

will speak to Base Realignment and Closure (BRAC) issues. 

Finally and importantly, we will hear from the service surgeons 

general, Lieutenant General Roudebush from the Air Force and 

Vice Admiral Robinson from the Navy, and Lieutenant General 

Schoomaker from the Army, of how well the current process supports their requirements. 

Welcome to all of you and thank you very much for being with 

us. 

Throughout our conversations today, it should go without saying 

that all of us, both members of the legislative and executive 

branches, are committed to providing the very best care possible to 

service members, their families and our retirees. 

Chairman Ortiz rightly mentioned the impressive feats that our 

military health system has made routine. 

On Monday, many of us had a chance to meet and speak with 

a wounded warrior at Bethesda. Given how recently he was wounded and the type and extent of his injuries, it was awe inspiring to 

see how far he has come so quickly. 

All of his caregivers agreed that just a few years ago, any recovery, let alone one as dramatic as his, would have been all but impossible. That the standard of care has risen to such a high is a 

testament to the commitment displayed on a daily basis by everyone who is associated with the military health system. 

We must all do our part to make sure this trend continues. 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 28.] 

Thank you, Mr. Ortiz. We look forward to the hearing. 

Mr. ORTIZ. The chair now recognizes the distinguished gentleman from South Carolina, Mr. Wilson. 

STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 

SOUTH CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE 

Mr. WILSON. Thank you, Chairman Ortiz. 

And it is an honor for me to be here today with Chairwoman 

Davis. I appreciate joining our good friends on the Readiness Subcommittee, led by Chairman Solomon Ortiz and Ranking Member 

Randy Forbes, for our hearing on military medical construction. 

I welcome the distinguished members of our witness panel. 

At this time, Congressman Forbes is actually in a markup of the 

Judiciary Committee, and I would like to move for unanimous consent to submit his opening statement for the record. 

Mr. ORTIZ. Without objection, so ordered. 

[The prepared statement of Mr. Forbes can be found in the Appendix on page 30.] 

Mr. WILSON. I believe that there is nothing more important than 

providing the outstanding members of our military, their families 

and our retirees with world-class health care delivered in worldclass medical facilities. 

There is no question, in my mind, that they deserve nothing less. 

As the grateful father of four sons in the military today, our family has experienced the quality service, with two grandsons born at 
4 

Bethesda National Naval Medical Center, and a granddaughter 

born at Portsmouth Naval Hospital. 

With that being said, I understand that there are a number of 

military treatment facilities that are 30 or more years old. In the 

district I represent in South Carolina, Moncrief Army Community 

Hospital at Fort Jackson was built in 1972 and the Navy hospital 

at Beaufort was built in 1947. 

I know that the outstanding medical personnel in each of these 

facilities provide excellent care to our troops and their families. 

On personal tours of each facility, I have been very impressed by 

the dedicated and competent professional personnel I have met. 

I also know that as a medical facility gets older, it is more challenging to keep up with the advances in medicine. 

As I prepared for the hearing today, I was reminded that the 

planning process for military medical construction is very different 

than that for other types of construction within the Department of 

Defense. 

I am interested to hear from our panel why medical construction 

is unique within the Department. To that end, today, I hope to 

hear from our witnesses how the Department and the military 

services plan to spend medical construction dollars to either replace 

or modernize our military hospitals. 

The members of our Armed Forces deserve the best. 

With that, I would like to thank our witnesses for participating 

in the hearing today. I look forward to your testimony. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 31.] 

Mr. ORTIZ. Today, we are very honored to have with us five distinguished witnesses representing the Department of Defense. 

We have the honorable Ward Casscells, the Assistant Secretary 

of Defense for Health Affairs; Mr. Pete Potochney, Office of the 

Under Secretary of Defense for Installations and Environment; 

Lieutenant General Eric Schoomaker, the Surgeon General of the 

Army; Vice Admiral Adam Robinson, Surgeon General of the Navy; 

and, Lieutenant General James Roudebush, Surgeon General of the 

Air Force. 

Without any objection, all of your testimony will be put in the 

record. 

Mr. Casscells, whenever you are ready, you can begin your testimony, sir. 

STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT 

SECRETARY OF DEFENSE FOR HEALTH AFFAIRS 

Secretary CASSCELLS. Thank you, Chairman Ortiz, Chairwoman 

Davis, Ranking Member Wilson. 

I am delighted to be here with my colleagues and I cannot tell 

you how much we appreciate your interest in our facilities and 

your recent visit to Walter Reed. 

Joining me here today, from left to right, I think you have already mentioned, General Schoomaker, General Roudebush, Mr. 

Pete Potochney, who is representing Wayne Arny, the director of 

installations and environment, and Vice Admiral Robinson. 

Secretary Gates has said over and over again that our service 

members and their families deserve the best medical facilities pos-
5 

sible. We certainly agree with him and we appreciate very much 

the fact that the Congress has taken that to heart. 

Let me be frank. We do not have big corporations and others for 

whom this is a top priority calling you. This is the group that advocates for military medical facilities and we are very grateful that 

you have taken it to heart. 

We are in a bit of an awkward position today, because the President’s budget won’t come to you until April. In fact, we don’t have 

the details ourselves. 

We know what we have requested, and this is being arm-wrestled with the Office of Management and Budget (OMB) and the 

comptroller and so forth now. 

So we don’t know. We won’t be able to answer some of your questions the way we would like to. 

Likewise, the details of the stimulus proposal and our military 

medical construction proposals, as part of that bill, are not yet approved. I can tell you that we have requested a balanced construction program favoring the urgent, the strategic and the joint. 

We also are a little bit handicapped today in the sense that we 

don’t have the report from the independent review of the hospital 

design. This group is due to report now to the defense health board 

and we should have that report, also, in a matter of weeks. 

Together, these have put us in a position of delay, as your staffs 

know well. The report that was due in January was only delivered 

to you, I understand, on your way out to Walter Reed, and I apologize for that. We had hoped you would have several days to digest 

that. And we will have a full report of all of this in early summer. 

Mr. Chairman, you alluded to the fact that we have a different 

funding mechanism, as did Mr. Wilson. We do, indeed, and as opposed to regular military construction, which is done by a top line 

allocation to the services, the medical construction is done differently, as recommended by or as required by Congress, and as 

we, the surgeons and I and installations and environment leaders, 

as we have jointly designed. 

The way this works has been different from other military construction since the defense health program was created by Congress several decades ago. 

And what it means is that instead of having service surgeons 

general having to ask the line leaders for their budget, Congress 

set this up so that there would be a defense health program so that 

the budgets could be put together jointly and we wouldn’t be trading hospitals versus weapons systems. 

I think the wisdom of Congress’ decision here is apparent, because we are now once again building hospitals, and I think that 

is good. 

There was a time when we were letting the hospital maintenance 

be deferred year by year by year. I think the members of these 

committees are well aware that our accreditation has been—we 

have passed, our hospitals pass their inspections, but not with commendation, typically. 

Usually, we are cited for deferred maintenance and we take the 

pledge to get to it. But you cannot defer these things indefinitely. 

Otherwise, you may compromise medical care eventually. 
6 

We are not doing that at this time, but we cannot defer the upgrades of these hospitals forever. 

As you mentioned, sir, some of these hospitals were built before 

any of us were even in medical school. So that is 35 years ago. So 

they can’t be neglected indefinitely. 

The mechanism that we use now to determine these allocations, 

the priorities, are set by something called the capital investment 

decision model, or CIDM. 

This is something that we and our predecessors actually developed. It has been a painstaking business model that has been developed, and we took our cues from the business community and, 

particularly, from the Veterans Administration (VA), which, as you 

know, has revitalized their facilities over the past couple of decades 

and they have some really first class hospitals now. 

One of the things that has come out of that is commercially 

available software that facilitates this decision-making. So this is 

what we have used. We have worked on it together, and I hope 

that what we will be able to do today, if not answer every single 

question about a given facility, is at least persuade you that we are 

working on it in a transparent and in an earnest and joint fashion. 

It remains to be seen whether this new process, CIDM, will actually be the right one or whether it is just another layer of DOD bureaucracy laid over top of service bureaucracies. None of us wants 

that. 

What we want, of course, is to have an even playing field and 

to have people speak and meet together, share their best ideas, 

cross-fertilize, and reach a consensus on what the military hospital 

should look like, and I believe we have. 

We want hospitals that will be welcoming, that will be empowering for the patients, that will be comforting. They will be a little 

bit different than the civilian hospitals. We compare ourselves constantly to what is happening at the Mayo Clinic or the Cleveland 

Clinic or Kaiser Permanente. 

Our needs are a little bit different, because we have such a preponderance of psychological issues to deal with. 

But many of the features are ones that we have been able to take 

from the VA and from the commercial competitors, and I say competitors in a respectful way, but we are the only Health Maintenance Organization (HMO) that deploys. I am sure you have heard 

that expression. And it is critical that the military treatment facilities (MTFs) be maintained strong and, in fact, be strengthened. 

The future of the military health system requires this. We cannot 

outsource everything. There are things we can do in that vein and 

I want to commend what the Air Force has done, with great wisdom and great innovation, working with the private universities 

and private hospitals, where that is the best thing to do. 

In other areas, we are working closely with the VA. So we have 

joint facilities. 

Still, we have to have a core called the MTFs, the military hospitals or military treatment facilities, where people train together 

and so that they can deploy together. This is critical for the efforts 

we are engaged in overseas, whether it is the wars in Iraq and Afghanistan, caring for our wounded, whether it is the best preventive, getting them in the best shape to deploy, and whether it is 
7 

teaching the Iraqis and the Afghans to take care of their own people medically. 

All these are things that we train to do together and the health 

of the MTFs is critical. 

So thank you for supporting them. It is very heartening for us 

to have this opportunity to talk to you about the military treatment 

facilities. 

I think next is General Schoomaker, and I think then we will 

have some questions at the end. 

But thank you, again, on behalf of my colleagues and the Department of Defense for this opportunity. 

[The prepared statement of Secretary Casscells can be found in 

the Appendix on page 32.] 

Mr. ORTIZ. Mr. Potochney, go ahead, sir. 

STATEMENT OF PETER POTOCHNEY, DIRECTOR, BASING, OFFICE OF THE DEPUTY UNDER SECRETARY OF DEFENSE, INSTALLATIONS AND ENVIRONMENT 

Mr. POTOCHNEY. Good afternoon, Chairman Ortiz, Chairwoman 

Davis, Congressman Wilson and distinguished members of the subcommittees. 

I am honored to appear today before you. I am taking the place 

of my boss. That is Wayne Arny, the deputy under secretary of defense for installations and environment, who is today attending his 

son’s change of command at Naval Air Station (NAS) Lemoore. He 

is the outgoing Strike Fighter Weapons School Commanding Officer 

(CO). 

