U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

i 

98–912 2016

[H.A.S.C. No. 114–84] 

MILITARY TREATMENT FACILITIES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

HEARING HELD 

FEBRUARY 3, 2016 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

JOSEPH J. HECK, Nevada, Chairman 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

MIKE COFFMAN, Colorado 

THOMAS MACARTHUR, New Jersey, Vice 

Chair 

ELISE M. STEFANIK, New York 

PAUL COOK, California 

STEPHEN KNIGHT, California 

SUSAN A. DAVIS, California 

ROBERT A. BRADY, Pennsylvania 

NIKI TSONGAS, Massachusetts 

JACKIE SPEIER, California 

TIMOTHY J. WALZ, Minnesota 

BETO O’ROURKE, Texas 

JEANETTE JAMES, Professional Staff Member 

CRAIG GREENE, Professional Staff Member 

COLIN BOSSE, Clerk 
(III) 

C O N T E N T S 

Page 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Ranking Member, 

Subcommittee on Military Personnel ................................................................. 2 

Heck, Hon. Joseph J., a Representative from Nevada, Chairman, Subcommittee on Military Personnel .................................................................................... 1 

WITNESSES 

Freedman, CAPT Rick, USN, Commanding Officer, Naval Hospital Camp 

Lejeune, United States Navy .............................................................................. 5 

Heimall, COL Michael S., USA, Chief of Staff, Walter Reed National Military 

Medical Center, Defense Health Agency ............................................................ 3 

Littlefield, Col Douglas M., USAF, Commander, 19th Medical Group, Little 

Rock Air Force Base, United States Air Force .................................................. 7 

Place, COL Michael L., USA, Commander, Madigan Army Medical Center, 

Joint Base Lewis-McChord, United States Army .............................................. 4 

APPENDIX 

PREPARED STATEMENTS: 

Freedman, CAPT Rick ..................................................................................... 59 

Heck, Hon. Joseph J. ........................................................................................ 37 

Heimall, COL Michael S. ................................................................................. 39 

Littlefield, Col Douglas M. ............................................................................... 70 

Place, COL Michael L. ..................................................................................... 49 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Dr. Heck ............................................................................................................ 83 

Mr. MacArthur .................................................................................................. 83 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

[There were no Questions submitted post hearing.] 

(1) 

MILITARY TREATMENT FACILITIES 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, SUBCOMMITTEE ON MILITARY PERSONNEL, Washington, DC, Wednesday, February 3, 2016. 

The subcommittee met, pursuant to call, at 2:03 p.m., in room 

2212, Rayburn House Office Building, Hon. Joseph J. Heck (chairman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM NEVADA, CHAIRMAN, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Dr. HECK. I will go ahead and call the hearing to order. Good 

afternoon, everyone. 

Today’s subcommittee meets to hear testimony on military treatment facilities, or MTFs, which are the medical centers, hospitals, 

and clinics that are owned and operated by the Department of Defense and the military services. 

For decades, military treatment facilities have been recognized 

as the foundation of military medical care. They are the primary 

location for Active Duty military to receive treatment and are the 

training and education platforms for medical providers worldwide. 

Every member of the military healthcare team, me included, has 

spent time in MTFs. If you have served in the military, chances are 

you have received care in an MTF for everything from immunizations, to routine health screenings prior to deploying, to witnessing 

the birth of your child. Depending on the size and location, MTFs 

provide a wide range of medical services to Active Duty, Active 

Duty family members, retirees, and retiree family members. 

However, military health care, alongside civilian health care, has 

evolved, and we have seen many changes to MTFs. The certainty 

that a military installation will have a full-service medical facility 

is a thing of the past. For example, in 1989, there were more than 

500 military medical facilities worldwide, 168 military hospitals 

and hundreds of clinics. Today, there are 55 hospitals and 360 clinics, for a total of 415 MTFs. Large medical centers, such as Fitzsimons Army Medical Center, once considered an enduring capability, have closed. 

The reasons for some of these changes are varied. Health care 

has largely shifted from an inpatient focus to outpatient settings 

such as ambulatory surgery and care models such as patient-centered medical homes. Another reason unique to military medicine 

is the realignment of troop units and closure of military installations, which has shifted the need for medical care among different 

locations. 
2 

So the question we now ask is: What is the future of military 

treatment facilities? How do they maintain the primary mission of 

readiness of the force and ready medical professionals? Are MTFs 

currently situated to support the readiness mission along with the 

mission to provide care to their beneficiaries? 

I am interested to hear from our witnesses about the challenges 

of running an MTF. How are MTFs different than civilian medical 

facilities? How does MTF leadership balance readiness requirements and the needs of the beneficiary population, including service members, family members, and retirees? 

And, finally, what can we do to ensure the Military Health System has trained and ready providers to support the readiness of 

the force and provide a valued health benefit to our beneficiaries? 

With that, I want to welcome our witnesses, and I look forward 

to their testimony. 

Before I introduce our panel, I would like to offer Congresswoman Susan Davis, our ranking member from San Diego, an opportunity to make her opening remarks. 

[The prepared statement of Dr. Heck can be found in the Appendix on page 37.] 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mrs. DAVIS. Thank you, Mr. Chairman. 

I also want to welcome our witnesses, and thank you very much 

for joining us today. 

You know, over the past several months, we have met with senior leaders in military medicine who have discussed the policies of 

providing health care to the force and their families, and we have 

also heard from beneficiary organizations that represent those on 

the receiving end of healthcare services. 

So today we have this unique opportunity to meet with the four 

of you, the military treatment facility commanders, three words, 

but they are all really important, all separate—who execute the 

policies, interact with the military providers as well as the beneficiaries affected by those policies and healthcare services. 

So I look forward to our discussion and hearing from each of you 

how you balance the requirements of maintaining medical readiness for your providers while providing access to quality health 

care for your beneficiaries and what can we do to help you in that 

endeavor. 

Thank you all so much for being here. 

Dr. HECK. Thank you, Mrs. Davis. 

We are joined today by another outstanding panel. 

Given the size of our panel and our desire to give each witness 

the opportunity to present his testimony and each member an opportunity to question the witnesses, I respectfully remind the witnesses to summarize, to the greatest extent possible, the high 

points of your written testimony in 5 minutes. 

The lighting system before you, when you have 1 minute left, it 

will turn yellow. When you are out of time, it will turn red. I assure you that your written comments and statements will be made 

part of the hearing record. 
3 

So let me welcome our panel: Colonel Mike Heimall, United 

States Army, Chief of Staff, Walter Reed National Military Medical 

Center—in the interest of disclosure, I was on staff at Walter Reed 

from 1998 to 2001; Colonel Mike Place, Commander, Madigan 

Army Medical Center at Joint Base Lewis-McChord; Captain Rick 

Freedman, United States Navy, Commanding Officer at Naval Hospital Camp Lejeune; and Colonel Douglas Littlefield, United States 

Air Force, Commander of the 19th Medical Group at Little Rock 

Air Force Base. 

Colonel Heimall, you are recognized for 5 minutes. 

STATEMENT OF COL MICHAEL S. HEIMALL, USA, CHIEF OF 

STAFF, WALTER REED NATIONAL MILITARY MEDICAL CENTER, DEFENSE HEALTH AGENCY 

Colonel HEIMALL. Thank you, Chairman Heck. And I was also on 

staff at Walter Reed 1998 to 2001. So it is great to have another 

alumnus of the Georgia Ave. campus. 

So, sir, Ranking Member Davis, and distinguished members of 

the committee, Mr. O’Rourke, it is great to see you again, sir, 

thank you for the opportunity to discuss the role our military treatment facilities play in supporting military readiness and how we 

care for our beneficiaries. 

I am the Chief of Staff at Walter Reed National Military Medical 

Center, and, until this past Monday, I served as the Center’s interim director. I would like to take a moment to highlight what we 

at Walter Reed are doing to ensure our staff are well prepared for 

future deployments and how we are enhancing access for our patients across the National Capital Region [NCR] while we continue 

to care for America’s heroes from around the world. 

Walter Reed is the largest MTF in the National Capital Region 

enhanced multiservice market. Together with the Fort Belvoir 

Community Hospital and 9 smaller MTFs, we are partnering to improve access to care for more than 245,000 TRICARE Prime enrollees across the National Capital Region. 

Today, providers from Walter Reed are seeing patients in nearly 

every one of those MTFs across our market in order to make care 

more convenient for our patients, eliminating the hassle of having 

to fight beltway traffic to come to Bethesda. We are also streamlining functions like appointing and referral management to gain efficiencies and improve access. 

My written testimony highlights several of the programs which 

Walter Reed-Bethesda is internationally renowned for. The Military Advanced Training Center for amputee rehabilitation, the National Intrepid Center of Excellence for traumatic brain energy and 

psychological health, and the Murtha Cancer Center continue to 

lead our Nation in developing evidence-based innovations that 

serve both a critical military medical need but also critical needs 

within American medicine. 

Our co-location with the Uniformed Services University of Health 

Sciences and the National Institutes of Health allow us to develop 

partnerships that better integrate education and research into patient care. These partnerships also afford us the opportunity to collaborate with renowned leaders in trauma care, cancer care, and 
4 

infectious diseases, improving care for our patients today while preparing our team for the deployments of the future. 

And we are also expanding this partnership to include our local 

and regional Veterans Administration medical centers so we can 

improve access to care for our veterans. Our veterans are as much 

a part of the military family as anyone who comes to us for care, 

and it is a privilege to care for them. 

These veterans are also often our most critically ill and complex 

patients, which exercises and strengthens the same critical care 

skills our entire team—providers, nurses, technologists, medics, 

and corpsmen—all need to care for a critically ill or injured service 

member on the battlefield, en route to a higher level of care, or 

back home at our MTFs. 

Thank you again for the opportunity to discuss these efforts with 

you, and I look forward to your questions. 

[The prepared statement of Colonel Heimall can be found in the 

Appendix on page 39.] 

Dr. HECK. Colonel Place. 

STATEMENT OF COL MICHAEL L. PLACE, USA, COMMANDER, 

MADIGAN ARMY MEDICAL CENTER, JOINT BASE LEWIS– 

McCHORD, UNITED STATES ARMY 

Colonel PLACE. Chairman Heck, Ranking Member Davis, and distinguished members of the subcommittee, thank you for the opportunity to represent Madigan Army Medical Center and Army Medicine today. 

Since 1944, Madigan has been a provider of world-class patient 

care, an unparalleled education facility, and a state-of-the-art research platform. Madigan cares for over 100,000 beneficiaries with 

around 5,000 staff members; supports over 250,000 beneficiaries as 

the tertiary referral hospital for the Puget Sound enhanced multiservice market. 

