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36–999 PDF 2007

IS THIS ANY WAY TO TREAT OUR TROOPS? PART

II: FOLLOW-UP ON CORRECTIVE MEASURES

TAKEN AT WALTER REED AND OTHER MEDICAL FACILITIES CARING FOR WOUNDED SOLDIERS

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY

AND FOREIGN AFFAIRS

OF THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

APRIL 17, 2007

Serial No. 110–16

Printed for the use of the Committee on Oversight and Government Reform

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.oversight.house.gov

(II)

COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

TOM LANTOS, California

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

——— ———

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

DAVID MARIN, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY AND FOREIGN AFFAIRS

JOHN F. TIERNEY, Massachusetts, Chairman

CAROLYN B. MALONEY, New York

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

CHRISTOPHER SHAYS, Connecticut

DAN BURTON, Indiana

JOHN M. MCHUGH, New York

TODD RUSSELL PLATTS, Pennsylvania

DAVE TURK, Staff Director

(III)

C O N T E N T S

Page

Hearing held on April 17, 2007 .............................................................................. 1

Statement of:

Dominguez, Michael L., Principal Deputy Under Secretary of Defense

(Personnel and Readiness), U.S. Department of Defense; Major General

Gale S. Pollack, Army Surgeon General (acting) and Commander, U.S.

Army Medical Command (MEDCOM); and Major General Eric

Schoomaker, Commander, Walter Reed Army Medical Center ................ 52

Dominguez, Michael L. ............................................................................. 52

Pollack, Gale S. .......................................................................................... 72

Schoomaker, Eric ....................................................................................... 86

West, Togo D., Jr., former Secretary of Veterans Affairs and former

Secretary of the Army; Jack Marsh, former Secretary of the Army;

Arnold Fisher, senior partner Fisher Brothers New York and chairman

of the Board for the Intrepid Museum Foundation; Lawrence Holland,

senior enlisted advisor to the Secretary of Defense for Reserve Affairs;

Charles ‘‘Chip’’ Roadman, former Air Force Surgeon General; and General John Jumper .......................................................................................... 17

Marsh, Jack ............................................................................................... 19

West, Togo D., Jr. ...................................................................................... 17

Letters, statements, etc., submitted for the record by:

Davis, Hon. Tom, a Representative in Congress from the State of Virginia, prepared statement of ........................................................................ 15

Dominguez, Michael L., Principal Deputy Under Secretary of Defense

(Personnel and Readiness), U.S. Department of Defense, prepared

statement of ................................................................................................... 54

Pollack, Major General Gale S., Army Surgeon General (acting) and

Commander, U.S. Army Medical Command (MEDCOM), prepared

statement of ................................................................................................... 75

Shays, Hon. Christopher, a Representative in Congress from the State

of Connecticut:

Prepared statement of ............................................................................... 12

Various bills ............................................................................................... 95

Tierney, Hon. John F., a Representative in Congress from the State

of Massachusetts, prepared statement of ................................................... 5

West, Togo D., Jr., former Secretary of Veterans Affairs and former

Secretary of the Army, and Jack Marsh, former Secretary of the Army,

prepared statement of ................................................................................... 21

(1)

IS THIS ANY WAY TO TREAT OUR TROOPS?

PART II: FOLLOW-UP ON CORRECTIVE

MEASURES TAKEN AT WALTER REED AND

OTHER MEDICAL FACILITIES CARING FOR

WOUNDED SOLDIERS

TUESDAY, APRIL 17, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON NATIONAL SECURITY AND FOREIGN

AFFAIRS, COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 10:05 a.m. in room

2154, Rayburn House Office Building, Hon. John F. Tierney (chairman of the subcommittee) presiding.

Present: Representatives Tierney, Yarmuth, Braley, McCollum,

Cooper, Van Hollen, Hodes, Welch, Shays, Burton, Turner, and

Foxx.

Also present: Representative Cummings and Delegate Norton.

Staff present: Brian Cohen, senior investigator and policy advisor; Dave Turk, staff director; Andrew Su and Andy Wright, professional staff member; Davis Hake, clerk; David Marin, minority

staff director; A. Brooke Bennett, minority counsel; Grace

Washbourne, minority senior professional staff member; Nick

Palarino, minority senior investigator and policy advisor; and Benjamin Chance, minority clerk.

Mr. TIERNEY. Good morning, everyone.

A quorum being present, the Subcommittee on National Security

and Foreign Affairs’ hearing entitled, ‘‘Is This Any Way to Treat

Our Troops? Part II,’’ will come to order.

I ask unanimous consent that only the chairman and ranking

member of the subcommittee make opening statements. Without

objection, so ordered.

I ask unanimous consent that the hearing record be kept open

for 5 business days so that all members of the subcommittee will

be allowed to submit a written statement for the record. Without

objection, so ordered.

I ask unanimous consent that the following written statements

be placed on the hearing record: Dr. Allen Glass, a military physician who has worked at Walter Reed for 20 years; Gary Knight, a

former patient at Walter Reed; Patrick Hayes, a police officer who

has worked at Walter Reed for almost 20 years; Dr. Richard Gardner, who worked at Winn Army Community Hospital at Fort Stewart in Georgia; Specialist Stephen Jones, an Iraqi veteran; and CorVerDate 11-MAY-2000 12:35 Aug 15, 2007 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\36999.TXT HGOVREF1 PsN: HGOVREF1
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poral Steve Schultz and his wife, Debbie. Without objection, so ordered.

I ask unanimous consent that the gentleman from Maryland,

Representative Cummings, and the Delegate from the District of

Columbia, Representative Eleanor Holmes Norton, members of the

full Oversight and Government Reform Committee, be permitted to

participate in the hearing. In accordance with our committee practices, they will be recognized after members of the subcommittee.

Without objection, so ordered.

We will proceed to opening statements.

I want to just say good morning to everybody here on the panel

and all of our witnesses on both panels here today. On March 5th,

you will recall that this subcommittee convened our first ever hearing on the care of wounded soldiers at Walter Reed Army Medical

Center. I think it is fair to say that all of us were appalled by the

heart-wrenching stories from Staff Sergeant Dan Shannon, Annette

McCleod, and Specialist Jeremy Duncan. They spoke of living with

mold, being lost in the bureaucratic abyss, and being treated with

a shameful lack of respect.

But their stories are not, unfortunately, isolated incidents. After

our first hearing, we created a special hotline, an e-hotline. We

heard from hundreds of people, and the problems went well beyond

Walter Reed.

A doctor who had come out of retirement to help out at Winn

Army Community Hospital at Fort Stewart, GA, said that there

they were understaffed, overextended, and ‘‘much worse than at

Walter Reed.’’

A soldier who fought in both Gulf wars spoke of cuts in the soldier advocate program at Darnall Army Medical Center in Fort

Hood, Texas, and that traumatic brain injury patients were being

un- or under-diagnosed.

Someone at 29 Palms Marine Base witnessed examples of post

traumatic stress disorder going undiagnosed, untreated, and purposefully ignored to return soldiers to active duty. She told us

about one navy psychiatrist who said ‘‘clearly he did not believe in

PTSD.’’

We also, unfortunately, heard additional troubling stories about

Walter Reed.

A 20-year police veteran there wrote of cockroaches and mice at

their police station. He also wrote, ‘‘The [police] station is not

handicapped accessible, which is ironic considering we have a large

number of handicapped veterans here that may need to come to our

station for police services.’’

A Walter Reed JAG lawyer spoke of a broken disability review

process that under-rates wounded soldiers, a system in which there

were only three JAG officers and one civilian counselor available

to represent all wounded soldiers at Walter Reed; a system so overburdened there was no time to get an outside medical opinion or

to adequately prepare for these absolutely vital hearings.

We also heard in the media about computer programs that can’t

talk to each other, a growing backlog of VA disability claims, and

egregious allegations of still-injured soldiers being returned into

battle.

3

At our March hearing, with the committee’s support, I made the

commitment that this subcommittee would perform sustained and

aggressive oversight, and as a first step we would followup with a

hearing in 45 days.

Today marks the 43rd day, and I hope we will hear across the

board from our witnesses that the Department of Defense acknowledges the seriousness and pervasiveness of these problems; that we

are rapidly fixing the broken bureaucracy, knocking down the institutional walls across the services and with the VA Administration,

and ensuring that each soldier and his or her family is treated with

the utmost respect. That is what we hope we can hear.