Absent a significant personal commitment like that—— 

Mr. ORTIZ. Sir, if you could get a little closer to your mic, sir. 

Thank you. 

Mr. POTOCHNEY. Absent a personal commitment like that, he 

would be here. 

I will keep my remarks brief, and I would like to relate what we 

do in the installations community, in the construction world, compared to what we do with the other witnesses today, in the health 

affairs world, as well as BRAC. 

So let me begin. 

The installations and environment community, my world, has 

oversight responsibility for the Department’s installation portfolio. 

We are the advocates for ensuring our facilities compete effectively 

for the investment necessary to sustain, restore and modernize 

them to ensure their continued operation in support of their mission occupants. 

As such, we support our colleagues in the medical community in 

their application of the resources supporting the Defense Department’s health program facilities. 

The Department places great emphasis on sustaining all of our 

facilities. Sustainment is the term we use to describe what is necessary to keep facilities in good working order and the preventative 

maintenance necessary to avoid the increased costs and mission 

impacts that result from premature deterioration. 

To this end, we use something called the facilities sustainment 

model, and it is a robust tool we have developed to parametrically 

estimate the funding required for this purpose, and it allows us to 
8 

gauge our investment against the requirement, and that was a substantial and significant development for us over the last couple of 

years, because now we had a tool to better compete for the limited 

resources we have in the Department, particularly because 

sustainment has been traditionally underfunded in the Department. 

In the 2009 President’s budget, we were at 90 percent of the 

overall requirement and health facilities were at 93 percent of the 

overall requirement. That is better than it used to be, but it is certainly not where it should be, and we are continuing to work to get 

it up, frankly, to 100 percent. 

Sustainment is only one piece of the equation. Facilities must 

also be modernized through the investment we make in their recapitalization. 

Modernization is driven by new standards, new technology and 

changing missions and, as such, it is not easily modeled. 

However, the fact that the average age of our hospitals is less 

than other facilities indicates we recognize the relative importance 

of their modernization. 

But here, too, there is certainly more to do and the witnesses at 

this table will provide details of the work we are doing in order to 

respond to medical care advances. 

Restoration is the final part of the equation. While, in the past, 

the Department had focused on recapitalizing facilities on a yearly 

rate, essentially, a ratio of the funding we were placing in the 

budget compared to the replacement value of all of our facilities 

and then our 67-year goal was something I think you heard about 

in the past, we have recognized the limitations of this metric, particularly with regard to medical facilities and are working on more 

comprehensive measures. 

To that end, we are using Q ratings now, much more so than in 

the past, and that is Q1 through Q4, Q1 being the best, Q4 the lowest, and they are essentially the percentage of work orders to repair a building compared to the building’s replacement cost. 

Medical facilities have a higher Q rating than the rest of the Department, but they are not a good indicator of our medical facilities’ 

health, because—no pun intended—because medical facilities have 

a high priority, as I just said, and they are subject to accreditation 

requirements, and the accreditation requirements drive us to more 

robust engineering assessments of the individual condition of the 

facilities in coming up with our estimates. 

So we are continuing to refine our approach and right now that 

is the best means we have available to gauge what it is we are 

doing as far as investing in recap, sustainment and restoration. 

There is one special area that I need to note, and that is BRAC. 

Particularly, here in the National Capital Region (NCR) and in San 

Antonio, those are the two major BRAC areas. 

BRAC is a significant recapitalization engine for the Department. 

BRAC is pouring a lot of money into our facilities across the board, 

but particularly in the medical community. 

Through BRAC, the Department is realigning, rationalizing military health care, particularly in the NCR in San Antonio, as I said. 

In the NCR, we have avoided recapitalizing the aged Walter Reed 

facility so that we can instead focus our resources more effectively 
9 

by realigning functions into the new Walter Reed National Military 

Medical Center. 

We are also building a new facility at Fort Belvoir that will address the significant demographic shift in patient population that 

has occurred in this area. 

In San Antonio, we are consolidating inpatient services into a recapitalized Brooke Army Medical Center and converting the aging 

Wilford Hall to an ambulatory care center. 

These two initiatives have produced investments in medical care in the NCR and San Antonio of $2 billion and $900 million, respectively. These two areas, coupled with lesser BRAC initiatives, represent a substantial recapitalization effort. 

In closing, I want to thank the subcommittees for this opportunity. The Department’s medical construction program has made 

great progress, but certainly more work remains, as you will hear 

from the other witnesses. 

We also recognize and appreciate the great support you have 

demonstrated for all of our efforts. 

Thank you. 

[The prepared statement of Mr. Potochney can be found in the 

Appendix on page 47.] 

Mr. ORTIZ. Thank you, sir. 

General Roudebush, go ahead, sir. 

STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH, USAF, 

SURGEON GENERAL, U.S. AIR FORCE 

General ROUDEBUSH. Thank you, sir. Chairman Ortiz, Chairwoman Davis, Ranking Member Wilson, it truly is a pleasure to be 

here today to review our MILCON activities with you, to hear your 

thoughts and to provide ours. 

We believe this is a very, very useful and necessary opportunity. 

Thank you. 

First, let me express our gratitude for the overwhelming support 

that Congress and you, in particular, have provided to address the 

critical needs of our medical facilities. Your efforts will greatly assist us in building and sustaining the state-of-the-art medical facilities that we require now and for the future. 

This is especially important in the Air Force, as much of our 

medical infrastructure was built in the 15 years following the establishment of the Air Force in 1947. 

The shortage of MILCON funds in the past several years has 

forced us to pursue ever increasing Operations and Maintenance 

(O&M) repairs on buildings well past their useful life. 

While we have been successful in implementing stopgap measures in this manner, we cannot sustain an adequate baseline of 

maintenance and repair. 

To properly characterize and prioritize our Air Force MILCON 

requirements, our Air Force health facilities division aggressively 

engages with each medical facility leadership to identify those modernization requirements that are most pressing. 

Our prioritization of these requirements is then aligned to an Air 

Force-wide perspective. 

For requirements that drive a MILCON solution, we now prepare 

a capital investment proposal and submit to the TRICARE man-
10 

agement activity to be scored in the military health service capital 

investment decision model, the CIDM process, which you have 

heard a bit about this afternoon. 

This CIDM process was successfully applied in 2008 to determine 

the Department of Defense fiscal year 2010–2011 military 

MILCON priorities, and I can report to you that the Air Force’s 

most pressing medical projects were appropriately prioritized within this process. 

As a result, we are beginning to turn the corner on our MILCON 

shortfalls. As we work to recapitalize our infrastructure in both the 

MILCON and O&M arenas, it is important to note that green design initiatives and energy conservation continue to be high priorities in the Air Force medical service. 

We are already incorporating nationally recognized benchmark 

processes to design and construct buildings with sustainable design 

elements, such as increased natural day lighting, recycled or recyclable materials, and optimized energy performance. 

We have established a rigorous system to capture and compare 

energy consumption data from all of our major facilities using the 

Energy Star measurement tool, and this system is already up and 

running at the majority of our medical facilities. 

And finally, we recognize that caring for our airmen, soldiers, 

sailors, Marines, and their families in safe and well maintained 

medical facilities is both our duty and a national priority. 

I assure you that the Air Force is meeting these expectations. All 

74 Air Force medical facilities undergo regular and thorough inspections, both scheduled and unannounced, by two national accreditation organizations, the joint commission and the Accreditation Association for Ambulatory Health. 

All Air Force medical facilities have passed inspection and are 

fully accredited. 

Again, we thank you and look forward to your continued strong 

support in this critically important task, and I look forward to your 

questions. 

Thank you. 

[The prepared statement of General Roudebush can be found in 

the Appendix on page 58.] 

Mr. ORTIZ. Thank you, sir. 

Admiral Robinson. 

STATEMENT OF VICE ADM. ADAM ROBINSON, USN, SURGEON 

GENERAL, U.S. NAVY 

Admiral ROBINSON. Good afternoon, Chairman Ortiz, Chairwoman Davis, Ranking Member Wilson, distinguished members of 

the committee. 

Thank you very much for the opportunity to testify before you 

today on the prioritization of military construction of medical facilities. 

Your unwavering support of our service member, especially those 

who have been wounded, is deeply appreciated. 

Navy medicine continues making significant strides in enhancing 

both living quarters and medical treatment facilities for our sailors 

and Marines. The military health systems capital investment decision model was implemented in May 2008 and was used in the pro-
11 

gramming and budgeting of military construction projects slated for 

construction beginning with fiscal year 2010. 

This new system serves all the services by carefully evaluating 

proposed medical MILCON projects through a rigorous capital investment prioritization method across the entire enterprise. 

In addition, the new methodology allows more costly projects to 

receive the funding they need by harnessing the global, enterprisewide perspective to effectively prioritize scarce resources. 

Another positive aspect of the CIDM prioritization process is the 

inclusive representation of those who care for our war fighters as 

members of the military health systems capital investment review 

board (CIRB). 

Clinicians, health system managers, resource managers and 

health care facility experts from the services and from TMA are all 

voting members of the capital investment review board. They represent their services or TMA and play pivotal roles in creating an 

enterprise-wide assessment of projects needed. 

As Navy Surgeon General, I, as well as my Army and Air Force 

colleagues, can engage the capital investment decision model process to clearly articulate our views and priorities to all the members 

of the CIRB for consideration and deliberation. 

The CIDM and the CIRB delivered the integrated military health 

system priority list of projects for the programming period from 

2010 through 2015. The services surgeon generals and the 

TRICARE Management Activity came to a joint agreement on the 

top priority construction project, and it is the Naval Hospital Guam 

replacement. 

This antiquated facility was built in 1954 and has survived 55 

years in tropical climates. 

The new prioritization system allows us to maximize our limited 

project planning money by focusing on projects that are considered 

by all to be a major priority and the best and most efficient use 

of limited resources. 

Distinguished members of the Readiness and Military Personnel 

Subcommittees, thank you again for the opportunity to testify before you today on the positive results Navy medicine has experienced from the new medical MILCON prioritization process. 

I believe that the military health systems’ CIDM and associated 

CIRB, as implemented to date, offers the military health system 

enterprise the best overall means to properly prioritize military 

medical projects. 

In addition, this new process ensures projects of the highest relative merit are consistently programmed, budgeted and executed 

first in a coherent fashion, while still ensuring the focus of the entire MILCON evaluation process remains where it should always 

be, namely, the health care needs of our sailors, our Marines, and 

their families, as our number one priority. 

Thank you very much. 

[The prepared statement of Admiral Robinson can be found in 

the Appendix on page 63.] 

Mr. ORTIZ. General Schoomaker. 
12 

STATEMENT OF LT. GEN. ERIC SCHOOMAKER, USA, COMMANDING GENERAL, U.S. ARMY MEDICAL COMMAND, SURGEON GENERAL, U.S. ARMY 

General SCHOOMAKER. Chairman Ortiz, Chairwoman Davis, Representative Forbes and Representative Wilson, distinguished members of the Readiness and Military Personnel Subcommittees, 

thank you for inviting me and my colleagues here to discuss this 

really important subject today of our medical infrastructure. 