Madigan supports Joint Base Lewis-McChord, one of the Nation’s 

premier power projection platforms, home to 1st Corps, 7th Infantry Division, 1st Special Forces Group, the 62nd Airlift Wing, and 

a variety of smaller units. Our forces are aligned to the U.S. Army 

Pacific and are integral to supporting partnerships and exercises in 

the region as well as operations around the world. 

Madigan has a two-fold readiness mission: to ensure our service 

members are medically ready to deploy; and generating and maintaining ready medical forces. 

By collaborating closely with our line commanders, as well as 

unit medical and dental providers, we have increased the available 

rate for soldiers in 1st Corps to nearly 91 percent. We will continue 

to work with our senior mission commander, Lieutenant General 

Lanza, to identify means to continue to improve the readiness of 

our soldiers, such as by increasing the availability of physical 

therapists for injury prevention or through implementation of the 

Army’s Performance Triad. 

As an academic medical center and one of only two designated 

Level II trauma centers in the Army, Madigan plays an important 

role in ensuring we have ready medical forces. In 2015, Madigan 

trained 319 individuals in graduate medical education [GME] in 33 

distinct training programs. Our residency programs boast a 95 per-
5 

cent 3-year, first-time board pass rate, readily exceeding the national average of 87 percent. Madigan’s orthopedics, neurology, and 

radiology programs’ in-service examination performance this year 

places them in the top 10 percent of the Nation. And our emergency medicine residency remains one of if not the top in the country. 

Most importantly, our graduates are prepared through a unique 

military curriculum which provides them the tools to successfully 

transition to serve as surgeons in maneuver units or to serve in 

forward surgical teams or combat support hospitals. 

As a hospital commander in Afghanistan, I witnessed firsthand 

how our GME and related medical training programs provided the 

capability to achieve our unprecedented 92 percent survival rate 

despite the increasing severity of injuries sustained in modern combat. 

However, the Army cannot focus exclusively on sustainment of 

trauma skills and surgical capabilities alone. My experience in supporting the 75th Ranger Regiment in Operation Uphold Democracy 

in Haiti and as a medical task force commander during the Kosovo 

air campaign shows that Army Medicine must be prepared to support a wide range of crises, from peacekeeping, to disaster relief, 

to humanitarian assistance. 

Military treatment facilities like Madigan are vital to ensure our 

medical teams are trained, ready, and relevant to provide care 

globally. Our partnerships with the VA [Department of Veterans 

Affairs] and the civilian community strengthen our programs by 

providing a diverse and complex mix of patients to hone our skills 

for our entire medical team. 

I am personally committed to improving the readiness of our soldiers and our medical teams so they can best serve our Nation. On 

behalf of Team Madigan and Army Medicine, I want to thank Congress for your continued support. I look forward to your questions. 

Thank you. 

[The prepared statement of Colonel Place can be found in the Appendix on page 49.] 

Dr. HECK. Captain Freedman. 

STATEMENT OF CAPT RICK FREEDMAN, USN, COMMANDING 

OFFICER, NAVAL HOSPITAL CAMP LEJEUNE, UNITED 

STATES NAVY 

Captain FREEDMAN. Chairman Heck, Ranking Member Davis, 

distinguished members of the committee, thank you for providing 

me the opportunity to share my perspectives as Commanding Officer, Naval Hospital Camp Lejeune, on the role that military treatment facilities have in providing medically ready service members 

and ensuring an operationally ready medical force. We in Navy 

Medicine are privileged to care for those entrusted to our care. 

Naval Hospital Camp Lejeune is a family medicine teaching hospital located in eastern North Carolina, providing medical support 

to forces stationed on and around Marine Corps Base Camp Lejeune, to include members of the 2nd Marine Expeditionary Force 

and members of the Marine Corps Special Operations Command. 
6 

The primary reason we exist is to build and sustain medical 

readiness. At Camp Lejeune, readiness takes three distinct but 

equally important components. 

First, readiness means that we as medical professionals who 

wear the cloth of our Nation are ready at a moment’s notice to deploy in support of our Navy and Marine Corps team. We must be 

physically, professionally, spiritually, medically, administratively 

ready to move out at a moment’s notice. Our MTFs are the reservoir of forward-deployable expeditionary medical support for our 

combatant commanders. Nowhere is that better understood than 

aboard Marine Corps Base Camp Lejeune, where it is common 

knowledge that no marine has ever taken a hill without a United 

States Navy corpsman. 

Second, readiness means that we ensure our marines and sailors 

are ready to be the first to fight in any theater of operation and 

we understand their demanding mission. Several of our clinics are 

located around the base and are staffed jointly with medical personnel assigned to both hospital and assigned to operational units. 

This initiative improves access, continuity and quality of care, and 

provides expanded capabilities for our teams to collaborate during 

real scenarios, as demonstrated during our recent successful response to two recent mass casualty events following training mishaps. 

A third but equally important mission is caring for our families 

because our team understands there is no surer way to make a 

combat marine, soldier, sailor, airman, guardsman more ineffective 

than to have them worry about their family. Family readiness supports force readiness. 

We at Camp Lejeune are committed to being leaders in quality, 

safety, access, and service. NHCL [Naval Hospital Camp Lejeune] 

is proud to be among the first to employ available technologies to 

increase how our patients communicate with our providers. From 

our patient smartphone application, to 100 percent primary care 

manager use of secure messaging, to strong support of our nurse 

advice lines, we are ensuring patients have 24/7 access. 

Another of our access initiatives is launching our tele-ICU [intensive care unit] project, virtually connecting our intensive care unit 

with that of Naval Medical Center San Diego; use of digital radiology and telepharmacy throughout our multiple clinics spread out 

over the 246 square miles of Marine Corps Base Camp Lejeune. 

We are proud to note that we have implemented the Centering 

in Pregnancy Program that offers mothers-to-be a unique group 

prenatal care model that promotes education and peer-group connections. It has been extremely popular with many of our patients, 

particularly those lacking built-in support systems, a deployed 

spouse, or other challenges associated with military service. 

It is critical to note the importance of our hospital given the location in eastern North Carolina and the vital role we play in a medically underserved area of our country. There are wonderfully talented and dedicated civilian medical partners in Jacksonville and 

the surrounding areas; however, our community does not have the 

medical infrastructure which may exist in other metropolitan 

areas. 
7 

Camp Lejeune’s family medicine residency program has received 

the highest level of certification by the ACGME [Accreditation 

Council for Graduate Medical Education], has grown by 50 percent, 

and achieved 4 years of unprecedented 100 percent board pass rate 

for our residents. 

Their re-affiliation with our retired beneficiaries, who have doubled in size in the last 2 years, has really improved the acuity and 

complexity of cases for our interns and residents and specialists 

and allowing our team to care for those who have previously served 

and who deserve the best that this Nation can offer. 

An integral aspect of care which has no counterpart in the civilian community is our Intrepid Spirit Concussion Recovery Center. 

This center offers exceptional support for our service members afflicted with traumatic brain injury [TBI]. A hallmark of the Intrepid Spirit Center is a holistic, integrated, interdisciplinary treatment approach that includes 10 different specialties, to include 

complementary alternative medicine techniques. Care is tailored to 

meet the unique needs of the warrior athlete, and, to date, approximately 2,000 of our warfighters have gone through the program, 

with over 90 percent of them, at least from the standpoint of TBI, 

returned to full duty. 

In summary, we are a critical part of the greatest and most highly capable Navy and Marine Corps team that the world has ever 

known. Our hospital serves as a readiness platform for the force 

and families stationed in the area. We will continue to be a forward-deployable expeditionary medical capability while maintaining the highest levels of readiness. 

Thank you for your support of military medicine, and I look forward to answering your questions. 

[The prepared statement of Captain Freedman can be found in 

the Appendix on page 59.] 

Dr. HECK. Colonel Littlefield. 

STATEMENT OF COL DOUGLAS M. LITTLEFIELD, USAF, COMMANDER, 19TH MEDICAL GROUP, LITTLE ROCK AIR FORCE 

BASE, UNITED STATES AIR FORCE 

Colonel LITTLEFIELD. Chairman Heck, Ranking Member Davis, 

and distinguished members of the committee, I too thank you for 

the opportunity to come before you today on behalf of the men and 

women of the Air Force Medical Service. 

As commander of the 19th Medical Group in Little Rock, Arkansas, my job includes leading a team of 350 dedicated Active Duty, 

government service civilian, and contract employees in supporting 

a population of 44,000 beneficiaries within a 40-mile radius from 

our clinic. 

Of those beneficiaries, approximately 14,000 are enrolled directly 

to our clinic and receive care across our spectrum of provided services, such as our family and women’s health clinic, flight medicine, 

optometry, and dental clinics. 

Some of the more unique services include both public health and 

bio-environmental sections as well as our aerospace physiology and 

High Altitude Airdrop Mission Support team that directly support 

a myriad of U.S. and coalition partners in conducting operations in 

unpressurized aircraft between 10,000 and 35,000 feet in altitude. 
8 

Each day, we strive to provide trusted care to the population we 

serve while continually looking for ways to provide safer, more efficient care and remain in touch with our patients’ needs. 

Supporting the mission is our first priority. It is why we exist 

and where we focus our daily efforts. At Little Rock, this means 

combat airlift anywhere, anytime. Our actions ensure our Active 

Duty population are ready physically, mentally, and emotionally to 

carry out their role in supporting the wing’s mission. It also means 

caring for family members, retirees, and their dependents with the 

services that we provide. Ultimately, military readiness is community readiness, and leading my team to recognize the role they play 

in this priority has benefited all involved. 

The next priority we focus on is people. Our amazing teammates 

are how we get this mission done. And we strive daily to treat our 

patients, family members, community partners, as well as each 

other with the utmost respect and professionalism. We are committed to resiliency in every area of our lives, which makes us 

more productive and better teammates. We also look for opportunities within the clinic, wing, and community to grow personally and 

professionally so that we can continue to become better airmen. 

Our final priority is communication. There is no substitute for 

clear and concise communication at all levels, which allows our 

team to function at its peak. We are always looking for opportunities to improve our communication methods by listening more than 

we speak and utilizing different sources of information across our 

available spectrums to get pertinent messages to those we support. 

By focusing on these priorities, we are committed to supplying 

safe and high-quality health care to all those we serve. While the 

pursuit of this may look different at each location, the Air Force 

Medical Service will provide trusted care anywhere as we strive for 

peak readiness and the highest reliability in all we do. 

Thank you for the opportunity to speak on this matter and for 

your continued support. 

[The prepared statement of Colonel Littlefield can be found in 

the Appendix on page 70.] 

Dr. HECK. I thank you all for your testimony. 

We will now move into rounds of questioning. Each member will 

be limited to 5 minutes. We will go in the order of arrival prior to 

gavel. Hopefully, because I know I have several questions, we will 

have time for multiple rounds. 