We will hear today from the Independent Review Group, led by

distinguished former Army Secretaries Togo West and Jack Marsh.

Their report, released yesterday, examines the problems at Walter

Reed and elsewhere and offers a series of recommendations.

I want to thank all of the IRG members and your staff for your

work, and welcome those members here with us today. I don’t

know if staff is here or not. At some point you may want to acknowledge them. They certainly did a great job, as did you, and we

are really indebted to them and you for your service.

As I suspect all these members will likely agree, we have heard

many, if not the vast majority, of these findings and recommendations from testimony before Congress, from the Government Accountability Office auditors, even from the President’s own 2003

Task Force to Improve Health Care Delivery for Our Nation’s Veterans. But the problems have not yet been fixed.

In February, this subcommittee asked the Defense Department

for documents on the problems at Walter Reed. These documents

show a rash of complaints about the now-infamous Building 18, including mold, mouse droppings, roaches, and flea bites so severe

they required medical attention.

There is a slide over there that indicates one of the complaint

forms that we received.

What is shocking is that these documents don’t recount the recent problems that were exposed by the Washington Post in February. What is remarkable is that these complaints happened in

the summer of 2005, well before the Post investigation. The documents show that, as a result, Building 18 was shut down. In the

words of the Walter Reed Inspector General at that time, ‘‘Building

18 was not up to standards for occupancy, and it has been temporarily evacuated of all personnel.’’

But then Building 18 was reopened. Specialist Jeremy Duncan

and others moved in; and inexplicably the same exact thing happened again.

I hope that we don’t do here with respect to the broader problems

identified by the IRG Group and others is to ‘‘Building 18’’ them;

that is, to simply paint over the problems. We literally and figuratively need to knock down some walls, to roll up our sleeves, and

to work together to completely overhaul the disability ratings process and to figure out how best to deal with traumatic brain injuries. Put simply, we need to tackle head-on the most difficult problems instead of once again simply covering them over with halfmeasures.

4

The fundamental question we all have to ask ourselves now is:

what is going to be different this time around in order to actually

solve these problems?

I am encouraged that the Independent Review Group has assigned specific responsibility to specific officials for specific recommendations, so that 2 years down the road officials can’t just

claim that solving a certain problem was somebody else’s responsibility.

Many of those who will be responsible and accountable going forward will testify on our second panel today. What I want to know

is very simple: what is going to be different this time around under

your watch to solve these problems once and for all?

Be assured that as you continue your work, this committee will

be right there with you—offering constructive advice and support

where helpful, but also ready to hold people accountable where necessary.

Our mutual goal of ensuring the proper care and respect for each

patient at each step of the recovery process demands nothing less.

The American people don’t want to hear any excuses or empty

promises. Our Nation’s soldiers and their families deserve better.

These are difficult challenges and it will take our cooperative efforts, all of us working together, to make sure that this broken system is fixed, fixed quickly, and fixed permanently.

I recently led a bipartisan congressional delegation to Afghanistan and met with our soldiers there, including some from our

Commonwealth of Massachusetts, a young man from Waltham,

MA, there on the monitors. If, God forbid, any one of them gets injured, they deserve to come home to a hero’s welcome and to the

best care and utmost respect we can give them, not to a building

with mold and mouse droppings, not to a maze of impenetrable bureaucracy, and not to a system that works against the very soldiers

it should be supporting. That, to me, and I think to members of

this panel, is the job that faces us today.

[The prepared statement of Hon. John F. Tierney follows:]

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Mr. TIERNEY. Mr. Shays.

Mr. SHAYS. Thank you very much, Mr. Chairman and my colleagues. Mr. Chairman, I thank you for your commitment to this

subcommittee’s bipartisan inquiry of medical care for our men and

women returning from war. If an American injured on the battle

field in Afghanistan or Iraq arrives quickly to a major surgical facility, the chances are he or she will be kept alive. If the wounded

are transferred to Walter Reed Hospital, the medical care they receive is unparalleled.

But it is after the soldier is treated and then transferred into

outpatient care that breakdowns occur, both in the delivery of outpatient services and with the outpatient facilities, themselves. We

have seen the deplorable conditions of Building 18 and the Byzantine bureaucracy through which wounded warriors and their families are subjected.

These breakdowns, in and of themselves, do not define the medical care offered at Walter Reed; however, they are clear indications

of systemic failings in the outpatient program. No one should have

to live in conditions like those reported in Building 18, and it goes

without saying that an outpatient should be treated with the same

care and focus as an in patient. The medical treatment of our

wounded warriors is non-negotiable, and our servicemen and

women have earned the right to a continuum of care that sets

standards.

Central to the military creed is the promise to leave no soldier

or Marine on the battlefield, but by subjecting our recovering soldiers and their families to appalling outpatient conditions we have

done just that. We have failed in our responsibility to ensure the

care of our brave men and women, and our task today and into the

future is to ensure our war wounded are being cared for completely

and for as long as they need care.

This committee’s oversight into these matters, which started

under Chairman Tom Davis, has been long and protracted. We

have heard excuses and promises of improvements, promises of

changes, and promises that this time things are really going to get

better. What is different is the imprint of the graphic representations of Building 18 and the accompanying calls for action have

forced action.

We want to hear what actions to correct these failings have been

taken and what actions are planned. We also want to hear what

we collectively need to do to ensure this does not happen in the future.

The Wounded Warrior Assistance Act of 2007, which was passed

unanimously out of the House, provides a good start toward the

comprehensive reform of military medical programs, but it does not

go far enough. Toward that end, a number of us advocated for comprehensive legislative proposals designed to streamline processes

for our war wounded and their families caught in the Department

of Defense’s never-ending bureaucratic maze. These proposals were

based on the work of this committee and subcommittee and were

vetted through patients we have helped in the past. These proposals included establishing medical holdover, MHO, process reform

standards to create comprehensive oversight of all military medical

facilities, patients, and hospital staff, and a patient navigator’s proVerDate 11-MAY-2000 12:35 Aug 15, 2007 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 C:\DOCS\36999.TXT HGOVREF1 PsN: HGOVREF1
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gram where independent navigators serve as representatives for

patients and families.

Our committee should support legislation supporting a DODwide ombudsman to assist wounded military and their families 24/

7 and establish the standard soldier patient tracking system to

help family members, installation commanders, patient advocates,

or ombudsmen office representatives locate any patient in the medical holdover process.

We look forward to hearing other solutions today. We view this

hearing as an opportunity to identify the best possible policies and

legislation as required to rehabilitate Walter Reed. Goodwill and

faith in our military medical system will be replenished not by excuses and promises but by solutions and actions. We support you,

General Schoomaker, and each of our witnesses in this process.

Nearly 150 years ago Abraham Lincoln closed his second inaugural address with the following words: ‘‘Let us strive on to finish

the work we are in, to bind up the Nation’s wounds, to care for him

who shall have born the battle, and for his widow and his orphan.’’

To care for him who shall have born the battle, such was our duty

150 years ago and remains our duty today.

I look forward to our witnesses’ testimony today and thank each

of them for their hard work over the past few months.

Thank you, Mr. Chairman.

[The prepared statement of Hon. Christopher Shays follows:]

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Mr. TIERNEY. Thank you, Mr. Shays.

We are going to hear testimony from our panel at this point in

time, but I want to begin by introducing the witnesses on our first

panel who look to be almost all of the entire Independent Review

Group. A few are missing. Two are missing, Mr. Schwartz and one

other.

I am going to introduce them in the order in which they are sitting to help people.

To my far left is Mr. Lawrence Holland, senior enlisted advisor

to the Secretary of Defense for Reserve Affairs. Next is the Honorable Jack Marsh, the former Secretary of the Army, who is the cochair of the IRG; Togo West, former Secretary of the Army and

former Secretary of Veterans Affairs, the other co-chair of the IRG;

Mr. Charles Chip Roadman, formerly an Air Force Surgeon General. We have Arnold Fisher, the senior partner of Fisher Brothers

New York and chairman of the Board for the Intrepid Museum

Foundation, amongst other responsibilities; and last General John

Jumper, General, the U.S. Air Force, retired, who was the Chief of

Staff of the Air Force from 2001 to 2005.

I want to welcome all of you and thank you again for the work

that you have done and the report entitled, Rebuilding our Trust,

which is a significant piece of work, considering we only had about

43 or 45 days to do it.