Before I go on, I would just like to take a moment to introduce 

my battle buddy, my Command Sergeant Major Althea Dixon. Although we are talking about buildings, brick and mortar today, I 

think we can all agree that the centerpiece of our formation are our 

people. 

And the Army has declared this year the year of the noncommissioned officer, the NCO, and probably nobody better symbolizes the 

NCOs of our Army than my senior medic here to my left, who has 

kept me honest and on track for a number of years now. 

The condition of our military medical facilities speaks volumes to 

our staff and our beneficiaries about how much the Nation values 

their service and their well-being. In fact, I used these exact words 

when I turned the soil with my colleagues at the new hospital at 

Fort Belvoir. 

The most tangible evidence of the Nation’s investment in the 

health and well-being of our people are the facilities that we build 

for them. 

As I testified before the two Defense Appropriations Subcommittees last year, medical facility infrastructure was and remains 

today one of my top concerns. 

On behalf of the 130,000 team members that comprise the Army 

medical department throughout the world and our 3.5 million beneficiaries whom we serve within Army medicine, I really want to 

thank you all here and the Congress as a whole for listening to our 

concerns about military medical infrastructure and taking some 

significant action to improve our facilities. 

With your help, I think we have made some real progress in the 

last year. 

Funding provided for military hospitals in the fiscal year 2008 

supplemental bill and what we hope to have in the American Recovery and Reinvestment Act of 2009 will positively impact the 

quality of life of thousands of service members, family members, retirees, as we build new world-class facilities in places like Fort 

Benning, Georgia, Fort Riley, Kansas, and San Antonio, Texas. 

And I think we can all sit here and talk to you about the abysmal state of some of our facilities, but I don’t want to get in a contest with my colleagues here. We all are working very, very hard 

to raise the quality of our facilities and, while doing that, using our 

Sustainment, Restoration and Modernization (SRM) dollars to 

maintain the safety and the reliability of even these aging facilities. 

Modern new facilities not only stimulate the local economy, they 

energize the hospital staff who work in these new spaces and they 

comfort the military beneficiaries who seek care in them. They become healing environments for our patients and they inspire confidence in their families. 
13 

As a child who was raised in and around Army hospitals and 

clinics myself, a husband and a parent of an Army family who has 

received care in these same and some newer medical treatment facilities, and as an Army physician who has served and commanded 

a variety of hospitals, I can tell you I have witnessed firsthand the 

impact that improvements of our infrastructure made. 

I was one of the first chiefs of medicine at the new hospital that 

we opened in 1992 in Madigan Army Medical Center at Fort Lewis, 

Washington and I helped lead the transition from that. 

The impact of that new facility was really nothing short of startling. 

The old hospital, although it was beloved for this sprawling onestory cantonment facility, it covered many, many acres and miles 

and miles of corridors, it was really a challenge for all of those who 

attended to the sick and for our patients, as well. 

And the new hospital, when we built it, was sited such that it 

either looked out over Mount Rainier or the Olympic Peninsula, 

and it had an instantaneous effect on patients. 

It created a sense of patient and family-centered care and patient-friendly waiting areas and clinic spaces, the impact of all that 

light and fresh air, and even the selection of photographs, of artistic photographs that we had really was instantaneous on patients. 

I saw it in my patients’ faces, I heard it in the voices of their 

families, and I witnessed it in the renewed energy of our staff. 

We really had little difficulty, following opening that building, attracting trainees into my department and we used it as a major recruiting tool for Army medicine, and continue to this day. 

The three services and the TRICARE Management Agency have 

worked hard to develop an objective process for prioritizing medical 

MILCON requirements through this capital investment decision 

model. I won’t go into it at length. You have heard about it from 

my colleagues. 

But its criteria focus on supporting all of our needs simultaneously and, also, targets the heart of health care, looking at the 

need for functional modernization and customer and patient-centered care, our productivity and how we use our space. 

In 2008, we in the Army participated in the development of the 

first version of this prioritization model and I believe it really is 

a step in the right direction. But it requires continuous development and refinement. 

The Army is challenged, as all my colleagues have described, 

with aging facility infrastructure, with growing workload, and caring for a large portion of our DOD beneficiaries. We maintain about 

40 percent of the total inventory of medical buildings, 1,800 in 

total, of which 386 are direct health care facilities with a replacement value of about $9 billion. 

Our critical priorities right now for hospital replacement are at 

Fort Hood, Texas and Fort Bliss, Texas, Landstuhl, Germany, Fort 

Irwin, California, and Fort Knox, Kentucky. 

We have identified requirements for another 12 hospital expansions, 25 health and dental clinic replacements or expansions, and 

16 force projection projects. These are research facilities and blood 

centers and preventive medicine clinics and training facilities. 
14 

As Landstuhl Regional Medical Center, which many of you, if not 

all of you have gone through and probably been impressed by its 

critical role in evacuation of casualties back home, approaches its 

56-year anniversary, we see this as a critical need for replacement. 

Landstuhl is an enduring part of our evacuation and treatment 

plan for wounded, ill and injured soldiers throughout the world and 

I would ask you to consider it as a significant infrastructure need. 

We also continue construction on a state-of-the-art replacement 

facility for the United States Army Medical Research Institute for 

Infectious Diseases, the hot zone up in Fort Detrick, Maryland. 

This is part of a national interagency bio defense campus that has 

partnered with the National Institute for Allergy and Infectious 

Diseases, the Centers for Disease Control and Preventive Medicine, 

the Department of Homeland Security, and the United States Department of Agriculture. 

It is a realization of a post-9/11 vision that brings vastly different 

and new government agencies together for a common cause. Providing appropriate facilities for this and other areas of medical research are just as important as our hospitals and contribute greatly 

to the readiness of our soldiers and the defense of our country. 

I respectfully request that we continue the support of the DOD 

medical construction requirements that deliver treatment and research facilities that are the pride of this Department. 

In closing, I want to thank you on the Readiness Subcommittee 

for your interest in this issue and the Military Personnel Subcommittee for your vigorous and enduring support of the defense 

health program and of Army medicine. 

I greatly value the insights of the Armed Services Committee 

and look forward to working with you and your staffs over the next 

year. 

Thank you for holding this hearing and thank you for your continued support of the Army medical department for our warriors 

and our families. 

[The prepared statement of General Schoomaker can be found in 

the Appendix on page 68.] 

Mr. ORTIZ. General, thank you so much. And we want to thank 

all the witnesses and all the staff for the fine work that you have 

done and will continue to do for delivering the best that you can 

medically for our soldiers. 

Mr. Potochney, let me ask you a question. On Monday, we had 

the opportunity to visit Bethesda and see the magnificent care that 

is being provided to the wounded warriors, and, frankly, I was 

very, very impressed. So were the members who were with us on 

this tour. 

We were also briefed on the magnitude of the BRAC effort associated with the realignment of Walter Reed. We were told that the 

moves associated with this realignment would occur in August 

2011, one month before the statutory deadline. 

Maintaining the quality of care that exists today is extremely important. Now, how important, in your estimation, is meeting the 

September 2011 deadline and what steps will be put in? 

I have been here several years in the Congress. I am just wondering, how did we get to the 2011 date? Was it you in the medical 
15 

field? Was it DOD? How did we get to that date, 2011? Was it the 

BRAC commission? 

Maybe that is the first question that we would like to know. 

Mr. POTOCHNEY. I will take the first shot at it, if I could, sir. The 

Department is implementing the BRAC commission recommendation on the schedule that it established. 

A year and a half ago or so, the Department also decided to enhance and accelerate, but mostly enhance, some of the construction 

and the facilities at Bethesda, which has stretched out some of the 

construction. 

So the Department itself, and we can’t blame it on the commission, has decided upon a construction schedule, a facilitization 

schedule that brings us bumping up against the end of the statutory six-year period, which is September 2011. 

That is the answer to your first question, sir, I believe. Yes, we 

did it. 

Mr. ORTIZ. The thing is this, I know you are going to receive the 

hospital when the construction is finished, but then you are going 

to have to buy a lot of equipment and a lot of equipment would be 

there, there would be testing on the equipment. 

Is it realistic to say that by September 2011, not only will the 

hospital be finished, but that you will also have all the equipment 

to start functioning as a first class hospital? 

Mr. POTOCHNEY. Yes, sir. I wouldn’t argue that it is an aggressive schedule and it is a challenge. Admiral Madison, who you all 

met on Monday, is confident, and we have spoken at length about 

this, that while it is aggressive and it is a challenge, he can do it 

and he wants to do it that way. 

He will have equipment delivered before then and the hospital 

will be run through its paces. But the actual transition of patients 

over into the new facility will happen in a compressed period of 

time within the statutory deadline. 

Why is it a compressed period of time? Admiral Madison feels 

strongly, based on his own opinion and the research that he has 

done, that doing it in a compressed period of time is the best for 

the patients. 

In other words, if you will permit me, it is do it in a concentrated 

effort, get it over with quick, so you are back up and running as 

fast as you can, and that is his position. 

Mr. ORTIZ. So you feel comfortable that by the date of September 

2011, you will be running smoothly and ready to go. 

Mr. POTOCHNEY. Yes, sir. But I can’t say that we are not wary 

and exercising a fair amount of vigilance to make sure that it remains on track. 

Mr. ORTIZ. We want to be sure that this does not degrade the 

quality of care. This is why earlier I said what we would like to 

do—and I don’t want you to feel pressure from me or from some 

of the members here—we want you to do it right. 

Mr. POTOCHNEY. Yes, sir. So do we. 

Mr. ORTIZ. And this is more important than anything of meeting 

a deadline. But it will not degrade the quality of care that you are 

going to—— 

Mr. POTOCHNEY. Yes, sir. We have signed up to that and right 

now we are on a schedule that we can meet. 
16 

If something changes, I am sure you will be seeing that as quickly as we are. 

Mr. ORTIZ. And just like I stated earlier, we walked into the hospital and we were so impressed. For once, I saw something that I 

said, ‘‘My God, they have it right,’’ the way you are giving treatment to the warriors. 

I don’t want to take too much time, because we have got a lot 

of members here who have a lot of questions. 

But I would like to turn it over now for questions to my good 

friend, the chairperson of the Military Personnel Subcommittee, 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

Again, thank you, all of you, for being here and for your service 

to our country. 

General Schoomaker, I wanted to ask you about any limitations 

that the Army may have providing care as a consequence of an undersized or antiquated military treatment facility. 

The issue really is that if we have an MTF commander who feels 

a need to send a beneficiary downtown, for example, because they 

can be treated in the facility for whatever reason that might be, 

perhaps it is because they would get treatment sooner if they did 

that, if they went to another facility. 