And I will start. 

Colonel Heimall, you know, the interesting thing about Walter 

Reed is that you are under the command of DHA [Defense Health 

Agency] and not a service. Can you give some insight as to how 

that works, answering to the Defense Health Agency as opposed to 

a service sector? And, you know, do you see pros and cons to having 

that type of an alignment? 

Colonel HEIMALL. Sir, from a functional alignment, based on my 

experience commanding within Army Medicine, DHA really functions like a regional medical command or a regional health command for us. That is where our resourcing comes from; it is where 

our policy guidance comes from. And so it is really not much of a 

different relationship between Walter Reed and the National Capital Region Medical Directorate and the Defense Health Agency. 
9 

I think some of the challenges with the way we are organized is, 

within the National Capital Region Medical Directorate, Defense 

Health Agency only operates two MTFs. And so when we look at 

resourcing, when we look at allocation of civilian hiring caps that 

are in place to allow us to bring civilians on board, we don’t have 

the degree of flexibility that Army Medicine, Navy Medicine, or Air 

Force Medical Service have, given the size and the scope of their 

regions. 

We have about 4,500 civilian authorizations across the National 

Capital Region Medical Directorate. I will compare that to my time 

at William Beaumont Army Medical Center in El Paso, when Western Regional Medical Command at the time had over 11,000 authorizations. And so it makes flexibility in hiring and shaping our 

workforce much more challenging. 

Dr. HECK. Great. Thank you. 

Colonel Place, you mentioned that Madigan was a Level II trauma center, one of only two within the inventory. Are you integrated 

into the civilian EMS [emergency medical system] system, and do 

you receive civilian casualties from trauma into your trauma center? 

Colonel PLACE. Yes, sir, absolutely. We are part of the Tacoma 

Trauma Trust. As that, we back up two civilian hospitals downtown. We average about one or one and a half activations of our 

trauma team every day. So we are basically the backup 365/24 

hours a day for anyone else. 

Dr. HECK. And how critical would you say that that integration 

with the civilian trauma center is in being able to maintain the 

trauma skills of your staff members? 

Colonel PLACE. Sir, I think it is enormously important. We have 

only one Level I trauma center down in San Antonio. I think it is 

important that we routinely see trauma in order to maintain those 

skills for not just the surgeons, because they are relatively easy to 

get to a trauma center to go do trauma, but, as you know, it takes 

a lot more than just the doctor to be able to do those things. You 

need to have the ER [emergency room] trained well; you have to 

have anesthesia and the PACU [post operative care unit] and the 

ICU. All of those need to have training, the pulmonologists, you 

know, the respiratory techs. Everybody needs to be part of that. 

So if we don’t see any trauma, that is a challenge for us. And 

I personally would like to see more because I think that adds to 

our capabilities when we go to war. 

Dr. HECK. Could you summarize how that relationship was established between Madigan and the civilian hospital system? 

Colonel PLACE. So, sir, I am not familiar with the actual history 

of that. I understand it was more than a few years ago that that 

was put in place. So I can get back with you for the details if that 

is important. But right now we are in discussions with our counterparts down there to make sure that we are all fulfilling our roles 

and responsibilities as part of that. 

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

page 83.] 

Dr. HECK. And as part of that relationship, do some of your providers rotate out to civilian hospitals? Or is it all done based on the 

trauma patients, civilian trauma patients, coming to your facility? 
10 

Colonel PLACE. Yes, sir, we have some external resource sharing 

agreements where we send some of our folks downtown. Right now, 

probably the most dramatic is our cardiothoracic surgeons. They go 

downtown to perform surgeries there to maintain their skills. We 

don’t have enough caseload within our population to really allow 

them to maintain their skills, so we let them go downtown, with 

preferential treatment of our beneficiaries. But even so, we end up 

doing some VA cases and things like that downtown. 

Dr. HECK. Great. Thank you. 

Since my time is almost up, I would rather not shoehorn an answer into my next question, so I will wait for the next round. 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

And, again, thank you all for being here. 

We have heard from a variety of sources, certainly, as we have 

worked through this over the last number of months, that access 

to healthcare providers is a challenge for some of the MTFs. And 

I wonder if you could talk about how you monitor or you balance 

the access to care for those depending on services. 

And when you think about additional services that have to be increased, in what area is there greatest demand? And how—do you 

track that so you have a sense of where that healthcare dollar is 

being spent? 

As you may know, there was a study last year, a Shelton study 

last year, that really looked at some of the contracted services, and 

they were pretty high, 70 percent, versus the MTF. 

So can you talk a little bit about that? And how do you do that? 

And what do you know about that, in terms of trying to provide 

that additional resource? 

Colonel HEIMALL. Well, ma’am, I can tell you within the National 

Capital Region we look very closely at where our patients are going 

to get their care and what we are paying for in the private sector, 

with the intent of trying to recapture as much of that care as we 

can. 

Every time we treat a patient inside of our MTF, there is value 

in maintaining the skill level of not just the physician or the midlevel provider who is seeing that patient but the entire care team 

around that provider. 

Additionally, if we have the capacity to see the patient and we 

send them downtown, the taxpayer has really paid twice for that 

care. And, as a taxpayer, I don’t like doing that, and I am sure not 

many others do. 

Within the National Capital Region, the needs really revolve 

around access to services like dermatology, gastroenterology, podiatry, and physical therapy. And I think the rest of the members will 

say physical therapy has been a challenge for most of us across the 

military services. 

And so you look at innovative ways, now, how can I bring that 

care back into the system. And, in many cases, what we are doing 

at Walter Reed and Fort Belvoir is looking at how we can take our 

providers to where the patient lives and works. And so we have 

gastroenterology providers living and working at Fort Belvoir and 

Fort Meade every day. The Air Force has assigned an additional 

gastroenterology provider to Malcolm Grow who actually works at 
11 

Fort Belvoir Community Hospital every day so that we can meet 

that demand. 

And we are justifying additional resources in the market not 

based on what we are doing at an individual facility but what the 

market needs to be able to take care of the patients that are enrolled to us. 

Mrs. DAVIS. Thank you. 

And how has that medical dollar been spent then as a result of 

what you are trying to do? What have you seen that is different? 

Colonel HEIMALL. Well, I think one of the things we have done 

in the last year in the National Capital Region is we have lowered 

our per-member, per-month cost significantly, about $90 per patient per month. And that has really been a result of trying to 

bring that care back in-house and better utilize the capacity that 

we have. 

I am interested to see what happens. We have just hired 11 

physical therapists for the entire market, and we are placing those 

physical therapists at the MTFs where that care is being referred 

to. So it will be interesting to see how much care we can recapture 

and whether or not we can make the care more convenient for the 

patient. 

It makes no sense for somebody from Pax River, for example, to 

drive to Walter Reed for physical therapy three times a week if we 

can provide that service much closer to Pax River. 

Mrs. DAVIS. Great. Thank you. 

Anybody else want to respond? 

Captain FREEDMAN. Congresswoman, I would like to say, too, as 

Navy Medicine and the MHS transitions from health care to 

health, access, service, these are indicators of health—very, very 

important. 

So we look at establishing that trust with the patient in a patient-centered medical home model to ensure that it is easy to get 

access. We monitor every single morning, making sure that our 

templates are built for open access for our patients. We are providing new and innovative ways for our patients to contact us, 

through nurse advice line, through secure messaging, through our 

patient smartphone application. 

We want to make sure that we establish that, because if you 

need to be seen today, our covenant is that we will see you today. 

And that is the trust that you build into your patients so they don’t 

seek care in the emergency room. Not that that is not good care, 

but that is not great primary coordinated care that leads us to 

health. 

We also work very closely with our managed care support contractor who manages our network of facilities. And if we see that 

there is an indication for additional resources to be brought back 

to the direct care system, we work very closely with them to do so. 

Colonel PLACE. Ma’am, I would like to add, as well, yes, we monitor all those things very, very, very closely. We have all kinds of 

briefings related to that. 

But I guess the take-home message, from my perspective, is the 

metrics don’t tell the whole story. If you call today at Madigan, the 

average time until you are seen for an acute appointment is .6 

days. The metric that we use for third next available appointment 
12 

is 1.6 is what that comes out as. But if you call today, most of the 

time we add you on. We just say, come on in, we will take care of 

you. So that is really what I want to get to in terms of access rather than how many appointments do we have. 

In terms of the whole dollar figure, we recently went through 

and kind of reviewed how we do on 37 different kinds of service 

lines, so gastroenterology, pulmonology, and so forth, that we have. 

For the multiservice markets, the 250,000 beneficiaries, for 25 of 

the 37 service lines, more than 85 percent of the care we provide 

inside the direct care system. 

So, yes, ma’am, we look at the value for healthcare dollars. When 

it makes sense for us to do it inside, we make that business case 

analysis and we try and provide it internal. If not, if it is more 

cost-effective to do it through a network provider, then we go that 

way. 

Mrs. DAVIS. Okay. Thank you. My time is up. 

Dr. HECK. Ms. Tsongas. 

Ms. TSONGAS. Thank you, Mr. Chairman. 

And welcome. 

As you all are speaking, I am reminded of I was a recipient of 

treatment in a military treatment facility in my early teens, as was 

one of my sisters. My father was a career officer in the Air Force. 

And I have always appreciated the great care we received for not 

insignificant problems. One was in an MTF here in the United 

States, another when we were stationed abroad. And in both 

places, we got such great care. So I thank you for that, as a family 

member. And I am sure, as we certainly hear from our military 

families, how important that is. 

I do have a question related to the fact, the ever-growing numbers of women that are now currently serving in the Active Duty. 

And I am curious, as this population is increasing, how well able 

you feel you are able to serve them as they are in this Active Duty 

status. And are there shortcomings and ways in which we could be 

more helpful? 

And I will start with you, Colonel Heimall. 

Colonel HEIMALL. Ma’am, I think we have had about a 10-year 

head start on some of the other Federal systems in how we manage 

women’s health. Within Walter Reed, we have a women’s health 

clinic, and there is a range of programs that are available. But we 

also have the luxury of having an obstetrics and gynecology residency program that allows us to provide a higher level of care for 

women who are serving, as well as for retirees and the veterans 

that come to us. 

I think one of the gaps that we have right now—and it is a matter of developing it, and we have just started developing the program about 6 months ago at Walter Reed, is a trauma program for 

women who are suffering from, and men—who are suffering from 

sexual assault trauma. While trauma is the same from an emotional standpoint, the way we manage that within groups and the 

therapy we provide really needs a different touch. And so creating 

an intensive outpatient program for victims of sexual assault is 

really, I think, a needed service as we go across MTF to MTF. 