It is the policy of the subcommittee to swear you in before you

testify, so I ask you to please stand and raise your right hands. If

there is anybody else who is going to be asserting answers to any

of your responses, I ask that they also stand and be sworn in.

[Witnesses sworn.]

Mr. TIERNEY. Note that the witnesses answered in the affirmative.

I understand that one of two of you will be giving a single opening statement. I remind you that our opening statements are generally about 5 minutes. We won’t hold you exactly to that line, but

if you would summarize it to 5 minutes then we will have more

time to ask questions and elicit as many responses as we can.

Mr. SHAYS. Mr. Chairman, before we begin could I just insert in

the record the statement of Tom Davis, who is visiting with family

because of the horrific tragedy yesterday at the campus in Virginia.

So he has a statement, and I would like to submit that for the

record.

Mr. TIERNEY. Without objection. Thank you.

[The prepared statement of Hon. Tom Davis follows:]

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Mr. TIERNEY. Secretary Marsh will start.

STATEMENTS OF THE INDEPENDENT REVIEW GROUP CHAIRMEN AND MEMBERS: TOGO D. WEST, JR., FORMER SECRETARY OF VETERANS AFFAIRS AND FORMER SECRETARY

OF THE ARMY; JACK MARSH, FORMER SECRETARY OF THE

ARMY; ARNOLD FISHER, SENIOR PARTNER FISHER BROTHERS NEW YORK AND CHAIRMAN OF THE BOARD FOR THE INTREPID MUSEUM FOUNDATION; LAWRENCE HOLLAND, SENIOR ENLISTED ADVISOR TO THE SECRETARY OF DEFENSE

FOR RESERVE AFFAIRS; CHARLES ‘‘CHIP’’ ROADMAN,

FORMER AIR FORCE SURGEON GENERAL; AND GENERAL

JOHN JUMPER

STATEMENT OF TOGO G. WEST, JR.

Mr. WEST. There are two of us that will give statements, but we

will meet your 5 minute requirements.

Mr. TIERNEY. I have read your statements. I think you can do it.

If you have to go over, go right ahead.

Mr. WEST. Thank you.

I would like to add that seated immediately behind us in the first

row is Rear Admiral retired Kathy Martin, former Deputy Surgeon

General of the U.S. Navy and a member of our panel. She stood

for the swearing in.

Mr. Chairman, members of the committee, let me offer just a few

comments with respect to our report and to what we at the IRG

did.

Walter Reed Army Medical Center bears the most distinguished

name in American military medicine. It and its colleague to the

north, the National Medical Center at Bethesda, set the standard

for DOD medicine. Our review suggests, however, that, although

Walter Reed’s rich tradition of flawlessly rendered medical care of

the highest quality, as you have pointed out, remains unchallenged, its highly prized reputation has, nonetheless, been justifiably but not irretrievably called into question in other respects.

Fractures in its continuum of care and support for its outpatient

service members have been reported and are being reviewed. We

have reviewed them.

Failures of leadership virtually incomprehensible, in attention to

maintenance of non-medical facilities, and a reportedly almost palpable disdain for the necessity of continuing support for patients

and their families have led the growing list of indictments against

this once and still proud medical facility.

Our recommendations cover a wide range. I have tried to lump

them into four quick questions. Firstly, who are we as a country,

as a military, as health care centers here in the Nation’s Capital?

Unfortunately, if one considers the reports you and we have received from service members and their families, we would conclude

that we may be answering that question in ways that are not attractive to us as military services or as a Nation. We say much

about ourselves by the attitudes we display toward those who look

to this Nation for support at their most vulnerable time.

A number of findings and recommendations involving the assigning and training of case workers, increases in the numbers of case

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workers, adjustment of the case-worker-to-patient ratio, assignments of primary care physicians, and attention to the nursing

shortages consequently have been included in our report.

Second, who are we and what are we to become? The base realignment and closure process and the A–76 process have caused

incalculable dislocations in Walter Reed operations, and they

threaten the future of both installations.

We concluded that BRAC should proceed for a host of reasons,

but we also concluded that the transition process is lacking, important coordinating efforts between the two installations need to be

improved, and increased pace for the transition is urgently needed.

Third, how are our service members doing? At every turn we encountered service members, families, professionals, thoughtful observers who pointed out the impact of TBI, traumatic brain injury,

and PTSD, post traumatic stress disorder, and how challenging

they have become, challenging in terms of DOD and Department

of Veterans Affairs diagnosis, evaluation, and treatment, challenging in terms of the ability of our system to respond to them.

We offer detailed recommendations with respect to both a center

of excellence for the treatment, research, and education with respect to these challenges, and increased attention to cooperative efforts by both Cabinet departments.

And finally, fourth, how long? The IRG has operated with what

is, for me, a rare sense of unity and cooperation for organizations

of this sort. But if there is one thing that we are most unified on,

it is the need to put the horrors that are inflicted upon our service

members and their families in the name of disability review and

determinations, bring those horrors to an end.

So our recommendations are several, but our thrust is one, and

that is that the process needs to become one single process.

It is no surprise to you nor to us that Government and its various parts can offer rationalizations, good ones, in fact let me say

reasonable arguments as to why each part of that process needs to

be reserved for a specific purpose, but we are a Nation that values

the sense of common Americans. We call it common sense, and

common sense tells us that, from the patients and the service member and the families’ point of view, it is an incredible maze.

Thus, virtually every finding leads back to those four things:

leadership and attitude; the transition from Walter Reed Army

Medical Center to Walter Reed National Military Medication Center; the extraordinary use of IEDs—improvised explosive devices—

and the current wars in the current two areas of conflict, and their

impacts on the brains and psyches of our service members; and the

longstanding and seemingly in tractable problem of reforming the

disability review process.

To be sure, it was the degradation of facilities that first caught

the eye of media reporters, but that is not our bottom line at the

Independent Review Group. That bottom line is this: we are the

United States of America. These are our sons and daughters, our

brothers and sisters, uncles, and an occasional grandparent or two.

We can and must do better.

Thank you.

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STATEMENT OF JACK MARSH

Mr. MARSH. Mr. Chairman, thank you for conducting this hearing. It is very, very important. All of the departments, all of the

services have been extremely cooperative in assisting us in this review, and members of our panel are very outstanding resource people, and some of your questions really should go to them, because

they have backgrounds in medicine and hospital management and

areas that we do not have.

So we have had great experience and help from the Department,

and I would tell you that under the leadership of the new commander at Walter Reed, General Schoomaker, who is here, and the

new Acting Surgeon General, Gale Pollack, I think you are going

to see some real progress.

But, by way of background, I am a veteran of World War II,

served and retired as a National Guard officer in the Virginia

Guard, former Member of the U.S. Congress from Virginia. Both of

our sons were called to active duty and took part in combat operation in the Persian Gulf. Our oldest son, a doctor, was a surgeon

for the Delta Force, and was severely wounded in Mogadishu, but

it gave us an insight to what families must go through in these circumstances and how important it is.

We also saw the magnificent medical care that our son received,

and also I am eternally grateful to the U.S. Air Force for the airlift

capabilities that they have. Go down to Andrews some evening

when one of the cargo flights carrying people come in these litters

and you will come away with an enormous admiration and respect

for our medical community and the Air Force.

I make a point of that because I believe there is a part of the

American ethic, and that American ethic is that America takes care

of its wounded. I knew that when I was in the service, myself, I

have seen it since, and I observed it, as did Togo when he was Secretary of the Army. Incidentally, he brought to our panel an enormous capability in his background with the Veterans Administration. Veterans Affairs has been exemplary and very, very helpful.

You are focusing on families, and I encourage you to do that, not

just to the active, but focus on the Guard and Reserve. Their family

support systems are different, and it also imposes different requirements.

It has been said that at Walter Reed it was a confluence of circumstances that became the Perfect Storm. The combination of A–

76, the requirement to contract out some 300 plus jobs, it took over

5 years to address. So we had not only A–76, you had the BRAC.

Then you had enormous increase of the number of casualties. So

it came into a confluence in a way that was very difficult to deal

with.

There are problems that you have identified and which you hear

on the disability evaluation system. The standards are not clear inside the Army, and they are not clear between the Army and the

Air Force or with the Navy or with the Department of Defense. The

medical community in many areas is in a sea of bureaucracy and

red tape that is creating enormous problems for these service people. If you want to move quickly, move there. Look at that red tape,

the bureaucracy.