Does the MTF then not get credit for that workload and can that 

come back at some future time to suggest that the workload isn’t 

as great as they might be representing? How might it affect future 

budgets down the line? 

How does the decision-making around that impact future budgets 

or even the workload generally? 

General SCHOOMAKER. Well, ma’am, I think that is an excellent 

question. I would say in the past, we would have been much more 

focused on what I call how many widgets of health care we build 

and deliver in sort of a simple productivity model. 

But I think that led to some bad clinical and business practices, 

not the least of which was an impetus to hospitalize people when 

perhaps management in an ambulatory setting was much more important. 

What we in Army medicine are doing, and I am pleased to say 

that we, across the Military Health System (MHS) are doing increasingly, is shifting to a model that really looks at the total outcome of care and asks the question, ‘‘What is best for a patient and 

what does the patient need for that particular condition and/or 

what can we do to prevent the beneficiary from being a patient at 

all by doing preventive measures.’’ 

And so we are shifting a lot of our resources and our revenue 

generation, if you will, toward prevention and toward outcomes. 

I, frankly, spend more time with my commanders, regional commanders and, through them, my medical treatment facility commanders, focusing on, ‘‘Are you practicing good evidence-based 

medicine? Are you practicing good preventive medicine,’’ and not 

whether they are shifting work downtown or keeping it within the 

hospital. 

Mrs. DAVIS. Is there a lot of care that is being shifted? How 

would you characterize the kind of care that needs to be diverted 

from a major facility? 
17 

General SCHOOMAKER. Well, we still perform the vast majority of 

the care, both inpatient and ambulatory care, within the direct care 

system. We are sending more cases of patients that are enrolled in 

our facilities downtown, as we are taking care of more wounded, ill 

and injured soldiers, as we are more intensively placed in there, as 

we deploy our own caregivers to theater of operation and don’t 

prompt replacement because of hiring lags and the like. 

But those are the dynamics that generally—and then there are 

highly specialized care that may be given, say, in South Carolina 

at Columbia. We won’t necessarily have highly specialized cancer 

care or something and so we lean upon or we depend upon our colleagues in the VA and Columbia or in the private sector to deliver 

that care. 

That is really kind of the rubber band between the direct care 

system, as we call it in our uniformed services, and our TRICARE 

managed care support contractors. 

Mrs. DAVIS. I know in certain areas it is going to be more than 

others, but is there a way of saying that a third of the care, a quarter of the care? 

General SCHOOMAKER. No, ma’am. I would say my ballpark 

would be across Army medicine, I would estimate that probably no 

more than about 20 percent of the care that we enrolled in our hospitals is going downtown and that shift to downtown for specialty 

care or when families are displaced by soldiers that are growing in 

the community, that is occurring in a minority of the cases. 

Does that answer your question, ma’am? 

Mrs. DAVIS. I think so. I think part of the concern is I think initially is that there is—is there a reluctance to even send a beneficiary for care someplace else? 

General SCHOOMAKER. Yes, ma’am. I think there is very much a 

reluctance, in part, because when we use the network of care, if I 

have enrolled—we use very, very strict enrollment models to ensure that our hospitals do not over-enroll to their capacity to deliver primary care, which is the principal driver for getting sub-specialty care. 

There is a reluctance to send our enrollees into the network, for 

a number of reasons. Number one, it disrupts continuity of care. 

Number two, we don’t have the information systems that give us 

ready access to what is done downtown and it may take us a month 

or longer sometimes to get information back about the patient that 

has gone downtown. 

So is there a reluctance? There is, but I have given direct and 

specific orders to all of my subordinate commanders that they will 

not compromise access standards under the TRICARE published 

access standards in order to hang onto a patient that should go 

downtown. 

Mrs. DAVIS. All right. Thank you. I appreciate that. 

Kind of quickly, I think it has been mentioned, Dr. Casscells 

mentioned the fact that there are about 59 hospitals in the military 

health system. 

And how many of those, Dr. Schoomaker, are Army of those 59? 

General SCHOOMAKER. I have a total of how many 36—35, 35 

hospitals in the Army. 
18 

Mrs. DAVIS. When you look at the system that is being used now 

in terms of the prioritization, and we, obviously, have representation here in Congress, no matter how many issues we have, we 

have one vote on a particular issue. 

Does that in any way compromise the outcome whether or not 

you could move and each have a single vote as opposed to a collective vote on those issues or even a proportional vote? 

General SCHOOMAKER. Well, I have suggested that I get the entire vote, but that didn’t go over very well with my colleagues. 

Ma’am, I think this is one of the really tough things about running the CIDM process is trying to decide the strategic value of 

various installations and various facilities and ensuring that, as a 

Department, that we don’t leave someone behind simply because 

they don’t have a constituency. 

You heard my comments about Landstuhl. I think you heard Admiral Robinson’s comments about Guam. It is very hard to get a 

constituency for some of our Outside the Continental United States 

(OCONUS) facilities, even though they may have strategic value to 

the force. 

So I look at the CIDM process, I characterize it the way we look 

at personnel sometimes, we are not happy until everybody is equally unhappy. 

Mrs. DAVIS. Thank you. Thank you, Mr. Chairman. 

Mr. ORTIZ. Mr. Wilson. 

Mr. WILSON. Thank you, Chairman Ortiz. 

I want to join you and my colleagues for the opportunity that we 

had to meet with Admiral Madison and his staff. It was really exciting to me, just as it was for you, to see the dedicated staff. 

They were so interested in the wounded warriors, each one. They 

were so proud of the progress that they were making. It just made 

you feel so good to see the extraordinary planning and thoughtfulness put into the individual care given to each one of these young 

people who make such a difference for our country. 

Additionally, for each of the surgeon generals, I think you should 

be—I want to thank you for making military medicine some of the 

most advanced in the world. 

It is looked to around the world as leading the efforts in terms 

of prosthetics, in terms of trauma care, in terms of preventive virtual medicine, on and on. I wish the American people knew of how 

extraordinary military medicine is and the challenge that you have. 

And for each of the surgeon generals, and you have touched on 

this, but all of you have hospitals and military facilities that would 

be considered old by any standard. 

How do you each of you prioritize the facilities that you submit 

to the military health system MILCON prioritization process and 

what are your top priorities for medical MILCON for the next five 

years? 

Admiral, I had the opportunity to fly over, I didn’t actually visit, 

the Naval hospital last month at Guam, but I am very happy, as 

the Marines are being relocated there, to hear that that is proceeding. 

Admiral ROBINSON. Yes, sir. Thank you very much for the opportunity. 
19 

Guam is proceeding. I think that Guam represents the overseas 

OCONUS facility that doesn’t necessarily have the constituency, 

does not necessarily have the TRICARE network downtown that 

can take care. 

Not suggesting a network doesn’t exist, but it doesn’t have the 

robust network that a CONUS facility may have. 

So the point is that the educational, development, instructional 

programs, the exceptional family member programs, the programs 

that are related to specialty care with the network, all of those programs may be at either lesser condition or may not exist OCONUS, 

which then makes those facilities a top priority, from a Navy medicine perspective, because then I would have to make sure that the 

men and women and families there are cared for appropriately in 

that particular geographic location. 

I also think, related to the question of network care and going 

downtown, network care and access standards are always going to 

drive how we do business, and they should. 

At the same time, the reasons that patients often don’t want to 

go downtown or we send them downtown is that they don’t want 

to go down, they would rather stay with us. 

With that said, we will never degrade care or get into a quality 

issue with the patient related to an access standard. 

I would suggest that if we could relook at network and how we 

run military networks within a geographic area and give more responsibility to local commanders with the network, that there could 

be a more seamless and effective method of how we would actually 

run our patients and the network, both from the direct and the 

purchase care side, so that we could have a better and a much easier system of care, and I think the continuity and the quality would 

follow. 

General ROUDEBUSH. Mr. Wilson, I appreciate your question, because it helps me put things in context for the committee. 

As I mentioned, a significant amount of our medical facilities 

were built within 15 years after the Air Force was established. 

The Air Force is positioned across the United States, generally 

in small communities, and many of our medical facilities were, in 

fact, small hospitals. 

But we very appropriately followed the U.S. medical model and 

we closed those small hospitals in favor of ambulatory clinics, because they didn’t have the critical mass, they were costly, and, 

frankly, they were not safe. 

They didn’t have the caseload and complexity to maintain the 

currency that the staff would require. 

So we followed that model and we have a significant number of 

ambulatory facilities, which really are in old inpatient chasses 

which have been modified over the years. 

So those do, in fact, create a concern. 

Now, I will tell you that we have 15 hospitals and we have leveraged our O&M dollars, as well as our MILCON, to maintain those 

platforms, although several of those come up on the priority list 

that you asked about, and two primary ones would be the Wilford 

Hall Medical Center, which, under BRAC, becomes a large ambulatory surgical center, as does the Andrews Hospital become an ambulatory surgical center. 
20 

So from an aging infrastructure standpoint, they need to be replaced, and from an alignment with BRAC, to assure that they are 

viable parts of that BRAC outcome, they need to be replaced. 

So that is, in fact, driving our prioritization as we work through 

this process, along with other facilities in the 2010–2011 window, 

but that is where we find ourselves with aging facilities, but also 

the need to align appropriately with other activities, with our sister 

services and BRAC. 

General SCHOOMAKER. Sir, we use a model of prioritization that 

is based upon three principal factors, what the current condition of 

the hospital or the facility is and how much it is going to cost to 

repair that. 

Obviously, the more that is going wrong within a facility that we 

can’t get back to a safe and high standard, then the more impetus 

to replace it. 

We look at the population that is supported by that facility and 

what its capacity is to take care of that population, to include the 

population that is moving. 

I think you all are aware that the Army right now is going 

through four simultaneous kind of word salads—Global Defense 

Posture Realignment, Grow the Force or Grow the Army, Army 

modularity, and Base Realignment and Closure—GDPR, GTA, 

AMF and BRAC are moving about 250,000 people right now, the 

largest movement of soldiers and their families across communities 

in a generation. 

And so we are also looking at projected populations served by 

those facilities. 

The last thing I will make a comment about, as General 

Roudebush says, although we tend to be sort of hospital-centric in 

our thinking, we are comprehensive in building facilities that attend to the health requirements and dental requirements and preventive medicine requirements and veterinary public health requirements of that community, and I don’t think we want to lose 

track of that. 

Mr. WILSON. Thank you very much. 

In the interest of time, I will submit further questions, because 

we have votes. 

Mr. ORTIZ. We will now allow Mr. Reyes to ask a question, because it will take 45 minutes before we come back and you are very 

important individuals. We don’t want to keep you here. 

So we will proceed with Mr. Reyes. Do you have a question? 

Mr. REYES. Yes, Mr. Chairman, thank you. 