Ms. TSONGAS. Is that a resource issue or an approach issue? How 

would you define the shortcoming? 
13 

Colonel HEIMALL. I think it is multivariate. It is an issue of recognizing the need, resourcing it, and then making sure you have 

the people who have the experience to be able to implement the 

program. 

Ms. TSONGAS. Thank you. 

Would others like to respond? 

Colonel PLACE. Ma’am, I agree. We have had a little bit more experience with this, and as a former operational medicine consultant 

to the surgeon general, I would say we have even a lot of experience going to war with women, which has, I think, given us some 

perspectives and some understanding of what those challenges are. 

I don’t think we have it perfect. I think there are some things 

that we can do. But I think they are more tweaks to the system 

rather than big gaps that need resources or major renovations of 

how we approach women’s health. 

Ms. TSONGAS. And as women go to war, how would you describe 

the challenges you have? 

Colonel PLACE. So there are a number of things that we look for 

in terms of hygiene, in terms of privacy, in terms of making sure 

that we balance security with lighting systems and so forth versus 

the risk of sexual assault and things like that. There are a number 

of small factors that come up. But those are things that we have 

to mitigate the risk against rather than create new programs, I 

think, from my perspective. 

We have a very active women’s health service line at MEDCOM 

[Medical Command] that helps us review these things and implement new methodologies. Recently, I will just give you an example 

from Madigan. An important women’s issue is breastfeeding, and 

we have actually purchased four pods for breastfeeding within 

Madigan because we didn’t have locations that we thought were 

reasonable and accessible for women to breastfeed in. So we purchased them, we sent them up, had them advertised and so forth. 

And we are helping the rest of the installation figure out where to 

put them, how to utilize them to make them effective for our female soldiers as well as for us, the patients that come there. 

Ms. TSONGAS. And we are glad to see Secretary Carter recognize 

that this is something that has to be dealt with across the services, 

not just in the MTF environment but in general. 

Colonel PLACE. Yes, ma’am. 

Ms. TSONGAS. Would others like to comment? I have just a little 

time. 

Captain FREEDMAN. Congresswoman, we are proud at the Naval 

Hospital Camp Lejeune to have many initiatives. 

We have been designated, applied for and designated as a threestar facility by the North Carolina Maternity Center for breastfeeding-friendly institutions. 

We have started a Centering in Pregnancy Program that I talked 

about in my opening remarks; that, according to the Centering 

Healthcare Institute, we have the most number of participants in 

the Nation, not just in DOD [Department of Defense], with 27 active groups that are going through this group prenatal care program. 
14 

And I am blessed in leadership with a partner, my executive officer, who is also a women’s health nurse practitioner, to make sure 

that we provide care for all our warfighters and their families. 

Ms. TSONGAS. Thank you. My time is up. 

Dr. HECK. Ms. Stefanik. 

Ms. STEFANIK. Thank you, Mr. Chairman. 

Thank you to the panelists for your service today and the sacrifice of your families. 

On Fort Drum, which is an Army installation that I represent in 

my district, we have a clinic as opposed to a hospital on post. Guthrie Army Health Clinic and the MEDDAC [Medical Department Activity] that oversees it supports over 14,000 Active Duty soldiers 

and 16,000 military family members. Due to this unique relationship, the MEDDAC at Fort Drum partners with the community to 

ensure that the highest quality of care is provided to all patients. 

So I wanted to turn to Colonel Littlefield. 

What are some of the unique challenges you have faced while 

partnering with civilian provider networks for services that you are 

unable to provide? And would you consider a model similar to what 

you have at Little Rock Air Force Base to be as efficient as other 

installations that have full hospitals with inpatient care on post? 

Colonel LITTLEFIELD. Thank you, ma’am. 

I think the opportunity is, or the word is ‘‘balance,’’ too. It is 

something, when we are looking at access, again, a clinic compared 

to a bedded facility and what we offer, we are in constant communication with our community partners. Some people don’t consider 

Little Rock as robust, but that is one of the things that I have 

found. Their civilian network is quite robust. Now, there are some 

specialty areas, particularly when you get in the pediatric ranges, 

some of the mental health services that need to be provided, there 

are long wait times there. But, overall, I have been very pleased 

with the availability of services. 

But we partner with them. We do things from holding provider 

collaborations every year to invite our partners in, meeting with 

them, developing relationships. We have been able to send some of 

our providers down to the Arkansas Heart Hospital, seeing open 

heart procedures and those types of events. 

So we are always looking for opportunities to partner. And I 

think with us being the only Active Duty facility in the State of Arkansas, that is where we are headed, is that we need that partnership for those things that we can’t provide. We will capture everything we can, bring it into our facility to keep the skills up of our 

team members, but we rely on our community partners. 

Ms. STEFANIK. Thank you for that. 

Does anyone want to comment on that question? 

Go ahead, Captain Freedman. 

Captain FREEDMAN. Thank you very much, Congresswoman. 

We are blessed in eastern North Carolina to have a fantastic, 

supportive community in Jacksonville and the surrounding area, 

where they understand the importance of the Marine Corps and 

the Navy team and what it does for the defense of our Nation. 

So our partner facilities in the civilian community have been 

wonderful for us. We have expanded some enhanced resource-sharing agreements with our local hospitals for a dual diagnosis pro-
15 

gram for dependency and behavioral health. We have our local hospital that provides operating room space for us as we undergo renovation of our operating room spaces. We have a great medical center in Vidant Medical Center that we have entered into an agreement with to allow our corpsmen, our nurses, and our physicians 

to be able to go up there and get training that we may not see in 

our institution. 

So it is a true community. And I think it’s understanding the 

mission. And I think no one does it better than Jacksonville, North 

Carolina. 

Ms. STEFANIK. Thank you very much. 

Any other comments? 

Colonel PLACE. Ma’am, I would just offer that I think it depends. 

You know, ‘‘balance’’ is a way to put it, but what we would like to 

do, and I think we do a pretty good job of it, is finding the talents 

and capabilities in the civilian community, and if it makes good 

business sense to capitalize on, then let’s do that. If it doesn’t, then 

let’s do it inside the facility with, you know, taxpayer dollars. 

So if the capability is there and it is a high-quality capability, 

then, by all means, we ought to do that. 

Colonel LITTLEFIELD. Ma’am, I agree with what the other panel 

members have said. I think you to have to look at, first, is there 

a compelling readiness reason why I would want to offer that service—inpatient care, complex surgeries, intensive care, for example, 

the things that Guthrie gets from the civilian community—in my 

MTF at a particular location. And health care is still a very local 

phenomenon, so every base has a different community and different assets in that community to support them. 

And so, if that case is there, we build it there. If that case isn’t 

there, then where can we get that in the civilian community, and 

how can we build the partnership to make sure that works smoothly. 

Ms. STEFANIK. I appreciate those comments. And we have had 

success stories in the broader Fort Drum community, partnering, 

for example, with River Hospital, with a very high-quality PTSD 

[post-traumatic stress disorder] program. That is an example of 

identifying a need and working with the experts and the practitioners who are within the community. 

So thank you for your testimony today, and thank you for the 

thoughtful answers. 

Dr. HECK. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

And I want to thank each of you for your testimony and your answers to our questions. 

And, Colonel Heimall, I would just like to thank you, especially, 

for your service, because I am most familiar with it, when you were 

the commander at William Beaumont Army Medical Center. And 

during that time, when you were both commander and I was the 

Representative for the area, I probably had 40 public townhall 

meetings, you know, where everyone was invited, no holds barred, 

any issue or topic, and you were there at every single one of them, 

whether Army Medicine or veteran care was the subject or not. 

And I think that sends a very powerful message to the community 
16 

about your interest and involvement in the community at large, especially veterans’ care as connected to Active Duty military care. 

And then, to that point, you did a tremendous job working with 

our local VA, which is physically conjoined with William Beaumont, 

while overseeing a billion-dollar construction project for the new 

William Beaumont. So I can’t thank you enough for what you have 

done for our community, for the veterans there, for the Active Duty 

military and their families. 

You mentioned in your testimony the need to ensure that there 

is a continuum of care for Active Duty service members into the 

transition to civilian life when they are veterans. And, anecdotally, 

in El Paso, I will often encounter veterans who served at Fort 

Bliss, which is served by William Beaumont, who said that for 

their mental healthcare needs, while they were Active Duty, they 

were met almost without fail, without complaints. If their prescription for their PTSD required seeing a therapist once a week, they 

were seen once a week. And, by contrast, in the civilian world, 

treated by the VA, maybe they get in to see a therapist, maybe 

they don’t get to see anyone at all. And we were later able to confirm that through a survey that found that one-third of veterans 

in El Paso could not receive mental health care despite trying. 

So how do we fix this? If we are able to recruit and retain or 

make use of mental healthcare providers who are in active service 

and do so effectively, how do we ensure that there is consistency 

and continuity in that care once that service member becomes a 

veteran, at a time when we have, officially, 22 veterans a day taking their own lives? And I know for a fact that that level of suicide 

is connected to care that is delayed or denied at the VA. How do 

we fix this? What have you learned at Walter Reed, at William 

Beaumont, in collaboration with the VA, that would allow us to 

begin to be more effective in combating this? 

Colonel HEIMALL. Sir, first, I want to thank you for your support 

and your district staff. The partnership we had there I think made 

my 33 months there incredibly successful and really helped me 

navigate a number of problems that could have derailed a lot of 

what we were trying to do. And that was the partnership that we 

had, I think, that really made that a success. 

Your question is very well put. Particularly in the area of behavioral health, there are a number of areas where we have the ability, I think, to help the VA with access to care. And we certainly 

try to do that at Walter Reed every day. But, in El Paso, one of 

the areas I struggled to be able to support the VA was in primary 

care services and behavioral health. And I think that is true at a 

number of our facilities and certainly true at Walter Reed, though 

we do have a little more flexibility with the inpatient capabilities 

that we have. 

There is a national shortage of behavioral health providers. It is 

not unique to the military, unique to the VA. I believe, nationally, 

we are not filling all the residency seats for psychiatry across the 

country. We are looking for innovative ways to grow psychology 

programs, internship programs, et cetera. And so we have to do 

something to address the supply at the national level. 

We are all competing for the same providers, and often what 

happens is we wind up into a bidding war with the VA or with our 
17 

civilian counterparts over how we retain providers. In our experience in El Paso, it was very common to have someone work for us 

for 2 years and then slide over to the VA for a couple of years and 

then come back to us 3 years later. And we have to do something 

to increase the pool so that we can meet the demands of our patients. 

Mr. O’ROURKE. And it sounds like there is going to be another 

round, so I will ask this again, and we will include the other colonels in the response. But I think my point is that you were somehow able to figure that out. 