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There is beginning to develop problems in recruiting for the medical community. I would suggest you also look at amending the

statute that permits the recruitment of doctors who are over 50 but

do not impose on them the 8 year obligation rule. It is a rare opportunity to avail yourselves and the armed services of the kind of

medical attention they need and deserve.

Now, finally, as a Member of the Congress at one time I am

aware that only the Congress of the United States can fix and address the real systemic problems that we are looking at here. I suspect that the systemic problems that have been evidenced at Walter Reed you are going to find evidenced in other places. It was not

our task to look at those, but I think they were there.

But the Congress has the constitutional authorities, article 1,

section 8, to raise the Army’s and Navy’s and to provide and maintain their support. Please, I beg of you, have the commitment and

the perseverance to see through that legislative challenge. It will

not be easy, but it is vital to our country and it is vital to those

who bear the brunt of war and who are wounded in doing that.

Thank you for addressing this issue.

[The prepared statement of Messrs. West and Marsh follows:]

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Mr. TIERNEY. Thank you both very much for those opening statements.

We are going to proceed to the question period under the 5-

minute rule. I am going to begin. I suggest that whoever feels best

qualified to answer the questions so select down there on that, or

I will leave it to the spokesperson if you want on that.

I noted under both your comments on that and in page 6 of your

testimonies that you recommend one combined physical disability

review process. That is the crux of much of what we are talking

about for both the Department of Defense and the Veterans Administration.

To whom should we look to be held responsible to make sure that

gets done?

Mr. WEST. My recommendation, Mr. Chairman, are the Secretaries of Defense and the Secretaries of Veterans Affairs. They have

the rulemaking authority for their two Departments and can probably solve that. To the extent that it requires any legislative adjustments, then, of course, that is your bailiwick.

Just one example. In the Department of Defense, if you are a

member of the Army and you are eventually going to end up leaving the service because of medical difficulties you have encountered, the wounds, whatever, you can face four boards to consider

your physical evaluation, your disability, before you even get to the

VA. That is because there is one that determines whether you will

remain in your MOS. Well, that is four including the VA. One determines your MOS. Then there is the medical evaluation, the

physical evaluation, and then, of course, there is the DAV’s Board.

When you look at the larger picture, they are all deciding two

issues: one, will you have to leave your current duty, and, if so,

under what circumstances.

Now, I understand that there are many analyses that can show

the other different aspects, but that is what it boils down to, and

for service members that is very difficult.

Mr. TIERNEY. Thank you. I would assume, and you probably don’t

have to answer, that is going to work fine if the Department of Defense and Veterans Administration Secretaries understand that

somebody at the White House wants an answer and wants to ride

herd on this thing, so I accept your answer, I think it is excellent.

They can suggest legislation to us. They can make the rule changes

on that.

But I would just add the caveat that I assume that this only

works if somebody at the White House is making sure that both

those Secretaries know that somebody has to answer the bell and

get that work done. It is not going to be enough to swallow, it is

not going to be enough to do it in silos; it has to be a cooperation.

Mr. WEST. Yes, sir.

Mr. TIERNEY. What is the estimated time that we should be looking for them to complete this implementation? I think it is going

to be a large task on that, but not one that we can let linger, so

this committee likes to set time lines for continued hearings to sort

of keep the process going here. What would be a reasonable time

for us to expect those Secretaries to have that done?

General ROADMAN. Mr. Chairman, I am Chip Roadman. I am a

former Surgeon General of the Air Force.

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I think re-engineering the system, putting it at a year is probably a reasonable issue. Common sense would say but there are

going to be people who are going through this system for the next

year. Actually, one of our recommendations was that every one of

the disability determinations, from 0, 10, 20, less than 30, from

2001 to the present should be re-evaluated to be sure that there

is consistency and that there is fairness in the decisions, in addition to all those that were discharged under the existing prior to

service.

Mr. TIERNEY. That is what you would do in the interim?

General ROADMAN. That is what I would do in the interim.

Mr. TIERNEY. And you would have one group do all that evaluation?

General ROADMAN. Yes, sir.

Mr. TIERNEY. Who would that be?

General ROADMAN. I think that a group of people who really understand the clinical issues, as well as the rehabilitative issues

that our servicemen have to undergo should be appointed to do

that.

Mr. TIERNEY. And that would be for both the VA and for the

DOD?

General ROADMAN. It probably would be, sir, but it would be a

significant group of clinical records to review and is a mammoth

task but should be done.

Mr. TIERNEY. Thank you.

General JUMPER. Mr. Chairman, if I could just add, for one moment.

General JUMPER. At some point during this continuum of care,

which is what we call it in the Corps, unbeknownst or unannounced to the wounded soldier or Marine the system turns from

one of tremendous advocacy, and you have heard the testimony

about getting people off the battlefield and into primary care in

record time, performing virtual miracles keeping people alive, but

at some point this continuum of care turns from one of advocacy,

profound advocacy, into an adversarial process.

The point of view of this single process needs to be from the

point of view of the wounded warrior and not from the point of

view of the bureaucracies that look down on the wounded warrior

and make the processes more comfortable for themselves. It has to

be that of the warrior, and be able to streamline, from the point

of view of the soldier, Marine, airman, sailor, the expeditious way

through this process. That is the point of view that has to be taken.

Mr. TIERNEY. Thank you.

I notice that the yellow light is on. I am going to move on. We

may come back for a second round on this, so I don’t want to keep

any of our other Members from that.

Dan.

Mr. BURTON. Thank you, Mr. Chairman.

You mentioned the wounded warrior. I had a young man from

my District who was severely wounded, and he went to Walter

Reed and received very good treatment. He went back home and

he has to come back for additional treatment on a regular basis,

but one of the things, he is still on active duty, and so he was being

34

required, even though he was almost completely blind, to come

back and stand with his company on a regular basis.

Now, I called out there and talked to the company commander

and he said, well, we will try to arrange for him to stand with a

company in Indianapolis so he and his wife don’t have to get on a

plane and come out here and stand for just a few hours and then

go back. I just wonder if any other personnel are experiencing that,

because it doesn’t seem logical to me, if somebody is severely injured, they have been treated at Walter Reed, to go home and, unless they are coming back for treatment, come back and forth and

back and forth just to stand with their company when they are

called out for regular order. It doesn’t make any sense.

I just wondered if that was addressed at all by this. I mean, it

is something that is not necessarily directly connected, but it seems

to me something that is very important.

You talk about treating the wounded warrior very well. This is

one of the things that should be done. They ought to take into consideration not only his condition and what they have to do to make

him whole, or whole as much as possible, but also try to make it

as convenient for him as possible to get to and from and do the duties that he has to do while he is still on active duty.

Major HOLLAND. Sir, it is very much appreciated for you to bring

that up, because, as the NCO on this group, non-commissioned officer, it is my job to look out for those folks. I have to tell you some

of the things you will hear as we try to get our wounded warriors

back to their units and back in formations at times. Secretary West

brought up the idea of using common sense. Somehow we have lost

some common sense. That is not the way we should be treating

these wounded warriors that are on very strong medication.

Now, yes, we do need to keep accountability of them, we need to

keep track of them. No doubt about that. For PTSD, TBI, we need

to do even a better job, sir, of keeping track of them.

Mr. BURTON. Well, in this age of computers and the way we keep

track of almost everybody any more, it doesn’t seem to me very difficult to say to a wounded veteran, you can go to a unit in Indianapolis to make sure that your attendance is shown. But this guy

is almost 90 percent blind, and for him to come back to Washington

requires his wife to come with him, they have to get a place to stay,

then they have to go to his unit, then they have to go back to Indianapolis or back to the district. He is outside of Indianapolis. That

didn’t make sense.

Major HOLLAND. Sir, one thing to add to that if you will, that individual may look at community-based health care, because we

have CBHCOs in a lot of the areas that they can go under.

Mr. BURTON. Well, in his case he still requires treatment at Walter Reed, and he has been getting good treatment. The problem I

am talking about is this unnecessary travel.

Major HOLLAND. Yes, sir.

Mr. BURTON. And I hope you will look into that for others, because this is probably not an isolated case.