Secretary Casscells, the Navy surgeon general stated in his opening statement that the replacement of the Naval hospital at Guam 

is the top military construction priority identified by the capital investment model. 

Can you share that report with our committee and, also, can you 

tell us how new missions, like expansion or Grow the Army and return of overseas troops are accounted for in that model? 

Secretary CASSCELLS. Mr. Reyes, I will be able to share the detailed analyses that Admiral Robinson mentioned in just a few 

weeks’ time. 
21 

I can say, as a general matter, that Grow the Force and Grow 

the Army initiatives are generally paid for by the Army, not by the 

defense health program. 

The defense health program pays for the bulk of the replacement 

and maintenance of these facilities, but those two initiatives are 

really line initiatives. 

We work closely with the services, for example, Fort Bliss, as you 

know, and Fort Sam Houston, which are both impacted by multiple 

Army initiatives, transformation, Grow the Force and so forth. 

So all the cards are on the table when we make the—when the 

military health system makes its decision. 

As you know, it is a process that the surgeons and I jointly devised and we jointly participate in with our staffs, equal votes. And 

I must say these are some tough calls, but we have ended up in 

unison on these so far. 

What we hope to be able to tell you in a few weeks is the detailed 

results of that as part of the President’s budget and, hopefully, a 

year from now, those who will still be with you, like General 

Schoomaker, will be able to tell you whether the capital investment 

decision model is, in fact, the plus that we think it is right now. 

Right now, it is promoting communication and transparency and 

unity. So far, it looks good. 

Mr. REYES. Well, it doesn’t look too good from where I am sitting, 

because Fort Bliss is about to quadruple in size, in troop size. We 

are going to have 100,000 to 125,000 people that are going to depend on the facility there, which was designed to accommodate 

about 12,000 troops. 

So my concern, and this is why I asked the question, my concern 

is being up there as the next priority, because if we are not, then 

we are not going to have a medical facility ready and prepared for 

all the troops that get assigned to Fort Bliss. 

I had a discussion with General Schoomaker earlier on that and 

he has promised to get back to me on several questions that I had. 

But there has got to be a way to factor into your formula, into your 

decision, facilities like mine that don’t have adequate medical facilities and are going to grow the way they are. 

So I hope you take that into account and I am going to follow 

up with both you and General Schoomaker in the next week or so. 

Secretary CASSCELLS. Yes, sir. May I just follow on and say that 

my medical privileges as an Army Reserve doctor are at William 

Beaumont and I know it well. I know its shortfalls. That was 

where my pre- and post-deployment experiences were. I have been 

a patient there, and I absolutely agree with you. 

I can only say that our understanding with the Army now is that 

they have got that covered, but it is our obligation collectively to 

make sure that that comes true. 

Mr. REYES. Very good. Thank you. 

Thank you, Mr. Chairman. 

Mr. ORTIZ. Thank you so much. 

I would like now to allow members—I am sorry. 

Mr. Kline, do you have a question? 

Mr. KLINE. I do, Mr. Chairman, thank you very much. I will just 

get the answer for the record once I ask for a nod. 
22 

General Schoomaker, you mentioned there are three services, 

and, of course, there are, that provide medical services. But there 

is a fourth service that uses those medical services, generally, in 

the responsibility of the admiral. 

But I know, from my past experience, there are a lot of Marines 

who live down at Quantico who go to Fort Belvoir because there 

is no Naval hospital at Quantico, and we are building a new facility 

there, as we are BRACing Walter Reed and so forth. 

And I just want to be reassured that CIDM and the system is 

accounting for that fourth service. 

And there will not be time for an answer, because we have got 

a vote. But if the system accounts for that, then we are on track. 

But it is an Army hospital. It has got a lot of Marines and other 

service, but particularly because there is a very large Marine contingent at Quantico, if somebody will just tell me that the system 

has accounted for that. 

[The information referred to can be found in the Appendix on 

page 77.] 

Secretary CASSCELLS. Absolutely, absolutely. 

Admiral ROBINSON. It not only does, because Guam is a number 

one priority partly because of the Marine growth at—— 

Mr. KLINE. I understand that, but that is because of Marines living there at Guam. This is a little bit different situation. 

We have got a vote. I am going to yield back, but I would like 

to follow up with your staffs on how that works. 

Thank you. 

Mr. ORTIZ. Thank you so much. 

What I would like to do is to allow other members who couldn’t 

be here to submit questions for the record, and I know that there 

are many questions. 

I wonder if my good friend, the chairwoman of the personnel— 

do you have any statement? 

Thank you so much. You were outstanding witnesses today. 

The hearing stands adjourned. 

[Whereupon, at 3:14 p.m., the subcommittees were adjourned.] 
A P P E N D I X 

MARCH 18, 2009 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

MARCH 18, 2009 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

MARCH 18, 2009 

(77) 

RESPONSE TO QUESTION SUBMITTED BY MR. KLINE 

Secretary CASSCELLS. The respective priorities of each component of the Military 

Health System (MHS) have been reflected in the efforts to develop and employ the 

Capital Investment Decision Model (CIDM). Representatives from the Surgeons 

General of the Army, Navy, and Air Force actively participated in the development 

of the CIDM. They collectively helped establish the evaluation criteria and business 

rules associated with the CIDM. The Capital Investment Proposals that were submitted for evaluation and prioritization were all generated by the staffs of the Surgeons General and reflected their highest priorities at the time of submission in 

May of 2008. One of the key evaluation factors for each proposal was alignment 

with elements of the MHS Strategic Plan, developed in concert with the Assistant 

Secretary of Defense (Health Affairs) and Surgeons General. Every effort has been 

made, and will continue to be made, to ensure the priorities of each of the Military 

Services find voice in the process to identify, evaluate, and prioritize medical capital 

investments in the MHS. 

With respect to Quantico, the Navy provides medical support to the Marines and 

operates the existing medical facilities on the installation, including the Branch 

Health Clinic and smaller clinics at the Officer Candidate School and the Basic 

School. The ongoing initiative to ‘‘grow the Marine Corps’’ will result in modest increases of approximately 300 per year to the levels of officers and officer candidates 

that receive training at Quantico. This increase is not sufficient to significantly augment the existing medical facility infrastructure or provide inpatient services at 

Quantico. 

The National Capital Region (NCR) is one of the largest and most complex markets in the MHS. The NCR is also experiencing profound change resulting from 

Base Realignment and Closure (BRAC): Walter Reed Army Medical Center will 

close; the current National Naval Medical Center will expand and become the Walter Reed National Military Medical Center; and the obsolete hospital at Fort Belvoir 

will be replaced with the most robust community hospital in the Department of Defense’s (DOD’s) inventory. Construction of the new facilities is well underway at Bethesda and Fort Belvoir. To support coordinated execution of the changes wrought 

by BRAC and manage the market-wide delivery of health care services, DOD established a Joint Task Force. The Joint Task Force will continue to assess demand 

within the market and will allocate resources to facilities in the NCR to best meet 

that demand. Should the Joint Task Force eventually determine the need to further 

expand medical capability in or around Quantico, it will pursue the appropriate facility or operational solution. But, for the foreseeable future, specialty care, hospital 

services, and inpatient care will continue to be provided at the hospital on Fort 

Belvoir. [See page 22.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

MARCH 18, 2009 

(81) 

QUESTIONS SUBMITTED BY MR. WILSON 

Mr. WILSON. I have heard that a major problem with military medical construction projects is that by the time the facility opens its door for the first time it is 

already either too small or not properly designed to accommodate the current and 

future population it is meant to serve. How does the new prioritization process 

produce a facility better aligned to the population it is intended to serve? 

Secretary CASSCELLS. Reducing the ‘‘time to market’’ required to bring new medical facilities online is a challenge faced in both the public and private sectors. The 

increasingly rapid evolution of health care technology, information systems, and 

clinical practices makes accurate forecasting of facility size and configuration extremely difficult. 

One of the stated goals of implementing the new Capital Investment Decision 

Model (CIDM) is expediting the planning and acquisition of military medical facilities. The template used by the Army, Navy, and Air Force for submission of proposed capital investments has been standardized and simplified. CIDM has emphasized increasing the use of parametric cost estimating in lieu of devoting the time 

and resources necessary to attain a 35% design. Less specificity on the exact size 

and content of a proposed facility is required prior to submission for approval. CIDM 

encourages the execution of more parallel activities and acquisition strategies such 

as design/build, in which the designer and builder work together. This contrasts 

with the more traditional design/bid/build approach, which relies on a sequential 

processing of tasks that in turn extended the time to market. 

There are other initiatives underway by the Military Health System. The United 

States Army Corps of Engineers and the Naval Facilities Engineering Command intend to expedite the delivery of Department of Defense medical facilities. Successful 

implementation of CIDM is one of many efforts that, hopefully, will reduce the potential for a misalignment of facility capability with the needs of the population. 

Mr. WILSON. How does the new Capital Investment Decision Model (CIDM) differ 

from the process used by the Department of Defense (DOD) and the Military Services to develop priorities for nonmedical military construction? What is the benefit 

of having a unique process for medical construction? 

Secretary CASSCELLS. The Military Health System (MHS) needed a rational, 

transparent, and structured method to evaluate competing priorities for a finite pool 

of military construction (MILCON) resources. Prior to implementation of the CIDM, 

a satisfactory process did not exist to prioritize candidates for MILCON funding. 

There was not a reliable procedure to rank order potential MILCON investments 

that reflected both the needs of each Military Service as well as the strategic imperatives of the MHS overall. The CIDM is similar to the manner the Department 

of Veterans Affairs (VA) has ranked their proposed facility projects for several years. 

As is the case with the MHS, the VA must also use a rational and structured process to identify its highest priorities across a large, complex organization with multiple stakeholders. 

The processes employed by the Military Services and other entities within DOD 

to prioritize their respective MILCON programs vary and may be influenced by such 

factors as size, scope, complexity, and culture. Each component establishes their 

own business rules and evaluation criteria consistent with particular needs as they 

strive to meet individual challenges in setting priorities and allocating resources. 