And, you know, very often I heard the reverse of the scenario you 

described, where it is DOD that is hiring away from the VA, and 

the VA felt like it couldn’t compete on salary or price or benefits 

or retention bonuses or whatever is provided. 

So I understand there is a scarcity, but some are able to receive 

care amidst that scarcity while others do not. And I would just 

think that if we are treating the same person for the same condition and we are able to do so successfully on this half of the divide, 

there has to be some way, perhaps even using the same providers, 

to continue that care once they are on the other side of the divide. 

So I am out of time, but I would like to come back to this if there 

is another round. Thank you. 

Dr. HECK. Mr. MacArthur. 

Mr. MACARTHUR. Thank you, Mr. Chairman. 

You each are overseeing facilities within one of the branches of 

our Defense Department. And I am interested whether that matters, that you stay within that particular branch, or whether all 

healthcare facilities within the MHS [Military Health System] 

could be managed together, which has been recommended. 

And I would like to know, beyond parochial concerns, I would 

like to know why you think one or the other is more effective for 

our primary objectives. 

And we will start with you. 

Colonel LITTLEFIELD. Yes, sir. Thank you. 

I think, at the end of the day, I think my panel members would 

agree, we are pretty much blind to who we are providing care to, 

as far as our sister services. We treat, you know, Marines, Navy, 

Army all across, even in our facility. And so I think that is the bottom line, is the provision of care and excellent care and how we do 

it. 

Mr. MACARTHUR. What about on the other end? Does the oversight within a particular branch matter? 

Colonel LITTLEFIELD. Ultimately, I don’t think so. I think providing the care, maintaining the readiness for our members, maintaining the readiness for our team members themselves, the medics 

that need to go out and be ready, and maintaining the care for our 

family members, dependents, and retirees is the factor that we are 

looking into. 

Mr. MACARTHUR. Okay. Thank you. 

Captain FREEDMAN. Congressman, thank you for that question. 

In Navy Medicine, as we move forward with readiness, jointness, 

and value, there are many initiatives that are taking place where 

we are doing best practices and sharing of resources. We started 

in Naval Hospital Camp Lejeune an Eastern Carolina Healthcare 
18 

Consortium, where we have brought together the leaders from 

Womack Army Medical Center, Seymour Johnson Air Force Base, 

their clinic there, as well as the VA, to see what we can do to better coordinate care and share resources. 

However, there are some service-specific things, and the important part of that readiness mission can’t be overstated. We are embedded, and the Navy-Marine Corps relationship is so strong. We 

go to combat together. We have to understand each other’s operations and missions, and we have to be trusted partners in leadership. 

And aboard Marine Corps Base Camp Lejeune, we are very fortunate to have incredibly strong leadership, but bring us in on a 

lot of decision-making that occurs right there on that Marine Corps 

base, brings that Navy hospital, makes sure that our training is together, our providers work together, they go to war together, they 

come back together. And there are a lot of specific service-related 

times where Navy Medicine is called for the Navy-Marine Corps 

team. 

Mr. MACARTHUR. So that service alignment matters is what I 

hear you saying. 

Captain FREEDMAN. It does, sir. 

Colonel PLACE. Sir, I think I am in a unique position. I am in 

a multiservice market that has Army, Navy, and Air Force in it. 

So Joint Base Lewis-McChord, ‘‘McChord’’ is for McChord Airfield, 

so there is the 62nd Air Wing there, kind of an important unit in 

the Pacific Northwest, as well as Naval Hospital Bremerton and 

Naval Hospital Oak Harbor. 

So I am the tertiary referral hospital for the two Navy facilities 

and actually provide facility space and oversight and IT [information technology] and logistics and so forth to the Air Force facility 

that actually is part of a wing of a clinic that we have up on 

McChord Field, on that side of the base. 

So I would answer it this way. The clinical care doesn’t matter. 

So when you look down from us, it doesn’t matter. It is doctors and 

nurses and so forth applying their skills. That is consistent across 

all of us. We have the same measures for quality and safety and 

so forth. 

Where it gets a little bit unique is then, when we talk to line 

commanders about, you know, what does readiness mean and how 

do we get there and the nuances of the mission, that becomes important, that we speak that language. And there is some service 

identification with that. 

The bigger challenge really, I think, for all of us is that we need 

consistency from us up for policy funding, all the rest of the things, 

that if they change a lot, that becomes a problem. And there are 

some very unique things about each of our services in how we receive that kind of guidance and information. 

So I think, from here up, it gets a lot more complicated, but from 

where we are down, it is pretty straightforward. It is clinical care. 

And we can do that regardless—— 

Mr. MACARTHUR. Just so we have time for the—— 

Colonel HEIMALL. Sir, my situation is a little bit more complicated than Colonel Place’s, in that we are a joint facility, and I 

do not have any of the traditional command authorities over the 
19 

Army, Navy, or Air Force personnel that work at Walter Reed on 

a daily basis. 

And one of the things that I have learned is, as you get more 

senior and your organizations get larger, you rarely have all the 

authorities that you want to do your job effectively, and the premium is built on relationship-building and consensus-building to 

accomplish the mission. 

And that is really what we have done, I think, exceptionally well 

within Walter Reed and the National Capital Region Medical Directorate, given the fact that, as a Defense Health Agency subordinate, we don’t have those traditional authorities that my counterparts at the table do have. 

Mr. MACARTHUR. Your dilemma sounds a lot like Congress. 

I yield back. 

Dr. HECK. Ms. Speier. 

Ms. SPEIER. Mr. Chairman, thank you. 

And thank you to our panelists. 

Recently, there was a study that shocked me and probably many 

of my colleagues, that the child abuse among members of our military is much higher than the national average. We are going to 

have a hearing on that, I believe. 

But I am curious what is being done within the various services 

in terms of providing specifically mental health services in child 

abuse cases. 

Colonel PLACE. So, ma’am, one of the things that we are looking 

at at JBLM [Joint Base Lewis-McChord] is that very fact. We actually have a higher-than-expected rate of domestic violence in our 

units. So General Lanza has charged several of us to figure out 

what to do about it and—— 

Ms. SPEIER. I am talking about child abuse. 

Colonel PLACE. Yes, ma’am. I am talking about domestic abuse 

of all sorts, both spouse as well as child. 

Ms. SPEIER. Okay. 

Colonel PLACE. And, with that, we use our Family Advocacy Program principally in order to identify families and get them into 

care. 

We also have a Child and Family Behavioral Health System that 

we use. We have resources specifically identified to assist with that 

particular problem, along with all the other behavioral issues that 

we have for young children. 

Ms. SPEIER. Anything else? 

Captain FREEDMAN. Congresswoman, aboard Marine Corps Base 

Camp Lejeune, we are a partner with the Marine Corps Community Services [MCCS] that, in addition with our Navy Medicine assets, provides training and resources so we can get to the prevention of this problem. 

We have embedded MCCS family life counselors that enter our 

clinics, as well, to make sure there are seamless handoffs for cases 

that are too significant or clinically important for the Marine Corps 

Community Services to handle so there is a seamless transfer 

there. 

So there are training opportunities and, I would say, embedded 

partnership with our other services. 
20 

Ms. SPEIER. I guess what I am asking is, to me, this is a crisis. 

It appears that, if it is seven times higher, I forget what the figure 

was, but I think it was something like seven times higher than the 

national average, we have a problem, and what we have in place 

isn’t enough. 

So I guess my question is more about are we redoubling our efforts, are we doing anything differently than we have been doing. 

Colonel HEIMALL. Ma’am, I think we are always looking for opportunities to change how we are doing and deliver the care that 

is required to intervene in these cases better than we have in the 

past. 

And the parallels within our child and adolescent psychiatry 

community, as well as the adult behavioral health community for 

the offenders, is how do you develop programs that meet the needs 

of the victim, change the behaviors of the offenders, and get at the 

root causes of what is leading to the abuse. 

Some of it requires criminal prosecutions, and those are run 

through our service-level detachments. Again, these commanders 

have the authority to prosecute that within their own ranks. We 

run ours through Army, Navy, and Air Force at Walter Reed. 

But my biggest concern in my current role is how do I get the 

emotional and clinical support to the victims, to the support system 

around the victims, and if the behavior from the offender is related 

to something like a combat experience or other traumatic experiences, how do we get help to the offender as well. 

Ms. SPEIER. The issue of chronic traumatic encephalopathy 

[CTE] is real. I have been doing some work with Dr. Omalu, who 

is the coroner who really exposed the issue and the impact that it 

is having on football players. He has also now looked at the brains 

of veterans and has developed a technology of being able to do 

MRIs [magnetic resonance imaging] and do the screening on living 

persons. 

And it would appear that within the military we have a serious 

issue relative to CTE. And I am wondering to what extent we have 

done anything to start to screen those who are serving who suffered sub-concussive or concussions and what steps we are taking 

to try and address that. 

I am running out of time, so maybe, if you can’t answer it in 21 

seconds, you can do so—— 

Captain FREEDMAN. Congresswoman, our Intrepid Spirit Concussion Recovery Center has partnered with Team TBI [traumatic 

brain injury] and the University of Pittsburgh to share resources, 

to share data, to share best practices. So I think this initiative may 

open up some doors to be able to help our warfighters and then address this problem. 

Ms. SPEIER. All right. I would like to talk to you further about 

it at some point. 

Thank you. 

Dr. HECK. Okay. We will begin a second round of questions. 

Understanding the importance of trying to recapture beneficiary 

care into the MTFs from a maintenance-of-readiness perspective for 

the healthcare provider so they have that broad array of diverse 

cases, one of the things that we are wrestling with is how do you 

incent the beneficiaries to come back into the MTFs. 
21 

In other hearings that we have had with beneficiary stakeholder 

groups, one of the concerns that was expressed is that, you know, 

a beneficiary doesn’t like necessarily having a military medical provider, because when that person PCSes [permanent change of station] or they get deployed, they are starting over with another, you 

know, military healthcare provider. 

The other issue that was raised was the inability to get a timely 

appointment at an MTF. 

So how would each of you address those two issues? What do you 

think it would take to incent beneficiaries to come back? How do 

you address the issues with the relatively transient nature of military healthcare providers and the capability within the MTF to actually expand access if we get more beneficiaries to come back in? 

And I am going to start with Colonel Littlefield since we always 

go this way and you tend to get left out. 

Colonel LITTLEFIELD. Thank you, sir. I appreciate it. 

Again, I have mentioned the word ‘‘balance’’ before, but being a 

clinic, it is something that we always have to be looking at. We 

work closely with my staff, my chief of the medical staff in particular, to look at our patient balance; how many retirees, what is 

the acuity and the complexity of care that we can provide for the 

provider mix that I have in-house too. 