One of the things that I noticed in your report, it says ‘‘Create

a recruiting and compensation plan including a review of the military service obligation should be pursued to address health care

professional staffing shortages.’’ I had a conference yesterday and

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had about 400 veterans there in Indianapolis, and we talked about

Walter Reed, and Bethesda. We talked particularly about the treatment at Roudebush Hospital in Indianapolis and the hospitals at

Fort Wayne and in Marion, IN, and one of the problems they

talked about was getting treatment in a relatively quick fashion

when they needed it, among other things.

I noticed here you were talking about having a problem in attracting health care professional and staffers, people on staff. Do

you need more money for that? Is it a logistical problem? What

kind of a problem are we talking about here?

General ROADMAN. Sir, I’m Chip Roadman. The money is an indirect issue, and that is you have to have the ability to hire. In other

words, if you have the money but it is not competitive in the marketplace and you can’t hire, then that is essentially not having the

money.

Mr. BURTON. If I might interrupt, I apologize for this. It seems

to me in time of war, when we have young men and women coming

back who are suffering severe injury, that whatever it takes to

make sure we hire the best personnel possible, even for a short

time, ought to be done. And if additional appropriations are needed

for that, I hope somebody will tell us what is needed so that we

can make sure that, if there is a shortage of nurses or doctors in

a given field, we can cough up the additional funds to make sure

they are there to take care of those guys.

General ROADMAN. Of course, as you know from our report, we

identify high expense marketplaces where, in fact, the pay grade

needs to be higher in order to be able to hire people. But your basic

point is almost as if you had been on our review panel, and that

is: if you are at war, and our view in many ways is that our bureaucracies have remained at peace while the war fighters have remained at war, and so we see the processes and the ability to have

other than business as usual as the way to get things solved is one

of the inherent issues that we have.

Now, if I might, you took the easy patient with the active duty

patient without sight. You have to think in terms of, as we look out

in the system, the Reservist, the Guardsman who is separated not

with retirement and goes out into their local area, and it may be

a very rural community where that health care is not available. In

fact, our system disconnects from them and they are on their own.

I think that there is a fundamental flaw in how we design our

systems to take care of individuals wounded in war in that we have

a lifetime obligation. It is the cost of war that I believe is there.

There is a moral and a human cost, and it can be costed fiscally,

as well, as a tail that has to be calculated in cost. When we put

force on force, we need to be willing as a Nation to stand up and

accept that.

Mr. TIERNEY. The gentleman’s time has expired. Thank you.

Mr. MARSH. Mr. Burton, there are 94 nurse’s vacancies at Walter

Reed Hospital, and you can’t fill them because they are not competitive because they are only permitted to pay in the pay scale directed by the Office of Personnel Management, which was set up

in 1972. They have tried to give them some leeway, but it is so far

below the going rates for nurses in the Washington area you can’t

fill the vacancies.

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Mr. BURTON. Mr. Chairman, let me just say I know my time has

expired.

Mr. TIERNEY. It has.

Mr. BURTON. This is critical.

Mr. TIERNEY. It is critical, and I would just ask the Secretaries,

would we not expect the Secretaries to make a recommendation to

Congress for adjustment of funding for just that purpose so we

wouldn’t be waiting here so many years later to catch up?

Mr. Welch.

Mr. WELCH. Thank you, Mr. Chairman.

I want to thank the members of the panel for your great work.

There is a lot of discussion about the disability review process,

that it is incredibly complicated, and you have addressed that. Professor Linda Bilmies from Harvard has made a recommendation to

try to simplify that by doing something such that there would be

a rating based on a scale, and you get a one, two, three, four, or

five. You would make that determination. It would be a simple

thing to do. Then the Department would audit these going back to

see whether those determinations, in fact, were consistent with

standards. That is the accountability.

It makes a lot of sense to me. My question is whether it makes

sense to you.

I would maybe start with you, General, because I thought that

the point that you made is really true. You go from advocacy to an

adversary situation. To some extent that is endemic in the entire

medical system, whether it is in the VA system or it is in the private health care system, because, no matter what, it is extraordinarily confusing, so finding some practical way to simplify and

take the complexity out of it to me sounds like an excellent recommendation that you made, so I would be very interested in making improvements.

General JUMPER. Let me start, and then I will call on my colleague, Chip Roadman, who really dove into this.

My observation is that this process could be extremely simplified,

and I don’t think it would take a lot of work. But when you get

down into the regulations and the rules and you look at, for instance, the coding process that is required by these outdated regulations to be used for traumatic brain injuries, then you quickly get

these people classified in a way that is completely out of step with

what their true injury is. And it is all caused because the coding

system, the deliberative coding system, has not been caught up to

date, brought up to date. We are actually subject to printing cycles

to update these regulations.

One of the things that didn’t get into the report that is, I think,

badly needed is a way to update the medical community on some

of the cutting edge things that are happening out there. At Bethesda there is a very forward-leaning diagnosis and treatment

protocols that have been advanced for TBI, but it is not promulgated system-wide. We need something like, in my business, the

FAA bulletins that are put out for aircraft discrepancies that are

immediately put out to the community, adjudicated by a scholarly

board that has authority over this and gets this out to the communities right away, something like that, along with a simplified rating process that you mentioned, sir.

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Mr. WELCH. Thank you.

General JUMPER. Chip.

General ROADMAN. Yes, sir. I think what you are describing is

an occupational medicine approach to if you lose a hand you are

compensated X amount of money, and that is a civilian type of a

model.

That clearly is easy to implement. The real problem comes down

to we took Johnny out of his community and we returned him not

in the same condition that we got him, and he is no longer able

to do the occupation that he was trained for.

Mr. WELCH. Yes.

General ROADMAN. And so if you are actually discharged or don’t

get a retirement, you are not eligible for the health care. You get

a severance pay, and that generally is not a livable allowance. So

there is an issue with how well compensated the warrior is as he

comes back into his community.

We said the real measure of success was that if his mother

thought he was treated fairly, that probably we hit the mark. That

is hard to put into bureaucratic measurable programmatic terms.

The issue that we have been talking about on coding is one

where PTSD and mild traumatic brain injury seem to be signature

injuries of this war. There is not an obvious civilian analog to this,

in that brain damage that is seen in our emergency rooms every

day is due to acceleration and deceleration injuries, coup

contrecoup within the calvarium.

The problem is that what we are seeing with TBI, mild and not

penetrating head wound but mild, is due to over-pressuring from

a blast injury and is an invisible injury and, in fact, is hard to diagnose because it overlaps with PTSD. They are in the area called

attributable diseases, which you take symptoms rather than findings, and we are out beyond what we now clinically know, and we

need a tremendous amount of research.

Now, all of us are very quick to say we need quick research, at

least getting to the 80 percent answer and not necessarily this

grinding peer-reviewed type of scientific study that we have the answer 20 years from now and then have a cohort of wounded soldiers.

So I think the issue is that we clearly need a way to track and

identify. What General Jumper was taking about, in the civilian

coding of medical records there are about 19 codes that could be

mild TBI. If you put that through the ICD–9 codes and then you

come back through the DSM-IV to try to actually finally—this is

more technology than even I understand, so I hope you don’t pin

me down on this, but what happens is those come out as psychiatric disease rather than a neurologic injury. That is not what

our scientists can do either retroactively or prospectively to define

the cohort that we need to study to get the answers.

So what we have found as we pulled the thread, it attaches to

everything else.

Mr. TIERNEY. Thank you. The gentleman’s time has expired.

Mr. WELCH. Thank you.

Mr. TIERNEY. Mr. Shays.

Mr. SHAYS. Thank you, Mr. Chairman.

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I would like to ask you gentlemen your opinion about the need.

First off, do you agree the challenge is primarily outpatient as opposed to inpatient? Second, I would like your opinion about what

you think about an ombudsman, someone to just be assigned to the

soldier for years, if necessary, at least in wherever location they

are.

Mr. WEST. Well, the answer to the first one is clearly yes. The

problems are in the outpatient as that applies to Walter Reed and

other areas. That is where we focused, that is where it arose. That

is not to say that in our course of reviewing things we didn’t come

across some ways in which there could be other improvements, but

the problem is in the treatment of the outpatient, the group that

are going through rehabilitation and the process for the physical

and medical evaluations, as well.

Mr. TIERNEY. Is that agreed by all of you?

Mr. MARSH. Yes.

Mr. FISHER. Yes.