However, several components have adopted the same approach and employed the 

same commercial software product, Decision Lens, as the MHS. For example, Decision Lens is used by the following entities to support their respective decision-making in the areas noted: 

Æ Joint Staff 

• Budget Allocation, Capabilities Planning, IT Selection, and Source Selection 

Æ National Geospatial Intelligence Agency 

• Budget Allocation, IT, Human Resources, and Intelligence Analysis 

Æ United States Navy—Commander, Navy Installations Command 
82 

• Budget Allocation 

Æ United States Army Special Operations Command 

• Budget Planning 

Æ United States Air Force Research Lab 

• Strategic Planning, Budget Allocation for Research and Development 

Æ United States Navy N6—SPAWAR—NETWARCOM—PEO C4I 

• IT Capital Planning and Portfolio Management 

The logic and approach to the CIDM is not unique to DOD or the Federal Government. The basic concept of using transparent evaluation criteria within a structured 

process to determine priorities is logical and has been employed in varying forms 

throughout the public and private sectors. It has proven to be particularly useful 

for the MHS for several reasons. Typically, medical facilities are some of the most 

expensive and complex buildings within the DOD. Health care is one of the most 

dynamic fields of endeavor, subject to constant change in medical technology, information systems, clinical practice, diagnostic techniques, and patient and family expectations. Few other facility types within the DOD inventory must address the 

challenges of cost, complexity, and dynamism. In today’s challenging environment, 

the MHS needs an approach to the capital investment decision making process that 

is transparent, logical, structured, and addresses the needs of each of the Military 

Services and MHS. Implementing the CIDM last year, and continuously striving to 

improve future versions, will help ensure precious medical MILCON resources are 

used to their best advantage. 

Mr. WILSON. I have heard that a major problem with military medical construction projects is that by the time the facility opens its door for the first time it is 

already either too small or not properly designed to accommodate the current and 

future population it is meant to serve. How does the new prioritization process 

produce a facility better aligned to the population it is intended to serve? 

Mr. POTOCHNEY. Reducing the ‘‘time to market’’ required to bring new medical facilities on-line is a challenge faced in both the public and private sectors. The increasingly rapid evolution of health care technology, information systems, and clinical practices makes accurate forecasting of facility size and configuration extremely 

difficult. 

One of the stated goals of implementing the new Capital Investment Decision 

Model (CIDM) is expediting the planning and acquisition of military medical facilities. The template used by the Army, Navy, and Air Force for submission of proposed capital investments has been standardized and simplified. CIDM has emphasized increasing the use of parametric cost estimating in lieu of devoting the time 

and resources necessary to attain a 35% design. Less specificity on the exact size 

and content of a proposed facility is required prior to submission for approval. CIDM 

encourages the execution of more parallel activities and acquisition strategies such 

as design/build, in which the designer and builder work together. This contrasts 

with the more traditional design/bid/build approach, which relies on a sequential 

processing of tasks that in turn extended the time to market. 

There are other initiatives underway by the Military Health System, the U.S. 

Army Corps of Engineers, and the Naval Facilities Engineering Command intended 

expedite the delivery of DOD medical facilities. Successful implementation of CIDM 

is simply one of many efforts that hopefully will reduce the potential for a misalignment of facility capability with the needs of the population. 

Mr. WILSON. How does the new Capital Investment Decision Model differ from the 

process used by DOD and the military services to develop priorities for non-medical 

military construction? What is the benefit of having a unique process for medical 

construction? 

Mr. POTOCHNEY. The Military Health System needed a rational, transparent, and 

structured method to evaluate competing priorities for a finite pool of military construction (MILCON) resources. Prior to implementation of the Capital Investment 

Decision Model (CIDM), a satisfactory process did not exist to prioritize candidates 

for MILCON funding. There was not a reliable procedure to rank order potential 

MILCON investments that reflected both the needs of each of the military services 

as well as the strategic imperatives of the overall MHS. The CIDM is similar to the 

manner in which the Department of Veterans Affairs (VA) has ranked their proposed facility projects for several years. As is the case with the MHS, the VA must 

also use a rational and structured process to identify its highest priorities across 

a large, complex organization with multiple stakeholders. 

The processes employed by the military services and other entities within DOD 

to prioritize their respective military construction programs vary and may be influenced by such factors as size, scope, complexity, and culture. Each establishes their 
83 

own business rules and evaluation criteria consistent with their needs as they strive 

to meet their own challenges in setting priorities and allocating resources. However, 

it is worth noting that several have adopted the same approach and employed the 

same commercial software product, Decision Lens, as the MHS. For example, Decision Lens is used by the following entities to support their respective decision-making in the areas noted: 

Æ The Joint Staff 

• Budget Allocation, Capabilities Planning, IT Selection, and Source Selection 

Æ National Geospatial Intelligence Agency 

• Budget Allocation, IT, Human Resources, and Intelligence Analysis 

Æ US Navy—Commander, Navy Installations Command 

• Budget Allocation 

Æ US Army Special Operations Command 

• Budget Planning 

Æ US Air Force Research Lab 

• Strategic Planning, Budget Allocation for Research and Development 

Æ US Navy N6—SPAWAR—NETWARCOM—PEO C4I 

• IT Capital Planning and Portfolio Management 

Decision Lens also has several other clients within the Federal Government and 

private industry, including the Department of Agriculture, National Archives and 

Records Administration, the Nuclear Regulatory Commission, Amtrak, and eBay. 

The logic and approach to the CIDM is not unique to the DOD or even the Federal 

Government. The basic concept of using transparent evaluation criteria within a 

structured process to determine priorities is logical and has already been employed 

in varying forms within the public and private sectors. It is has proven to be particularly useful for the MHS for several reasons. Typically, medical facilities are 

some of the most expensive and complex buildings within the DOD. Health care is 

one of the most dynamic fields of endeavor, subject to constant change in medical 

technology, information systems, clinical practice, diagnostic techniques, and even 

expectations of patients and families. Few other facility types within the DOD inventory can match these challenges of cost, complexity, and dynamism. In today’s 

challenging environment, the MHS clearly needs an approach to capital investment 

decision making that is transparent, logical, structured and addresses the needs of 

each of the military services as well as the MHS. Implementing the CIDM last year, 

and continuously striving to improve future versions, will help ensure that precious 

medical MILCON resources are used to their best advantage. 

Mr. WILSON. I understand that the new MILCON prioritization process has only 

been in place for a short time but from your perspective how can it be improved 

to better meet service priorities? 

General SCHOOMAKER. The three Services, in conjunction with the TRICARE 

Management Activity, are currently working on the next version of the medical 

MILCON prioritization process with the intent of using this new process during the 

next program build. Areas for improvement include refining evaluation criteria, 

structuring submissions to ensure a consistent approach in addressing criteria, and 

accounting for the various service equities (for example, the Army comprises 46% 

of the overall medical building square footage in the Military Health System). The 

evaluation criteria should separately address the different types of medical facilities 

(i.e. hospitals versus medical clinics versus dental clinics versus veterinary clinics 

versus medical warehouses) rather than attempting to compare them against each 

other. The criteria should validate the beneficiary populations versus the enrolled 

populations when describing the required capacity, and should normalize the infrastructure assessments across the three Services to achieve an equivalent comparison. 

Mr. WILSON. The military medical facilities at Ft. Jackson, Naval Hospital Beaufort and Naval Hospital Charleston in South Carolina are all at least thirty-five 

years old. What are your plans to either modernize or replace these facilities? 

General SCHOOMAKER. Fort Jackson is an important installation that supports the 

Army’s training mission. In FY08, the Army funded a facilities planning effort at 

Fort Jackson to determine whether any gaps exist between healthcare requirements 

and facility capabilities. This effort will also scope requirements to address any 

identified gaps. The analysis is still underway and will culminate with the most critical military construction requirements being prioritized in the spring of FY10 for 

inclusion in future budget requests. 
84 

Mr. WILSON. What are some of the challenges of providing world-class medicine 

in aging facilities? 

General SCHOOMAKER. The greatest challenge is keeping our facilities functionally 

relevant to the changes in the provision of care. Adaptability and flexibility are the 

keys to meeting the facility needs of a dynamic healthcare system. A properly maintained facility ‘‘ages’’ due to the lack of proper recapitalization to meet the changing 

needs. The Military Health System (MHS) recently established a 31-year capitalization rate, with the expectation of several renovations before the 30-year mark. The 

decision to reduce this rate from the original 50-year target led to a requirement 

to increase the overall funding in the medical military construction program. DOD 

responded by providing a significant increase in funding, which will help us improve 

our facilities after years of flat funding. 

Healthcare advances through improvements in technology and use of evidencebased medicine. In many cases, improved practices and procedures rely on equipment and infrastructure to ensure proper clinical outcomes. A great example is the 

diversity of imaging, which focused on the traditional X-ray for many years. This 

area has now grown into multiple forms of imaging, to include interventional radiology where procedures are conducted using real-time imaging. These changes require the facility to transform to accommodate the technology and the procedures. 

Keeping pace with these changes in aging facilities requires more frequent renovations to meet the demand. The MHS is faced with facility functional failure, as 

opposed to infrastructure failure. The Army Medical Department’s aggressive approach to Facility Life Cycle Management ensures reliable facility infrastructure, 

but is limited in addressing a facility’s functionality. The majority of the Army’s 

healthcare facilities were designed between 1950 and 1980, when our focus was on 

inpatient care. Healthcare delivery has changed significantly from inpatient to outpatient settings and now includes new methods such as same-day surgery and 

mother-baby care. The inability of some of our facilities to adjust to these changes 

has rendered them functionally failing. 

Maintaining relevancy in a dynamic healthcare environment requires either more 

flexibility in using operations and maintenance funding and/or a military construction program that is more adaptable to the environment. Current budget planning 

cycles do not allow for rapid adjustments. The current ‘‘new work’’ limitations for 

DOD facilities severely limits the use of operations and maintenance funds to meet 

rapid changes in healthcare. This leads to operating outpatient clinics and administrative functions within inpatient spaces, resulting in high maintenance costs, poor 

space utilization, and frustrated staff. 

Mr. WILSON. Over the past twenty years BRAC requirements and decisions by the 

military services have significantly changed the size and type of medical facilities 

in the Military Health System. How well do the remaining hospitals and clinics 

meet our beneficiaries’ needs and where would you make additional changes to provide the best care possible? With so many clinics and small hospitals, how do you 

provide medical personnel with the necessary experience to maintain their clinical 

skills? 

General SCHOOMAKER. With the reduction in medical services available because 

of BRAC and Overseas Contingency Operations, the Army Medical Department 

(AMEDD) has taken steps to ensure that our beneficiaries continue to receive the 

highest level of care. For example, the AMEDD routinely cross-levels resources from 

areas of less need to areas of greater need. In addition, we hire contract providers 

and use TRICARE network providers in the local community. 

BRAC and Grow the Army decisions drove construction and staffing requirements 

to meet the expanded population’s health and dental care needs. In some cases, with 

the help of the DOD and Congress, we were able to consolidate these growth requirements with additional funding to completely recapitalize a facility instead of 

adopting a piecemeal approach. The DOD also recognized the positive impact that 

facilities have on the quality of care and increased the levels of funding in our medical MILCON program. Additional actions to provide the best care possible include 

continued full funding in our Sustainment account (to ensure proper maintenance) 

and continued funding of a robust medical MILCON program to address all our 

medical facilities beyond the current focus on hospitals. This would include medical, 

dental, and veterinary clinics. 