I think some of it is communication. That was one of the priorities we mentioned. But talking to the community partners, we go 

out to the chamber of commerce meetings, we go out in the community, those provider collaborations, and talking to the members 

that are out there and letting them know the services that we have 

and can provide to allow them to come back in if that is allowed. 

So we maximize everything we can. We fill up our appointments. 

But we also focus on the access to care and keep that as a priority, 

to make sure we can get them in. It is not good to advertise services and then not be able to get them to that. 

Captain FREEDMAN. Chairman, I think that this is where the 

MHS and Navy Medicine is particularly well-suited to take care of 

this issue. The nature of our demographics, our beneficiaries, they 

are transient, as well, as they change duty sections or duty stations 

multiple times in a career. We are blessed to have a system of care 

that may be unlike anything else in civilian medicine. Our medical 

records systems talk to each other. So even if they go to one service 

to another or one institution or another, there is some continuity 

in that. 

Patients want to come back to us because we are set up not to 

produce health care but produce health. We are looking at things 

differently. Our remuneration system is different so that we are 

perfectly focused and aligned right now to be able to look at outcomes. Patient-centered care is getting them to partner in their 

own health care. 

And then with generational challenges or generational differences, looking at how access to care is different. What does that 

mean to some of the millennials? We are using our smartphone 

technology. We are using virtual messaging. We have appointments 

that are booked on our providers’ schedule that are just talking to 

patients virtually. Evidence-based research has shown that these 
22 

cohorts of patients that are connected with their doctors do better 

in many of our health metrics. 

Our quality is great, and no one is going to care more than our 

providers. 

Dr. HECK. Colonel Place. 

Colonel PLACE. Sir, I agree with the idea of what is access. I 

think we have to broaden our horizons a little bit and recognize 

that different people want different things, and it all gets lumped 

into this concept of access. Some of them want secure messaging. 

Some of them want to have a nurse advice line; they don’t want 

to come in at all. Others really want to have that face-to-face, doctor-patient touch to happen for them. 

But I think the biggest thing is that our veterans, our retirees, 

and our soldiers and their families, quite frankly, want to be part 

of us. We are the same. You know, we are brothers and sisters in 

arms. They are our families too. So what I am trying to do and I 

think is most important for us to do is to celebrate that, to change 

the culture from, you know, it being difficult to get in to say more 

that we want them here and we embrace each other. 

You know, we have the opportunity—I tell my staff this all the 

time—we have the opportunity to have the best job in the world 

because we get to take care of America’s sons and daughters every 

day. And we get to work with people like us who really care about 

them because most of them have some sort of affiliation with the 

military in some way, shape, or form. Many of them could probably 

make more money going to a different civilian job rather than staying with us. 

So I am really trying to change the culture to say, you know 

what, this is a special place where we do special things for special 

people that makes a difference to our country. And once we start 

having those conversations, my experience has been the retirees 

say, you know what, I will do it, I want to come be part of that. 

And our staff actually celebrates when they do and say, you know, 

‘‘Sergeant Major Retired Jones, we are glad you are back with us 

today. We are happy to provide you care.’’ I think when we do that 

that a lot of those other issues will really go away. 

I was in with the other Representative Heck this morning, and 

he told me, for us, essentially, our complaints about lack of access 

have declined precipitously recently. And I hope that is related to 

some of that culture that we are working on that really changes 

the dynamic, I think, of those interactions. 

Dr. HECK. Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

You know, I think you just sort of capped off, brought together, 

I think, Colonel Place, I mean, you know, what is the problem we 

are trying to solve here. We know that the affiliation is critical and 

combined with culture and tradition and a whole host of other 

things. And, at the same time, we have a lot of stakeholders out 

there who do think that there are some changes that should really 

be made. You have attacked a number of those, I think, over the 

last, you know, few years, and we have certainly seen changes as 

many of our men and women have returned home. We are not in 

the same OPTEMPO [operational tempo] that we were. 
23 

But, you know, if you could change something, if you really felt 

that there is something there that does need to change, not because 

people are critical or because, you know, you think you just have 

to do it because somebody is asking for it, but, you know, is there 

something that really is important? Because, in many ways, I 

think, we come back to arguing the status quo a little bit even 

though that status quo is changing somewhat; it is being defined 

differently. 

But, you know, is that important? I mean, do you think there are 

some things that absolutely should change? 

Colonel PLACE. So, ma’am, let me start this way. I have a fair 

amount of operational background. I was at a combat support hospital in Afghanistan. I was division surgeon, 101st, at the start of 

the war in Afghanistan. So I have seen what happens. I am enormously proud of my colleagues up here and all that we represent 

to achieve that 92 percent survivability rate. When I was in Afghanistan, 98 percent—98 percent of the people that came to us 

alive left us alive. Enormously proud of that, unprecedented in the 

history of war. 

So I would just urge caution before we begin thoughts of changing that system. I think it works pretty well. 

Can it get better? Absolutely, ma’am. I believe that we do need 

to have more trauma, more diversity, complexity, acuity in our system. It is very hard to have complex surgical cases when you have 

young, healthy people. So we need to figure out ways to make that 

happen. But in terms of dramatic changes, no, ma’am, I don’t think 

at this point that I am convinced that that kind of thing is necessary. 

Do we have to have better access? Absolutely. We have two community-based medical homes to try and get to where our patients 

are. We are trying to expand physical therapy at those locations to 

make it more convenient. We have school-based medical homes, or 

school-based health clinics, rather, that we are putting in the middle schools and high schools to actually have the kids get care 

there so they don’t have to come out of school. 

So I think those are all, you know, innovations that are going to 

help us in this process. I think we can do those without wholesale 

change of the system. 

Mrs. DAVIS. Uh-huh. 

Anybody else want to comment on that? 

Just to follow up really quickly, whether or not we have some 

more organized ways of helping, you know, for lack of a better 

term, moonlighting for our men and women to have more formalized connections within communities. There are plenty of communities that do that, but it is more on the initiative of the individual. 

Colonel PLACE. Ma’am, do you want me to answer that or—— 

Mrs. DAVIS. Well, let me just make sure, if you want to just—— 

Colonel HEIMALL. Ma’am, I think, you know, from a moonlighting 

standpoint, that is really great for the physician that goes out and 

is able to practice their trauma skills in a Level I trauma center 

on a weekend or when they are taking leave, but it doesn’t exercise 

the team that takes care of that patient when the surgeon finishes 

in the operating room. The operating room nurses, the ICU nurses, 

the respiratory therapy techs, the folks that manage the blood 
24 

bank and have to get blood into the operating room during that 

case don’t get to practice their skills. 

I think a better model is bring as much of that trauma into the 

doors of our major facilities as possible and co-locate our deployable 

platforms, the combat support hospitals, forward surgical teams, 

the Navy FRSSes [forward resuscitative surgery system] at those 

locations where they can practice those skills every day. But we 

have to be careful in how we do this. 

And I think it gets to Chairman Heck’s question, as well. When 

we make that commitment to a community, whether it is to take 

our surgical teams and embed them in a civilian hospital or to 

promise to provide Level II, Level I trauma care inside our facilities, the next time the kinetic activity in the battlefield picks up, 

are we going to be able to sustain that commitment to the community and to those retirees, family members that we have brought 

back into our system? And we have to be very, very careful that 

we do not overpromise, because the first time we sever that relationship, we lose the trust of those beneficiaries as well as that 

community. 

Mrs. DAVIS. All right. Thank you. My time is up, so maybe we 

will get back later. 

Dr. HECK. Mr. MacArthur. 

Mr. MACARTHUR. Actually, I want to give you a little more time 

to unpack that, because I think that is an interesting idea. And I 

agree with you, but there is a sort of unspoken side to what you 

just said about beefing up these facilities, these major care facilities, and getting all these disciplines there, recapturing care. And 

the other side is the many, many other facilities in the MHS that 

are not of that size. 

And so what do you think has to happen to those? Do they have 

enough critical mass, in your view, to provide value? Or is there 

a different model that should be used in those non-concentrated 

areas? 

Colonel HEIMALL. Sir, I think we are already doing that. I know 

the Army has gone through this recently, at looking at a number 

of their smaller facilities. The MHS modernization report, which I 

don’t think any of us has seen, is still working through staffing in 

the Department and is coming to you for review shortly. 

I think it really becomes location-dependent. Colonel Place and 

I both served at Fort Campbell, Kentucky. I think we would have 

the opportunity and the density to be able to do that at a place like 

Fort Campbell. I think Lejeune is probably a similar size, and so 

I will allow Rick to tell you whether or not he could do that in his 

facility. 

But I think there is a density and a size, and we have to be able 

to look at that from a, first, is it sustaining the readiness capability 

that we need at that location and with those deployable forces, and 

then does it make good business sense for us to be able to provide 

that there. 

Mr. MACARTHUR. While you are talking, I want to follow up on 

my prior question from the last round. And I heard different perspectives from all four of you on how important it is for individual 

facilities to be within a specific branch of the Defense Department. 

You suggested that it is difficult because, if you are in one branch 
25 

or not, you are in a place where you have to do a lot of collaborating with others, and you have to focus heavily on the softer side 

of management, the relationship building, the managing up and 

down and sideways, to get things done that you may lack specific 

authority to get done. 

What qualities, what management qualities, would we need in 

commanders of facilities that we are not—if they were moved—and 

I am not implying we will, but if they were moved to a combined 

medical command as opposed to being aligned within each service, 

what qualities would you need in commanders that have to navigate that world? 

Colonel HEIMALL. Sir, I think you need the same skill set. The 

premium placed on my soft skills, my negotiating skills, consensus 

skills, that I have to use every day at Walter Reed are really not 

much different at all than what I had to do at William Beaumont 

or that I had to do at a much smaller MTF at Fort Riley, Kansas, 

as the commander. 

I think when you have reached the colonel-level command and 

really some of the lieutenant colonel commands, you have got to 

have those soft skills to be able to get done what you need to get 

done. 

Mr. MACARTHUR. Okay. 

Switching to recapturing patients, particularly at some of the facilities where there is enough critical mass to do it, are there any 

specific—and I will look to others of you now—are there specific incentives that we could offer that might encourage people to access 

the MTF instead of private-sector care? 

Captain FREEDMAN. Congressman, I think we are doing a lot of 

those right now. And it may even be on the softer side, of 

incentivizing. With the patient-centered medical home and putting 

the patient in the center of the care, really partnering with them 

and, as my colleagues were talking about, having them being part 

of our mission, we have really brought people back to our institutions, probably each one of us, in unprecedented numbers. We have 

had a 30 percent increase in enrollment at Lejeune. We have doubled the size of our retiree beneficiaries, which has helped with 

acuity in our cases. 