Major HOLLAND. Yes.

General ROADMAN. Yes.

Mr. SHAYS. Do you have an opinion as to why the system broke

down? Or did the system never work properly when it involves outpatients?

Mr. WEST. I think everybody on the panel—who wants to start?

General ROADMAN. I will start on that. Health care generally is

taught and oriented in an acute care inpatient setting. What we

are talking about is rehabilitative care, which is fundamentally different from acute care. The only reason I think this came up is that

the system was stressed by the volume of patients. The system will

work today by bailing faster, but as you get more and more patients the system actually has to be fixed.

There are three ways we need to look at health care: prevention,

acute care, and rehabilitation. Our job we are talking about now

is taking Johnny back to his community able to re-engage in life,

and that is different from the acute care that we normally deliver.

Mr. WEST. You raised a question of an ombudsman, Mr. Shays.

I wonder if the Sergeant Major might say something on that.

Major HOLLAND. Sir, the service member certainly needs an advocate, but they need an advocate that is schooled enough to be

able to help them walk through the mine field that they have to

walk through.

Now, we talk about the ombudsman, but we also talked about

the rating system. Let’s make sure that no one gets service concern. The services still should have the ability to say whether or

not I am fit for duty or not fit for duty. Once it is said that I am

not fit for duty and I go in that other category, then I ought to go

to the disability system, and that is where I really need an ombudsman.

We talked about case workers. We talked about case managers.

But with a load of 30 and 40 to 1 they are not given a good, positive situation.

Earlier you brought up legal staff. Three legal folks at Walter

Reed is unacceptable. I talked to the head of the JAG. They tell me

that there are five Reservists, legal staff, coming in that will be

there for the next year or two. We need certainly more advocates

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for the individuals to understand what their rights are and to

make sure that they get treated fairly every day, sir.

Mr. SHAYS. Thank you.

If you would all describe to me the differences of what you saw

at Walter Reed versus Bethesda.

General ROADMAN. Sir, I am Chip Roadman. There was a significant difference between the two. Bethesda had reorganized their

patient care as a team so that very holistic health care was delivered per individual. In other words, if someone had an orthopedic

injury and a soft tissue injury, they didn’t have to go to two physicians at Bethesda. They had a team approach to that. At Walter

Reed what we found was that the disease were treated by organ

systems, primarily, sequentially rather than in parallel. We made

that point in the report, saying that was one of the really best practices that we had seen.

Mr. WEST. There are some other differences that come out. First

of all, of course, the numbers at Walter Reed exceed those at Bethesda. What that means then is that when you are talking about

folks who can function as an ombudsman for, say, service members

and families, Bethesda had theirs covered. The Marines who are

there are well helped in making their way through the process and

also through the regulatory procedures. That wasn’t happening at

Walter Reed. That is the impact of the ratio to case worker, the

ratio of patient to those who can help them through the process.

The Marines take their folks the minute they get off the plane,

in fact perhaps even before the plane that comes in, and has someone assigned to be responsible for that serviceman through the

whole process, all the way back to their wounded warrior barracks

on either coast. The Army folks at Walter Reed just don’t have

enough people to see that that happens.

Now, in some cases it does. Special Forces are there from the beginning to sort of follow their people. But the fact is numbers can

make a difference and did make a difference there.

There are some other things. The Navy does its facilities maintenance at Bethesda much better than the Army does it at Walter

Reed. Now, is that a service tradition that the Army fighting in

worse conditions somehow lives in worse conditions? Even if it is,

it is no way to treat the wounded. But the point is you can notice

those distinctions, and they make a difference in what service

members and their families experience at those two facilities.

Mr. SHAYS. Thank you very much.

Mr. TIERNEY. Thank you very much. The gentleman’s time has

expired.

Mr. Yarmuth.

Mr. YARMUTH. Thank you, Mr. Chairman.

I would also like to thank the panel for their work and their testimony, and I would particularly like to commend General Jumper

on your comments about the nature of the relationship toward the

soldier throughout the system. I think we can all agree that the

focus ought to be on the soldier’s welfare from beginning to end.

I have a question about resources. During the initial hearing we

had, I and others on the committee continued to ask those in

charge at Walter Reed whether resources, namely financial resources, were part of the problem, and they kept saying no, no, no,

40

which I don’t think that made sense to many of us because there

was so much implied argument to the contrary.

I know you have mentioned in your report that resources were

contributing, a lack of resources contributed to the problem, so I

would like you to comment on, first of all, the notion of the efficiency wedge, what that is, because I know that was mentioned in

your report, and how this might have adversely affected care, and

also why you think there was denial of the fact that resources were

part of the problem.

Mr. MARSH. Mr. Congressman, the resource methodology is very

difficult to understand for the medical community in the Department of Defense. It has undergone a very significant change some

time in the last 15 or so years, where the funding is taken out of

the service, either Army or Navy or Air Force, and is moved up to

Defense Health Affairs, and then the funding will be allocated at

the Defense level without review or input at the Secretariat level

of the three services.

I think some of this is done because it is thought to be more effective, but I am not sure it is working out here in the time of war.

Out of this comes what are called wedges, and either Admiral

Martin behind me or General Roadman can tell you better, but the

wedges come down to the service. They may tell the Army medical

community your wedge is $42 million, which means that you have

to find that $42 million in your whole total community and the answer is you will find it in efficiencies. You often can’t find it. And

the last wedge I think that came down I think was $142 million,

and I believe the Surgeon General indicated there was no way he

could execute that. In the previous wedge, to protect Walter Reed,

they kept them out of the wedge. The wedge means a wedge into

your medical budget that comes back up to Health Affairs.

Chip, do you want to speak to that?

General ROADMAN. Yes, sir. Chip Roadman.

The wedge is a formula applied to workload that is retrospective.

As your workload goes down, it is assumed that your costs go down

in a formula relationship. I call that the death spiral of health care,

because as we mobilize critical skills and send them into the theater of combat, those skills are no longer available within the treatment facilities at home, and the workload of course will go down.

The problem with that logic as you extend that out is you ultimately end up with only a deployable medical force with everything

else being bought in the civilian sector. I don’t think that is where

we need to be going as a military health care system.

You know, I hate to give you a flip answer, but the efficiency

wedge is a death spiral.

Mr. WEST. Sir, it can also be very misleading, Congressman.

Having overseen two Departments, I can tell you that the wedge

goes in and you are given inducements to meet it. You meet it or

you don’t, but if you meet it, having accepted essentially that percentage cut in your budget, you are rewarded by having the budget

the next fiscal year set at that level with a new wedge.

General JUMPER. Sir, may I add there is also a stealthy dimension to this as far as resources go. A lot of the resources that are

put against the immediate problem, for instance, at Walter Reed,

come from other areas of the budget, the line of the Army that

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come in there to do and pick up some of the slack that was identified in the Washington Post and other places. Eventually, those

functional areas from which those resources came—that is money

and people—will be asked to go back to those functional areas. Unless they are institutionalized, they stand a good chance of

evaporating when the immediate crisis evaporates. That gets to the

recommendations in our report that talk to institutionalizing and

some strong oversight to implementing the measures that are written in the report.

Mr. TIERNEY. Thank you. The gentleman’s time has expired.

Mr. Hodes.

Mr. HODES. Thank you, Mr. Chairman.

I want to also thank the panel for your good work on this.

I have two areas of questions. The first concerns the office of the

ombudsman. I asked my office to send me some information just

to check. I want to make sure that the panel is aware that Congress recently passed the Wounded Warrior Assistance Act of 2007,

and I have not matched up what we passed with your recommendations, but I would urge you to take a look at that. I don’t know how

the timing worked with your study and that act, but I think we

really probably need to take a look at that in light of your recommendations, and any help or guidance you could provide Congress on that I think would be helpful.

One of the things that the act did was it set up an office of an

ombudsman in the Department of Defense. Section 102 of the act

sets up an overall office to coordinate, as I read it, other offices of

ombudsmen in the various military divisions.

I am hearing that, while the Navy and the Marines have done

a pretty good job with somebody, some office, some way to coordinate all the benefits, care, and services that may be available to

the wounded warriors on that side, the Army has not. So one of the

things it sounds like we need to look at is making sure that there

is specifically an office of the ombudsman, and perhaps at each

medical facility, whose duty is to the soldier and their family, not

to the armed services so much but to the soldier and their family,

their duty runs to them to help them coordinate what they are

going to have to go through. Is that, as a concept, something that

you agree with?