Medical personnel within the Military Health System maintain their clinical skills 

in a fashion similar to their civilian colleagues. Licensure and credentialing criteria 

apply for each individual, as well as a competency-based assessment system. This 

system sets certain thresholds that medical personnel must meet to maintain credentials in their specific specialty. If a facility is unable to supply the resources a 

provider requires to perform in his/her specialty, the provider will be moved to a 

location where resources remain available. Our staffing is frequently adjusted to op-
85 

timize use of our providers and to ensure all providers have the necessary experience to maintain their clinical skills. 

Mr. WILSON. I understand that the new MILCON prioritization process has only 

been in place for a short time but from your perspective how can it be improved 

to better meet service priorities? 

Admiral ROBINSON. As the Navy Surgeon General, I was able to use the new Capital Investment Decision Model (CIDM) process to clearly articulate my views on 

Navy Medicine MILCON priorities for the current budget cycle. The new evaluative 

process also accounts for the MILCON priorities of my colleagues in the Army and 

Air Force through decisional criteria weighting which helps ensure overall Service 

priorities are considered on a level playing field. This process fully reflects common 

agreement achieved to support the new Medicine MILCON prioritization system 

across the Services. Current efforts underway by the CIDM Tri-Service Working 

Group to refine the CIDM evaluative process will retain this key decisional factor 

to ensure the Services and Military Health System (MHS) leadership share a common understanding of high priority Medicine MILCON needs. The CIDM process 

also allows the MHS enterprise the ability to communicate those urgent needs to 

leadership of the Department of Defense and beyond. The Medicine MILCON project 

priority list delivered through CIDM represents the core success of the new system 

over the previous allocation system which did not capture the critical enterprise perspective required to effectively program vital capital investments. 

Mr. WILSON. The military medical facilities at Ft. Jackson, Naval Hospital Beaufort and Naval Hospital Charleston in South Carolina are all at least thirty-five 

years old. What are your plans to either modernize or replace these facilities? 

Admiral ROBINSON. The Medical Facilities on Fort Jackson are owned by the 

Army and are under the purview of the Army Surgeon General. 

The replacement facility for existing Naval Health Clinic Charleston is in the final 

stages of construction, and is scheduled to be operational by 30 Nov 2009. The replacement facility in Charleston will be classified as a Naval Ambulatory Care Center with state of the art ancillary services required to support our beneficiary population. All inpatient services will be handled by the TRICARE network and supported by local community hospitals in the area and other Military Treatment Facilities as required. 

Naval Hospital Beaufort is approaching 60 years of age and is in need of replacement. The aging infrastructure at Beaufort is not conducive to modern, outpatientcentric, healthcare delivery. We have developed planning and programming documents for a 17 bed, 233,847 square foot replacement hospital and have submitted 

them to Office Assistant Secretary of Defense, Health Affairs/Tricare Management 

Activity for project consideration within the Defense Health Program Military Construction Program. We have also secured site approval on Marine Corps Air Station 

Beaufort for the replacement facility. 

Mr. WILSON. What are some of the challenges of providing world-class medicine 

in aging facilities? 

Admiral ROBINSON. Aging infrastructure is not conducive to modern, outpatientcentric healthcare. Aged facility designs are not energy efficient and create dysfunctional flow for both healthcare providers and patients alike. Further, modern 

healthcare legislation and accreditation practices such as the Americans with Disabilities Act, Health Insurance Portability and Accountability Act, and Joint Commission on Accreditation of Healthcare Organizations are major drivers for current 

Military Health System (MHS) space requirements. Worth mentioning is the vast 

change in healthcare architecture and engineering. Modern healthcare design and 

construction has led to better patient outcomes and satisfaction. Modernizing our facilities will greatly complement our efforts to provide world-class medicine moving 

forward. Finally, aged infrastructure prevents us from taking full advantage of new 

medical technologies and equipment that enhance health outcomes in similar populations across the United States. 

Mr. WILSON. Over the past twenty years BRAC requirements and decisions by the 

military services have significantly changed the size and type of medical facilities 

in the Military Health System. How well do the remaining hospitals and clinics 

meet our beneficiaries’ needs and where would you make additional changes to provide the best care possible? With so many clinics and small hospitals, how do you 

provide medical personnel with the necessary experience to maintain their clinical 

skills? 

Admiral ROBINSON. Navy Medicine is committed to meeting the health care requirements of our beneficiaries by maintaining a well-qualified and robust complement of health care providers. Although Base Realignment and Closure (BRAC) 

may ultimately alter the size and scope of the health care services provided at medical treatment facilities (MTFs), those changes are addressed and mitigated by Navy 
86 

Medicine during the BRAC planning process. In those instances where MTFs are 

reduced in capability and capacity, the delivery of health care is complemented by 

civilian-based provider networks established through the TRICARE Program. 

As active participants in the Joint Commission accreditation process, we embrace 

the Joint Commission standards that focus on maintaining the clinical skills of our 

providers. Joint Commission standards include the Focused Provider Performance 

Evaluation (FPPE) and Ongoing Provider Performance Evaluation (OPPE) programs. To maintain an infrequently used skill, a provider can go to another facility 

for temporary additional duty (TAD) where the patient volume and MTF capacity 

and capability exist. 

In the event that medical procedures cannot be safely supported with the required 

staff and resources at a facility, those privileges will not be granted to the provider 

and the medical procedure will not be performed. Upon the providers transfer to another MTF, the provider participates in FPPE to assure clinical competency. 

Navy Medicine incorporates a Quality Assurance system and robust Graduate 

Medical Education programs to maintain provider skills and meet the health care 

needs of our beneficiaries. The Navy Medicine Quality Assurance system provides 

continuous monitoring of the medical practice of every privileged provider. Trends 

and deficiencies are identified for corrective training. In addition to the informal 

TAD training noted above, Navy Medicine has initiated a formal Professional Update Training program that coordinates periodic clinical training to ensure that specialists maintain their clinical skills when the circumstances of their current assignment do not provide cases in sufficient numbers or diversity to maintain all the clinical skills required by their clinical privilege sheets. Navy Medicine also engages 

centers of excellence, fostering internal and external partnerships, and leverages our 

Navy Fellowship Training Program to provide our physicians with training in the 

latest treatment and surgical modalities. 

Currently, Navy Medicine is focused on improving the integration of health care 

delivery between the MTFs and the civilian networks. Our main objective is to improve the continuity of patient and family-centered care as patient care is provided 

in multiple venues. This area represents an opportunity of improvement for the entire Military Health System, including our civilian partners. 

Mr. WILSON. I understand that the new MILCON prioritization process has only 

been in place for a short time but from your perspective how can it be improved 

to better meet service priorities? 

General ROUDEBUSH. The Capital Investment Decision Model (CIDM) was developed by TMA and the Services to assist in prioritizing future capital investments 

across a diverse Defense Health Program (DHP) facility inventory. Lessons learned 

from CIDM 1.0, the model used to prioritize the FY10–15 DHP MILCON POM, are 

being incorporated into CIDM 2.0—building on our successes with selection criteria 

and overall process. It is important to recognize that CIDM provides a baseline priority list to be further shaped by variables that may include alternative budget constraints, incremental versus phased or full funding guidance, or supra-departmental 

‘‘must-pay’’ project inserts. Various scenarios may be presented to the Service Deputy Surgeons General and the DASD (Health Affairs) for consideration. Their recommendation going forward to the Service Surgeons and ASD (HA) provides for a 

full vetting/advocacy of Service-specific priorities. While CIDM 2.0 is not intended 

to exclusively address AFMS priorities, it provides a reasonable and appropriate balance of our needs against those of our sister Services and TMA. 

Mr. WILSON. The military medical facilities at Ft. Jackson, Naval Hospital Beaufort and Naval Hospital Charleston in South Carolina are all at least thirty-five 

years old. What are your plans to either modernize or replace these facilities? 

General ROUDEBUSH. Since these are Navy facilities, the Air Force defers the response to the Navy. 

Mr. WILSON. What are some of the challenges of providing world-class medicine 

in aging facilities? 

General ROUDEBUSH. The challenges in delivering world-class medicine within our 

aging facilities occur in four major categories; patient safety, technology integration, 

cost, and functional efficiency. In aging facilities, ensuring patient safety becomes 

increasingly challenging. Infection control is a major facet of patient safety. Numerous studies have shown that modern air handling systems decrease the risk of hospital acquired infections, and the installation of anti-microbial surfaces can also decrease hospital acquired infections. Another aspect of patient safety is minimizing 

falls, which can be accomplished through proper facility design. 

Integrating new technologies is difficult, with many of our legacy facilities having 

limited floor-to-floor heights that preclude larger duct sizes, fiber optic backbones, 

and enhanced air handling for rooms with the latest equipment. 
87 

The financial burden of higher sustainment costs necessary to provide world-class 

medicine in older, often re-purposed, former inpatient facilities has been significant. 

In one study of 3 bases with former hospitals operating or proposed to operate as 

clinics, the estimated additional cost for maintaining the outmoded and oversized 

infrastructure was $29.5M per year. 

Clinics operating in former hospital chassis often maintain excess emergency generators, medical gas systems, inefficient air handling systems, steam boilers, and 

nurse call systems. Functional efficiency is compromised due to operating in ‘‘as-is’’ 

inpatient footprints. Clinicians cannot optimize their practice when operating 

around existing load bearing walls, tight column grids, and inefficient circulation 

patterns. While this issue is challenging, we appreciate that Congress has provided 

funding to make targeted renovation investments where appropriate and replacement when necessary. 

Mr. WILSON. Over the past twenty years BRAC requirements and decisions by the 

military services have significantly changed the size and type of medical facilities 

in the Military Health System. How well do the remaining hospitals and clinics 

meet our beneficiaries’ needs and where would you make additional changes to provide the best care possible? With so many clinics and small hospitals, how do you 

provide medical personnel with the necessary experience to maintain their clinical 

skills? 

General ROUDEBUSH. Our beneficiaries tell us we are doing extremely well. Their 

satisfaction rate for the past 6 consecutive years has been the highest among 50 

leading healthcare plans according to independent Wilson Health Information surveys. We’ve accomplished this through the care we provide in our Military Treatment Facilities and our Managed Care Support Partnerships. These complementary 

means of healthcare delivery have allowed us to optimize our services as directed 

by BRAC while still delivering a world-class benefit to our military families through 

our civilian partners when needed. 

The Air Force Medical Service is undertaking two additional strategies to further 

optimize services, the Family Health Initiative (FHI) and Surgical Optimization. 

The two primary goals for these programs are to enhance access and continuity of 

services to our population, and increase the complexity of the patients seen. FHI utilizes a patient centered medical home model to provide appropriate staffing. This 

model makes the coordination of all a patient’s care the primary focus of the team 

and is led by a Family Practice Physician. Surgical Optimization combines AFSO 

21 advanced management and production techniques to decrease operating room 

changeover time resulting in a greater throughput of surgical cases. This increase 

in cases bolsters the currency of surgeons and their staff. It also improves outcomes 

through increased proficiency of surgical techniques. 