So I think really partnering with them and really discussing the 

benefits of not a fee-based system and doing health care, not just 

leaving with a prescription. There are often questions about why 

don’t we have a big billboard that says, ‘‘Four-minute wait in the 

ER.’’ Now, that is because our ER physicians are phenomenal and 

our ED [emergency department] is great, but that is not patientcentered—— 

Mr. MACARTHUR. Could I ask you to follow up and show the statistics that you are alluding to and then some of the things you 

have done that you believe have caused that recapture. Because 

that is at the heart of one of the things we are looking at. 

I yield back. 

Captain FREEDMAN. We would happy to share that, Congressman. 

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

page 83.] 

Mr. MACARTHUR. Thank you. 
26 

Dr. HECK. Mr. O’Rourke. 

Mr. O’ROURKE. Thank you. 

I wanted to start this second round by just thanking Colonel 

Place for your description of what you do, why you do it, and who 

you do it for. When you finished, I wanted to work for you. And 

I feel like we should approach recruitment for these hard-to-recruit 

specialties—DOD, VA—with that spirit of service and this really 

unique, extraordinary opportunity you have to do something, you 

know, profoundly important for people who are doing really important things for this country. And so, anyhow, I thought that was 

great. 

I wanted to continue with the question I asked and would allow 

anyone who would like to answer it to do so. If a service member 

prior to separation is seeing a therapist every 2 weeks for his or 

her PTSD, is it possible to continue that regimen once they separate? Is that already happening, perhaps? If not, could it? 

And then the second scenario is a veteran who is diagnosed with 

PTSD after their service and is having a hard time gaining an appointment at the VA or a community provider. What is the opportunity to be seen at an Army medical or a military treatment facility? 

And so I will begin with Colonel Heimall, since you were starting 

to answer that, and then anyone else. 

Colonel HEIMALL. Sir, yeah, I was going to say, you know, I am 

very proud of what we were able to do for our Active Duty service 

members at Fort Bliss, from a behavioral health perspective. And 

we had some phenomenal success. We fell well short in what we 

were able to do for our family members and for our retirees, and 

we had to lean very heavily on the civilian community to be able 

to do that. And so what you saw from the Active Duty side was not 

what we were able to provide for everyone else. 

I think we would like to get to a system where we could have 

that continuity. I think the challenge becomes, does the veteran 

stay in the community where they were receiving care when they 

were on Active Duty? Increasingly, in your district, that is happening, but in a lot of districts, there is an out migration, as well, 

and so sustaining the continuity becomes a problem. 

Certainly if we had sufficient capacity at Walter Reed for Active 

Duty family members, retirees, and veterans, we would be reaching 

out to the VISN [veterans integrated service network] five facilities 

and making sure that we were using that capability well. 

Mr. O’ROURKE. Anyone else? 

Colonel PLACE. Absolutely. So, sir, you are welcome to join anytime. We will send you an application. 

So this is a real problem for mental health in particular. I have 

talked to our public health department in Pierce County, and one 

of the concerns that they have is they have one of the lowest per 

capita behavioral health; psychiatrists, psychologists, inpatient 

beds, and so forth. They are trying to fix that. And it is at the same 

time that I am opening a residential treatment facility for substance abuse within Madigan. So we are literally trying to get the 

same people to come to work. And so I am a little concerned, and 

I have expressed that concern, that we are in this competition together. 
27 

Mr. O’ROURKE. How about that specific scenario of a service 

member being treated, they separate, they are still in the community; could they go back and see the same, very same psychologist 

that they saw at your military treatment facility? 

Colonel PLACE. So I can’t answer you right here, sir. I would 

check with our managed care folks. And then probably I think the 

way that I would have to approach that is see whether or not we 

could do secretarial designee for them in order to get them in for 

a short period of time until whatever the crisis was—— 

Mr. O’ROURKE. In other words, it is not a standard operation procedure. It would—— 

Colonel PLACE. No, sir. 

Mr. O’ROURKE [continuing]. Be an exception. 

Colonel PLACE. It would all be an exception of policy for all of 

those. 

Mr. O’ROURKE. Yeah. And I guess my thought is, you know, just 

using the El Paso anecdote again, if the service members with 

whom I have spoken about this say, ‘‘While I was at Fort Bliss, I 

got excellent behavioral health care; if I was supposed to see someone every 2 weeks, I saw them every 2 weeks; when I transitioned 

to the VA, I did not,’’ if you are able to serve, you know, 100 percent of the need in the Active military and some percentage far 

short of that in the VA, could you expand, stretch your capacity a 

little bit to ensure that people are receiving their treatment? Or am 

I hearing you all say that you are at capacity, you cannot spare additional hours? 

Captain FREEDMAN. Congressman, I think that we talk about relationships, and certainly I am proud of the relationships that we 

have established with the VA in our local area. We are partnered 

with the VA Medical Center in Fayetteville and the VA Center in 

Wilmington. 

We have actually embedded a community-based outpatient clinic 

in one of our branch health clinics aboard Marine Corps Base 

Camp Lejeune and started a pilot project at our Wounded Warrior 

Battalion, where we have our most vulnerable marines who are 

transitioning out of the service, and doing a warm handoff right to 

our branch health clinic to see a VA team so we don’t lose them 

in the system, they can have some continuity. And I think that 

that is going to pay great dividends in the future. 

Mr. O’ROURKE. Thank you. 

I am out of time. I will yield back to the chair. 

Dr. HECK. Well, with the panel’s indulgence, we will do something that we haven’t done before, at least in my tenure as chair, 

and that is move to a third round of questions. 

Colonel Heimall, I am really intrigued about the command structure at Wally World [Walter Reed] right now. So you have a director with no command authority, as I understand it, over the personnel within the facility. So who actually does exert command authority over those individuals? And how is that a benefit or a hindrance to the overall operation of the facility? 

Colonel HEIMALL. Sir, I think, first of all, it is important to understand, and to put it into Army terms, the director exercises mission control for the healthcare delivery mission at Walter ReedBethesda. 
28 

We have a very large Army detachment and a very large Navy 

detachment. The special court-martial convening authority that I 

would have normally had as an Army commander, that Colonel 

Place has, resides with an Army troop commander who sits on Bethesda. I see him several times a day normally, and we talk closely, 

particularly on senior NCO [noncommissioned officer] and officer 

issues. And General Becker, the Military District of Washington 

commander, holds the general court-martial convening authority. 

Same thing for the Navy, though now with Rear Admiral Lane 

as the director, Navy Bureau of Medicine and Surgery has delegated UCMJ [Uniformed Code of Military Justice] authority for the 

Navy detachment at Walter Reed and Fort Belvoir to Admiral 

Lane. And so he is able to exercise that for the Navy detachment. 

Our small Air Force detachment, the authorities are over at Malcolm Grow. 

That really is no different than what my experience was as an 

Army MTF commander, where I had a medical chain that really 

had no general court-martial convening authority over my soldiers 

at Fort Bliss. That went through the Fort Bliss commander. 

And so you are constantly building a relationship with your senior commander on your installation and with your higher headquarters to coordinate—you know, is every privileging action on a 

physician an officer misconduct issue? It is not. And so it doesn’t 

need to be in the UCMJ chain. And how do you build that understanding? It is through building the relationship with your senior 

commander and with your medical chain of command. 

Dr. HECK. Okay. Thank you. That is very helpful. 

You know, one of the other issues that we have discussed—again, 

you know, the whole purpose behind this and this series of hearings is in preparation for the MHS study and what does MHS look 

like in the future. And that is why we thought it was critically important to talk to the MTF commanders that are really the foundation upon which MHS is built. 

If you can, just talk a little bit about your staffing models and 

how you figure out how many bodies you need in your facility in 

uniform of given specialties. I would imagine it is based on your 

go-to-war mission and what you are going to need to send forward 

should the balloon go up. 

And how do you balance that with then meeting the needs of 

beneficiaries, you know, when you look at a specific model of having so many in-uniform providers? And your feelings on the substitutions of, well, you know, an OB/GYN [obstetrician/gynecologist] 

can be .5 general surgeon if we move forward, and is that the right 

way to staff for military contingencies. 

I am going to start with Colonel Littlefield, if I could. 

Colonel LITTLEFIELD. Certainly. Yes, sir. 

Again, I come back to the word ‘‘balance.’’ It is something we try 

to look at for the Air Force when we POM [program objective 

memorandum] out or look ahead, years ahead. We try to determine 

what that is going to be and have that ability to provide the care 

to our members. 

But it does start with what our wartime mission is. You know, 

at the end of the day, there is no separation. We are constantly 

keeping people ready; doesn’t matter if it is wartime or not. But if 
29 

our people are deploying, we have to have those people ready to go 

at a moment’s notice and still take care of the people back home, 

as well. 

So I would just say projected out as much as we can, discussions 

with our headquarters, and talking through the benefits that we 

need to provide our community. 

Dr. HECK. So would you say that, you know, you have a certain 

number of uniformed healthcare providers based on your wartime 

mission, and then do you beef that up based on your beneficiary 

population is? Or do you just look to then get in civilian providers 

to take care of the delta? 

Captain Freedman. 

Captain FREEDMAN. Mr. Chairman, much like Colonel Littlefield, 

our OPLANs [operational plans] determine a bit of our manning 

there, with the combatant commanders feeding that information. 

And it is put through what we call MedMACRE, which is Medical 

Manpower All Corps Requirements Estimator. And in that, we 

build a seashore rotation base, a platform for our service men and 

women to rotate overseas, those forward contingencies. And then 

we have the beneficiary mission and the training mission all built 

into that too. 

To get to your question on can we flex to meet the needs in the 

local community, absolutely. We have a great mix of Active Duty, 

as we have talked about from that estimate, but also GS [general 

schedule] and contract staff members, all playing an integral role. 

We have our GSes, our continuity to make sure that when we PCS 

and transition there is someone to provide that continuity of leadership and training for the staff. The contract force can be brought 

in easily to meet mission requirements from our commanders on 

the base or from working with our managed care support contractor in trying to recapture care. 

So we have that base from the OPLANs, and then we have some 

flexibility on the ground as a commander. 

Dr. HECK. Either of the other—anything different from either of 

you in that regard? 

Colonel PLACE. It is remarkably similar. Once we get through 

Total Army Analysis based on the COCOM [combatant command] 

requirements, we go through a human capital distribution program 

that then allocates out the uniformed members. And then, after 

that, we preferentially go to GS. And then, when we need to, based 

on, you know, time, how long you need to have it, how quickly, and 

so forth. So we do the analysis based on that to follow it up. 

Colonel HEIMALL. Sir, I think the challenge we have at Walter 

Reed, as I have learned over the last 5 months, is we are dealing 

with three different staffing models. And we somehow—everybody 

thinks theirs is perfect. I think there are some really great things 

about each of the services’ staffing validation models. 