Mr. WEST. Mr. Hodes, the answer is yes. I think that Command

Sergeant Major Holland has already indicated, and his indications

are certainly those of the panel.

In fairness to the Army and to Walter Reed, much has changed

since we did our review, and they have, in fact, addressed the case

worker issue, the imbalance, reworked the numbers, and so you

will hear, I think that they have made an effort to address it.

Whether the case worker does what the act requires is another

matter to be looked at. Certainly from our perspective the need for

some advocate who can help guide individual service members and

their families through that time when the service member cannot

be expected to be thinking clearly, when the family is tormented

by anguish and concern, is one that we think the Army is trying

to meet, but certainly what you have mentioned in the act also

seems a way to be helpful.

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Mr. HODES. My concern is amplified by a meeting I had with a

constituent at home recently. I met with the soldier and his wife

who was at Walter Reed. He described a similar story to that

which we heard when we were there for testimony, you know, having to navigate 14 different signatures to have somebody say what

he already had been told, which is he is blind in one eye, half blind

in the other, his arm is busted in 13 places; having to show up for

formation when he could hardly stand, with nobody to go to to help

him, a case manager who seemed more interested in telling him

what he didn’t need than what he did. So my concern is very personal to me with that constituent.

The second question is perhaps briefer. General Jumper, I listened with interest when you talked about essentially an attitude

issue. The same constituent that I met with described a suck it up

soldier attitude to what he was dealing with. I don’t think you can

legislate attitude. How are we going to change the mind set from

suck it up soldier to these are wounded patient soldiers who need

our care? How are we going to change that attitude, because I don’t

think we can pass an act that would do it.

General JUMPER. Sir, I think that is a very good question. Indeed, it is the tradition of all of our military services to, as you say,

suck it up. That is the way we look at things. I don’t think the

American people would want it any other way.

However, when you transition yourself into this sort of an environment where you now involve families and loved ones, and, indeed, in a process where the families and loved ones are necessary

to be able to coordinate all of the activities of our more severely

wounded warriors, then that is when compassion has to take over

for a little of the suck it up attitude.

I think everybody agrees with that. I think everybody agrees that

it was probably a bit overboard in that direction. I know that the

commanders that we have talked to have instituted steps to correct

that, to pay more attention to the families and to the loved ones.

Mr. TIERNEY. I thank the gentleman. His time has expired.

Mr. Braley.

Mr. BRALEY. Thank you, Mr. Chairman.

Quite frankly, General, telling a patient suffering from post traumatic stress disorder or traumatic brain injury to suck it up is

counterproductive. Isn’t that correct?

General JUMPER. Yes, sir.

Mr. BRALEY. And one of the problems that we have sitting up

here is that when we had our first hearing at Walter Reed on

March 5th I asked General Schoomaker, General Cody, and the

Acting Secretary Garon if any of them could tell me how many patient advocates were serving the patient population at Walter Reed,

because the Post article indicated not only were case managers

being added to the population, but also patient advocates. You

know what they told me? None of them could answer the question.

I made a request at the end of that questioning for a clarification

on what the number of patient advocates were, because it is contained in the Wounded Warrior Assistance Act. It is contained in

your independent review. And nobody has answered my question.

So when you want to talk about the frustration of inaction, it is on

both sides of the table here.

43

One of the things that we have to do is get back to the point of

view you talked about. One of the recommendations you made in

your report has to do with employment assurances. My brother

works at the VA Hospital in Knoxville, IA, which has been on a yoyo for 10 years on whether they are going to close the largest VA

hospital in Iowa, spend $260 million of new facilities management

and move them to Des Moines, and they are losing their best employees who are going to other VA facilities around the country because no one is giving them that assurance. This is an endemic institutional problem that has to change, and you have to be the

voice to make it change, because, quite frankly, we are not getting

a lot of answers on this end.

One of the things that I think that is very important is you

raised the point, General Roadman, about what is the cost of war.

You have talked in your report about the advancements in medical

care that are changing many former fatalities into wounded warriors with injuries that are, frankly, going to cost us staggering

sums if we invest the money we should to take care of them.

If you look at a life care plan for somebody with a traumatic

brain injury or PTSD, the average life expectancy of a 19 year old

male, according to the U.S. life tables, is 57 years. You cost that

out. It is a lot more than your $100,000 DOD death benefit. Yet,

we are not getting any information from the administration on

what the long-term consequences of health care are for the casualties of this war. You have to use your platform to be an advocate

for that, because that is a hidden cost that nobody is talking about.

One of the things that was also frustrating to me is one of your

recommendations deals with promoting education and research in

prosthetic care, production, and amputee therapy, and we heard

very compelling testimony about people with multiple amputations

going back to active duty performing valuable functions as active

duty personnel, and yet we know when we are dealing with the

rampaging cost of long-term health care that if we want them to

be active throughout that 57 year life expectancy and not be a burden on our health care system, we have to invest in the type of

prosthetic care that keep them active and functioning. Yet, if you

look at those DOD reimbursement schedules, they provide initial

prosthetic care and then they are left to fend for themselves.

So what I want to emphasize is your value to this country in

keeping this topic front and center, because we can have hearings

until hell freezes over, we can pass the assistance act, but unless

the military and Department of Defense do something to act on

their recommendations nothing is going to change.

Female SPEAKER. What if you stop funding war?

Mr. TIERNEY. Excuse me 1 second. The witness will suspend,

please. We have been more than, I think, lenient with what is

going on here. Now I am going to ask that you sit down and not

disrupt the room. As long as you are quiet and you don’t disrupt

other people and you don’t get in the way with their hearing of this

witness, this hearing, we are perfectly fine. There are people sitting

behind you who want to watch the proceedings, people who want

to listen to it, so I ask you to keep your comments to yourself, keep

in your seat, and you will be just fine.

44

Otherwise, we want to be respectful of what is going on here,

about the people who are returning from Afghanistan and Iraq that

we all have great concern for, including you. We appreciate that

concern. So please work with us. We have been as lenient as we

could. Now we expect that you are going to stay seated and stay

quiet. Thank you.

The witness may proceed.

Mr. MARSH. That was a very timely and powerful statement you

just made.

Let me mention something to you that I am afraid the Congress

is going to overlook, because we had a tendency to overlook it.

There are statutory differences between the National Guard and

the Reserves and the active force. Those statutory differences, unless they are identified, in the process of treating the wounded can

have some very significant consequences.

For example, if the National Guard or Reservist soldier goes off

of active duty when he returns home with his unit, if he goes back

to his unit and is mustered out, his chances of being able to get

back into the system are extraordinarily difficult and very hard for

him to achieve. I don’t think that Congress is looking enough at

these two very important distinctions in the service. And there is

a difference between Reservist and Guard, too. But the point you

make I’m sure was not lost on all these military people sitting here

behind me, but you are quite correct.

General ROADMAN. Mr. Braley, I absolutely agree with you on

the hidden cost issue. After leaving active duty, I represented nursing homes and assisted living in the District here with the American Health Care Association, and I understand fully what the lifetime costs of rehabilitation care and care for people with chronic

diseases are.

We have had some interviews, and the question was, well, who

do you think is going to pay for these recommendations? The panel

generally has taken the position of actually that is not our problem

to fix. Our problem is actually to point out the remaining gap for

the people who serve our country, and we recognize the cost is immense and it is our moral obligation to address those issues. As we

engage in force on force, recognize that it is not just bullets, it is

not just weapons systems, it is also the tail programmatically of

people who are wounded in defense of our country.

I would like to add one thing quickly. We have talked about

wounded warriors. One of the things that we have seen going from

facility to facility is people saying, wait a minute. I have been injured and I am not a warrior. It wasn’t in Afghanistan and it

wasn’t in Iraq. The fact of the matter is what we are talking about

is service members, regardless of where they were wounded, they

need the same standard of care, the same standard of access, and

the same standard of respect and priority.

I don’t want us to fall into the trap of saying this is for ‘‘wounded

warriors’’ and therefore limited to particular operations. This is an

all volunteer force. We have obligations to take care of them.

Mr. TIERNEY. Thank you, General.

The gentleman’s time has expired.

Ms. McCollum.

45

Ms. MCCOLLUM. Thank you, Mr. Chair, and thank you, gentlemen.