The Air Force Medical Service has developed a variety of training programs to ensure our health care providers remain the best trained and equipped in the world. 

The Air Force Expeditionary Medical Skills Institute’s Center for Sustainment of 

Trauma and Readiness Skills (C–STARS) is a medical training program embedded 

in three civilian academic trauma centers. C–STARS is a skills sustainment platform with multiple affiliations to refresh or hone trauma and reconstructive surgical 

skills. A newer training platform, Sustainment of Trauma and Resuscitation Skills– 

Program (STARS–P) has begun at five other locations. STARS–P is a readiness 

skills verification training platform providing personnel the opportunity to perform 

clinical rotations several weeks annually at host facilities for the purpose of skills 

sustainment. Training is also accomplished using no cost Training Affiliation Agreements (TAAs) with civilian or other sister-service facilities to include VA Sharing 

Agreements. Since 2006, the AF has entered into over 262 TAAs for clinical proficiency and sustainment training. Another trend is using Simulation Laboratories 

(SIMLABs) utilizing high quality human-like training models. The Air Force has a 

network of simulation laboratories to enhance skills sustainment. Each year AFMS 

personnel retain professional licensure and certification status by attending civilian 

conventions/symposia or military formal training courses to obtain continuing education. Humanitarian missions also expose our practitioners to pathology and challenging cases that improve diagnostic and clinical skills when treating a large number of patients in a short time period. 

QUESTIONS SUBMITTED BY MR. KISSELL 

Mr. KISSELL. I represent the Fort Bragg area. Fort Bragg is projected to grow 

from just 57,000 military personnel assigned in 2006 to just under 70,000 by the 

end of fiscal year 2011. These numbers, of course, do not include all of additional 

family members that will come with these 12,000+ soldiers. Now, Womack Army 
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Medical Center is a relatively new and unquestionably beautiful facility, but it 

doesn’t seem large enough for our current population on Fort Bragg, let alone the 

growth we’re expecting over the next few years. For example, the emergency room 

waiting area is tiny, with something like twenty chairs. What analyses have the 

Army done to assess the capacity of the current facility, and what plans have been 

made to ensure that the military personnel assigned to Fort Bragg, and their families, will have access to the care they need? 

General SCHOOMAKER. Based on the projected population growth at Fort Bragg, 

the Army has planned and programmed medical military construction projects totaling $141M to support the projected increase of Soldiers and Family members. These 

projects include: an addition/alteration to the Robinson Health Clinic ($18M, FY 08), 

a new Primary Care Clinic ($27M, FY 10), a new Blood Donor Center ($4.8M, FY 

10), a new Behavioral Health clinic ($32M, FY10), and an addition/alteration to 

Womack Army Medical Center (WAMC) that will expand the Emergency Department, Women’s Health, Pediatrics, Pharmacy Services, and various other departments ($59M). This addition/alteration is desired in the FY 12 program following 

completion of the new Behavioral Health Clinic, which is programmed in FY 10. 

That stand-alone facility will remove Behavioral Health Services from WAMC to accommodate staffing increases and allow for the expansion of hospital-based functions, such as the Emergency Department. 

Once completed, the MILCON projects will significantly expand the medical infrastructure at Fort Bragg. Approximately 65% of the Fort Bragg growth in population 

has already been realized. A dedicated recruitment effort has led to filling 82% of 

the new positions identified to support this population. In the interim period while 

MILCON construction is ongoing, WAMC is coordinating with Pope Air Force Base 

to assume control of the Pope Clinic in July 2010. This will provide a partial expansion of primary care until the new clinic is built. In 2008, WAMC completed a construction project that converted 12,700 square feet of storage area into administrative and educational space which freed approximately 16,000 square feet of clinical 

space. Currently, WAMC has initiated a renovation project that converts seven 

former administrative offices into treatment rooms for the Emergency Department. 

Additionally, we relocated the TRICARE offices to provide the Emergency Department a secondary waiting room and an additional 10 offices or exam rooms. 

The most profound change has been the development of the Warrior Transition 

Battalion (WTB), which at Fort Bragg has grown to four companies. Until the Warrior Transition Complex is completed, the hospital has dedicated over 20,000 square 

feet of clinical space to the WTB. Clinical services for all beneficiaries, not just the 

Warriors in Transition, continue to improve and expand. At Fort Bragg, prominent 

examples are Traumatic Brain Injury (TBI) treatment and research, and the Pain 

Clinic’s advanced technology and multidisciplinary alternative therapies. Behavioral 

health services are another area of growth that is defined by the population’s increase as well as the population’s increasing needs. 

In summary, the Army has assessed the projected population growth at Fort 

Bragg and is implementing actions to provide all the necessary health care services 

to support these beneficiaries. 

Mr. KISSELL. And since we are talking about how medical military construction 

is centrally managed by Health Affairs/TRICARE Management, is it the Army’s responsibility or Health Affairs’ responsibility to do these analyses? 

General SCHOOMAKER. The US Army Medical Command (MEDCOM) conducts the 

detailed analyses required to develop medical military construction requirements. 

These analyses include facility requirements, staffing requirements, and the right 

mix of personnel skills to ensure we properly support our beneficiary population. 

MEDCOM provides our completed analyses and facility requirements to Health Affairs/TRICARE Management Activity for prioritization and programming. 

QUESTIONS SUBMITTED BY MS. BORDALLO 

Ms. BORDALLO. My question is about how the Navy, in conjunction with the 

TRICARE Management Activity and the Department of Defense’s Office of Health 

Affairs, developed the requirements for number of beds and services that will be 

added as a result of the renovations. It is my understanding that the current requirement will only increase the number of beds by eleven and given that the military build-up will include, at the very least, 8,000 additional Marines and 9,000 

family members, is that an adequate enough requirement to meet the demands with 

increased personnel on Guam? I understand from your testimony that Navy implemented the Capital Investment Decision Model (CIDM) in 2008 which will impact 
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Fiscal Year (FY) 2010 projects. If the CIDM were implemented early, would that 

have potentially altered the requirements for the hospital? 

Admiral ROBINSON. The CIDM, which was employed for the first time last year, 

identified replacement of the United States Naval Hospital on Guam as the highest 

priority for medical military construction funding. The CIDM is used to prioritize 

competing proposals and not to develop specific facility requirements. Navy medical 

planners, in concert with others, analyzed the specific requirements for the replacement facility and determined the appropriate mix of capabilities required to support 

the needs of the projected population. The planning process was continuously updated as the scope of the Guam military build-up was refined. It is unlikely that 

implementing CIDM prior to 2008 would have altered the requirement for the new 

hospital. 

Ms. BORDALLO. Additionally, can you comment on the anticipated level of increase 

in specialty care that might be offered on Guam as a result of the increased military 

presence on Guam as well as renovations to the facility that will allow such services 

to be offered? Many of my constituents have concerns about the current level of 

services that are available at the Naval Hospital and see the military build-up as 

an opportunity to attract additional specialty care services to the island. 

Admiral ROBINSON. The United States Naval Hospital, Guam replacement facility 

will support delivery of a broad range of primary and specialty care services. The 

new hospital will provide 42 inpatient beds for provision of intensive care, general 

medicine, surgery, orthopedics, obstetrics, urology, ophthalmology, proctology, 

otorhinolaryngology, behavioral health, and oral surgery. It will operate four operating rooms and two rooms dedicated to performing Caesarian Sections. Robust diagnostic imaging will include magnetic resonance imaging (MRI) and computerized 

axial tomography (CT) scan capabilities as well as full laboratory and pharmacy capacity. In addition to a Level III emergency room, outpatient capabilities will include a variety of primary and specialty care services, including diet and wellness, 

dermatology, nuclear medicine, physical therapy, and environmental health. 

The new community-based Outpatient Clinic now under construction will increase 

the range of potential for sharing with the Department of Veterans Affairs (VA). Its 

location adjacent to the new hospital will increase both the visibility of the clinic 

and its accessibility to VA beneficiaries. 

Ms. BORDALLO. To what extent has the Department of Defense worked with the 

Department of Veterans Affairs pursuant to Section 707 of H.R. 5658, the Housepassed National Defense Authorization Act for Fiscal Year 2009? Are there any 

issues of concern regarding the development of these implementation guidelines? 

Secretary CASSCELLS. The DOD and the DVA studied a combined federal health 

facility as identified in H.R. 5658, Section 707, but the DVA decided they could not 

support a joint effort. Therefore, planning and programming of Naval Hospital 

Guam replacement was performed with Presidential Executive Order 13214 (dtd 28 

May 2001) and Public Law 108–136, Section 583 as the drivers for extensive collaboration with the DVA from a health facility perspective. The planned replacement of 

Naval Hospital Guam accounted for all workload currently performed in support of 

the robust resource-sharing agreements in place between Navy and the DVA for inpatient, specialty, diagnostic, and ancillary services. In addition, the DVA is currently constructing a new Community-Based Outpatient Clinic on a convenient site 

provided by the Navy to the DVA immediately adjacent to the Naval Hospital campus. The DVA designed their new outpatient clinic to enhance DVA primary care 

capabilities to better serve the Guam veterans. 

Ms. BORDALLO. I am wondering why the Department of Defense has not designated Guam or the other territories, specifically Puerto Rico as a Prime Service 

Area for military retirees to be eligible to receive TRICARE Prime? If specialty care 

services will not increase to cover all the needs of our local retiree population isn’t 

there a benefit to extending TRICARE Prime to the territories? I see this as a key 

quality of life measure and as a commitment to those who served our nation. 

Secretary CASSCELLS. It is recognized under 32 CFR § 199.17, (a), (3), the Assistant Secretary of Defense (Health Affairs) has the authority to modify the scope of 

the TRICARE program as implemented outside the 50 States and the District of Columbia. Currently, TRICARE Prime is not available as an option for retired service 

members and their eligible dependents in the territories of Puerto Rico and Guam. 

Navy Medicine recognizes the tremendous contribution and sacrifice that all of 

our current and prior military members and their families have endured to serve 

our Nation. They deserve a generous health care benefit in recognition of their important service. The extension of TRICARE Prime in Puerto Rico and Guam for retired service members and their eligible dependents may improve the health of 

those members as a result of improved access to care, and would create parity of 
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health care benefits with those beneficiaries residing in the 50 States and the District of Columbia. 

If implemented, the broader challenge will remain in meeting the specialty care 

requirements in remote locations with limited local health care resources. The 

TRICARE program relies heavily on civilian-based provider networks to augment 

and support the Direct Care System (Military Treatment Facilities—MTFs) in meeting their mission. Any actions taken to expand or change the health care benefit 

in Puerto Rico and Guam must be carefully reviewed to consider the impact on existing resources, both civilian and military. 

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