The challenge is—and DHA has been very, very supportive in 

helping us work through this—is how do we find the right one to 

support what we are doing and demonstrate to the services that 

their military staff assigned to us are really getting the competencies and skills sustainment that they need when they go back 

out to a smaller service platform or when they deploy with their 

service. 
30 

Dr. HECK. Great. Thank you. 

Mrs. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

And perhaps I will give Captain Freedman and Colonel Littlefield, if you have something you would like to add to the discussion 

of: What should change? What would you like to see? 

Captain FREEDMAN. Thank you, Ranking Member Davis. When 

you had asked that question, I had hoped to get to answer it. Because when we talk about change, I am truly excited to be living 

that change right now, as we look at changing from providing 

health care to health and bringing patients involved in making decisions. When we are looking at outcomes, we are not looking at 

productivity models but really getting our populations healthier, 

which, in the long run, is going to provide a cost-benefit and it is 

going to be a more able fighting force. 

It is truly an exciting time in medicine but particularly in military medicine and MHS as we lead the charge on some of these initiatives. 

Mrs. DAVIS. Thank you. 

Colonel. 

Colonel LITTLEFIELD. Ma’am, I would concur. I would say the 

focus on prevention, as opposed to taking care of it after the fact, 

an injury or medical condition; educating the patients on the importance of that, and not just the Active Duty members but the 

families, the retirees, and just placing the importance on how much 

more you can save doing that. And the access to care can become 

an important factor in that, as well, too, when you may not have 

to rush in to get an appointment if you are taking care. 

So I would just say the education on prevention. 

Mrs. DAVIS. Great. Thank you. I appreciate that. And we are seeing a lot of those changes. 

Just very quickly, one of the concerns that was expressed here 

at one point was, shouldn’t we have fewer OB/GYNs and more 

trauma surgeons? You all mentioned—I think most of you mentioned in your remarks that, you know, obviously, that preponderance of physicians are really helping to deliver babies, which is a 

good thing. But what do you say to people when they say, shouldn’t 

they be doing that in the community? 

Colonel PLACE. Well, I would frame it a little bit differently, 

ma’am, if I could. I think we have to make sure that we have a 

broad perspective. You know, we have to respond to all things. So 

Ebola, a great example. We have professionals whose full-time job 

is to look at those kinds of tropical and emerging diseases and so 

forth. We have folks that specialize in disaster management. So 

there are a lot of other things that, frankly, the Nation is going to 

ask us to do, and we have to be prepared to do that. 

So I always become concerned when we talk about trauma management, and that is the coin of the realm for what we talk about, 

when most of the care that gets provided in theater is not. I am 

a family physician, so most of what gets done is what I do. And 

every now and then, we go do some trauma too. 

Being a combat support hospital commander in Helmand province with our British colleagues at Camp Bastion and so forth, I 

understand trauma and I understand how important it is to do 
31 

that well. But there are a lot of other things that we have to be 

very good at. 

So I would just urge caution if we say that the thing that is important is trauma, because that is going to leave us a shortfall in 

a lot of other things. 

Colonel HEIMALL. And, ma’am, I think that is one of the things 

that really makes military medicine unique compared to a civilian 

healthcare system. Increasingly, as Ms. Tsongas pointed out, larger 

numbers of women serving in our force. One of the things that we 

are seeing is an increase in the number of new cancer diagnoses 

among our forces every year. A portion of those are gynecological 

cancers. It gives us an opportunity to be able to manage that from 

a readiness perspective with those providers and our force. 

As Colonel Place said, he is a family physician. Oftentimes, the 

first physician that a wounded soldier or sailor or service member 

sees on the battlefield is going to be a pediatrician or a family physician or a cardiologist who is in a battalion aid station. 

We ask those providers to go through advanced trauma life support and tactical combat casualty care, and then we ask them to 

actually execute that on the battlefield. Our civilian counterparts 

do not do that with their pediatricians and their cardiologists and 

their internists. 

Mrs. DAVIS. Right. Yeah. 

Captain FREEDMAN. And I would like to point out that taking 

care of families impacts readiness. It is not just a benefit. This 

truly impacts the readiness of our Nation. I bring our commanding 

generals from Marine Corps Base Camp Lejeune to our centering 

room for pregnancy so he can see what happens to the family members, because that is truly a concern of his because he knows that 

impacts readiness. So I think that that is important. 

And the other piece that we do incredibly well in military medicine is as providers to give disposition to the line commanders. 

That doesn’t happen in the civilian communities. You can get a diagnosis, but a disposition—does this marine or sailor or soldier, airman, do they need to be on light duty? Can they carry a weapon? 

Can they do their mission? You can’t learn that overnight. That 

has to be brought up in the system. So I think we are very proud 

to be able to do that. 

Mrs. DAVIS. Thank you. 

Thank you all. 

Thank you, Mr. Chairman. 

Dr. HECK. Thanks. 

All right. I have one last question. 

Captain Freedman, you talked about some of your innovative access programs, whether it is using a smartphone or your advice 

line. Is that a best practice through BUMED [Bureau of Medicine 

and Surgery], or is that something you are just doing at your facility? 

Captain FREEDMAN. Thank you, Chairman. 

It is actually brought by Navy Medicine to innovate—and that is 

what is great about our system—through our regional commands 

to share best practices with each other. So we are not the only 

MTF to have a smartphone application. We have an incredible 
32 

number of downloads, over 6,000 right now, and patients are actually using them. 

So we learn from each other, but it is not—even though we developed it at Camp Lejeune, it is something that we share throughout 

the services. 

Dr. HECK. So it populates amongst the tri-service community, not 

just within Navy Medicine. 

Captain FREEDMAN. Well, the innovation, I mean, it is an individual application for our facility. But the concept is something 

that we share throughout Navy Medicine. And I think it is going 

to really, I mean, I am sure, as you are aware, will change the way 

that we deliver medicine in 5 or 10 years from now. 

Dr. HECK. Yeah. 

Colonel Place, you got something you want to add there? 

Colonel PLACE. Yes, sir. I would add I know of at least two Army 

facilities doing the same thing, that have created similar apps. And 

we have talked; as commanders, we get together and have opportunities to discuss. 

So, yes, I think we do a pretty good job overall within the services of innovating, to try and keep up with what the expectations 

are from our beneficiaries. I think that is important that we do 

that and they become best practices and then we disseminate them 

out. So that whole knowledge management piece is important, I 

think, within the services, and I think we are doing much better 

at that. 

Dr. HECK. Great. 

Well, again, I want to thank all of you, the four of you, for taking 

the time and hanging here in this very hot room for an hour and 

a half and through three rounds of questions. 

I found the information very insightful and helpful as we try to 

tackle the MHS reform study, when and if we get it, but certainly 

in looking forward of how we make the military healthcare system 

meet its vision of having a dual readiness mission of making sure 

we have ready healthcare professionals to deploy and we keep our 

force ready to deploy. 

So, again, thank you all very much. 

And, Mrs. Davis, thanks for staying so long. I know it has been 

a long one. 

And we will be adjourned. 

[Whereupon, at 3:37 p.m., the subcommittee was adjourned.] 
A P P E N D I X 

FEBRUARY 3, 2016 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

FEBRUARY 3, 2016 

(37) 
38 
39 
40 
41 
42 
43 
44 
45 
46 
47 
48 
49 
50 
51 
52 
53 
54 
55 
56 
57 
58 
59 
60 
61 
62 
63 
64 
65 
66 
67 
68 
69 
70 
71 
72 
73 
74 
75 
76 
77 
78 
79 

WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

FEBRUARY 3, 2016 

(83) 

RESPONSE TO QUESTION SUBMITTED BY DR. HECK 

Colonel PLACE. Prior to 1995, no Level 2 trauma centers supported Tacoma and 

Pierce County. All major trauma victims were transported to Seattle, Washington 

or Portland, Oregon. In 1995, Madigan Army Medical Center (MAMC), was approved and received full Washington state designation as the only Level 2 trauma 

center serving the Tacoma area. From 1997–2000, MAMC worked with civilian 

health systems to establish civilian Level 2 trauma centers in Tacoma. The Tacoma 

Trauma Trust was formed in 2000 and established two civilian Level 2 trauma centers to serve Tacoma and Pierce County. Trauma duties are split between two civilian hospitals, St. Joseph Medical Center and Tacoma General Hospital, alternating 

coverage every other day. MAMC accepts trauma patients every day. [See page 9.] 

RESPONSE TO QUESTION SUBMITTED BY MR. MacARTHUR 

Captain FREEDMAN. Thank you for your question and the opportunity to provide 

additional information. One of the key components of readiness is to ensure that we 

hone, train and sustain the clinical skills of our providers. An important element 

of that strategy is ensuring we have the right mix of patients with the appropriate 

level of medical complexity to maintain the currency of skills for our entire clinical 

staff. To help achieve this at Naval Hospital Camp Lejeune, we focused on the enrollment of our eligible retired and retiree family member beneficiaries. 

Our multi-phased recapture efforts began with a concentrated and sustained informational exchange campaign outlining our strategy. Our team employed multiple 

information pathways to include our command’s Facebook page, Marine Corps Community Services and Base website releases, Family Readiness Office exchanges and 

community media outlet notifications to inform our retiree population of our plan 

and solicit their partnership. Our hospital is an active and pivotal part of our community and my leadership team and I participated in multiple events to encourage 

retiree participation and enrollment. These events occur throughout the year and 

included retiree town halls, the annual retiree appreciation fair, Regiment of Retired Marines Breakfast, Disabled American Veterans Gatherings, USO/VFW 

events, Chamber of Commerce, Military Affairs Committees meetings, and regional 

TRICARE benefit briefings. 

On the administrative front, we directed policy changes to open enrollment to the 

retiree population within a 30 minute drive time to Camp Lejeune. We focused on 

service members and families transitioning from active duty and automatically enrolled all who selected TRICARE Prime and resided within the Prime Service area, 

or PSA. Additionally, we invited retirees currently receiving care in the network to 

change their enrollment to NH Camp Lejeune, sending a retiree invitational letter 

to 7,702 eligible beneficiaries in the PSA. 

As a direct result of these efforts, we have had a 100 percent increase in the number of enrolled retiree and retiree family members, growing from 3,861 in January 

2014 to an all-time high of 7,891 enrollees as of January 2016. Through this reengagement, we have been able to meet our commitment to ensuring the readiness 

of our medical staff, attracting and retaining the best clinicians while expanding our 

clinical capability and service to the operational forces assigned to Marine Corps 

Base Camp Lejeune and the local community. Perhaps most importantly, we have 

re-affirmed our commitment to serving the most deserving men and women in the 

world, those who have worn the cloth of our nation and the families who support 

them. [See page 25.] 

Æ