Mr. Marsh, you are right. We are not doing our Reservists and

our Guards and our active duty members any favors by having

compensation and everything being so jumbled and such a mess

when they come home, because they all talk to one another, they

all live in the same communities, they all served in Afghanistan,

Bosnia, Iraq, with great honor. To come home and find out that

they are treated differently when they worked and served and

stood in harm’s way is a huge, huge disservice to the sacrifice and

the commitment that they and their families made, so thank you

for pointing that out. I look forward to correcting those inequities,

especially as our Guards in Minnesota have been now extended.

The second wave just got extended an additional 4 months.

My concern that I am coming with is the seamlessness between

the DOD and the VA, and, where appropriate, maybe DOD people

who would still be covered by DOD might be more appropriately receiving care in a VA facility. It should be seamless. It should function in a way that really takes care, puts the patient first.

So I am concerned when I see that the focus on Walter Reed and

Bethesda, which I think needs to be because of the current problems we had, but I think your panel needs to be looking at the VA

system, the outreach that we have in community rural health services, how we take care of our soldiers when they come home and

their homes need to be refitted in order to accommodate a wheelchair, accommodate a walker, accommodate kitchens so that they

can be active not only in their communities but in their homes,

which helps toward healing.

So my question to you is going to be, what do we need to do—

and I met with my county Veterans Service officers who are great,

wonderful people, but they are all close to retirement. What are we

going to do to make our Government live up to its obligations, to

be advocates for families, to have case workers and ombudspeople,

as well as county Veterans Service officers? They all have very separate roles.

What I am concerned about, just as we have people mixing up

what the Guards and the Reservists and what the regular service

members are entitled to and people not understanding the differences in that and correcting it, I am also concerned about making sure that case workers are given their jobs to do, which are

very different than what an ombudsperson does, very different

than what a county Veterans Service officer would do. Who is going

to track and provide that seamless integration between DOD and

VA, and who is going to make sure that we have all the different

layers of paraprofessionals available and that the ombudsperson

truly is independent?

Let me give you an example of where I think we are failing already. DOD has someone assigned to the VA hospital in Minnesota.

VA system loves having that person there. DOD tries to keep someone there. That person rotates on an average of every 4 months.

How do we, you know, have someone who understands the difference between the systems and really working with someone?

Can you address the human need of making sure that we have

DOD/VA be seamless in all the different levels of people who works

46

with patients that aren’t providing health care but access to health

care?

Mr. MARSH. He’s the former Secretary of VA.

Mr. WEST. Congresswoman McCollum, you are absolutely right.

When you outlined the problem, you outlined a whole host of problems that need to be addressed, and that we in the panel got to

some of them in terms of the seamlessness. We got to the question

of the transfer of records back and forth, which is so extraordinarily important to our service members. We got to that question

of what had to be looked at in terms of the physical disability review system.

Some of the other issues, in fact, in 45 days we just didn’t get

to. There is a panel that comes after us. It is already started. I

think you know of it, the one chaired by Senator Dole and Secretary Shalala, whose mandate is to look at precisely that interface

and in its broadest context as well as in narrow ways.

In terms of the DOD representation at the military locations, you

know, even that small presence, that one person is something that

is vitally important and that, frankly, a lot of advocates had to

work hard to get. As with any agency, but especially with DOD, if

there is one person there is a whole history of re-deployments and

reassignments in their career. If it is a civilian person, then certainly they could stay longer.

My point is you probably need more than one person, and you

probably need it to work. You are certainly right that 3 months,

or whatever that period was, is not nearly as helpful as a year.

Frankly, from DOD point of view and every other assignment I

have ever heard of, you can’t even get to know the territory in a

year, at least 2 years.

So you make a good point. We didn’t address that. We did address the broader issue of seamlessness. And, of course, there is a

panel to whom we just reported our findings on Saturday, the Presidential panel, that is going to look at that broader issue.

Mr. TIERNEY. Thank you, Mr. Secretary.

Mr. Van Hollen.

Mr. VAN HOLLEN. Thank you, Mr. Chairman.

Secretary West, Secretary Marsh, thank you for your leadership

on this in co-chairing. Thank you to all the others who served on

this panel, and for your prior service to our country, as well.

I just have a few comments, and then a question.

First, with respect to the role that the A–76 process played in

your findings here, and you state in the report, ‘‘The A–76 process

had a huge de-stabilizing impact on the civilian work force at Walter Reed Army Medical Center,’’ and indicate that if the military

had taken advantage of the waiver opportunities or didn’t have to

go through the A–76 process we would have avoided at least part

of the problem where a lot of attention was focused on A–76, No.

1. No. 2, as a result of A–76 there were lots of people who decided

to leave Walter Reed.

I only suggest that I think that problem is endemic not only to

Walter Reed but to other Government agencies. AS someone who

represents a congressional District right outside our Nation’s Capital, I hear regularly from the heads of those agencies—and I include political appointees in that group—who say that this A–76

47

process has significantly compounded their management problems,

the way it has been implemented, not that contracting out doesn’t

have an important role, I think it does, but the way it has been

implemented in a fairly ideological fashion. So I think that recommendation can be generalized to other Government agencies, as

well.

With respect to BRAC, as you know, in terms of the BRAC process, you have entered into sort of a discussion that is going on in

Congress. Some people have responded to the terrible situation

with regard to the treatment of our soldiers at Walter Reed by saying we should not move forward at all with the BRAC process and

the transfer. Others have suggested we should push the accelerator

pedal and really accelerate it. In your recommendations, you say

that you might even want to accelerate or waive the environmental

impact statement.

Now, Senator Warner, who is the ranking member on the Armed

Services Committee, has said he doesn’t want to short-circuit the

process. I must say, given that part of the lessons at Walter Reed

was the failure to plan in advance for the influx of wounded soldiers we would have, I would think that we would not want to

short-circuit that planning process. I think in the long run it will

cause more problems for the soldiers who are being treated, as well

as the people who have to provide the care, if you rush into a situation without adequate planning, including the environmental impact statements.

Third, I know someone raised the issue of H.R. 1538, the Wounded Warriors. It has passed the House and is pending in the Senate.

I am interested in your comments on that, whether you have had

an opportunity to review it.

Finally, I was at Bethesda Naval Hospital recently. It is in my

District. Talking to Admiral Robinson there, he said one of the

issues in discussion—and there is not really a meeting of the minds

right now as part of this transfer—is this whole question of medical

hold. It gets a little bit to Congresswoman McCollum’s comments.

At the Bethesda Naval Hospital they were pretty clear that they

tried to push earlier for people to be returned to their communities

and provide care through the veterans hospital system. This was

an ongoing and quite pointed discussion even as we gather here

today with respect to the merger between the two and the different

philosophies. Given the fact that outpatient care and the medical

hold system is clearly implicated as one of the real problems here,

I am curious as to your view of how to resolve that debate.

Mr. FISHER. I am Arnold Fisher. I would like to address the point

about the BRAC Commission that 2 years ago decided to close Walter Reed. It is like moving out of your house before you buy a new

one. There is no reason why the addition to Bethesda on the third

floor, which would create 50 new ICU rooms, can’t be done yesterday. I don’t understand. We don’t need an EIS. You don’t need any

approvals. You have to have plans made and you need to build it.

I still to this point do not understand why that has not been started now.

My problem with all of this is that the one word that has been

mentioned a few times today but is not addressed when it comes

to fixing Bethesda is that we are at war. This is not peacetime.

48

This is not a time where we can go through 13 months of EIS approval or to go through 16 months of an architectural and engineering plan. We are at war. We have to address this now. In Vietnam we had three wounded to every dead. We now have 16 to

every death coming back. We need to take care of them. We need

to have the facility for them. We can’t sit around and wait like we

would in peacetime and do it in 2 or 3 years.

As far as the EIS is concerned, it is Government land. Waive it.

Waive it. I know that the environmentalists will kick and scream,

but they are not going to scream and kick as much as these kids

that are coming back without arms and legs. They can bring them

in. We can satisfy them. This is a golf course we are talking about.

You don’t have to knock anything down. You can start it. You

should start it now, not wait for 13 months for this approval. We

should start Bethesda now.

These kids have not stopped coming back. The first day I was on

this Commission, Secretary West and I went to Andrews Air Force

Base and we watched a C–17 come in with eight stretchers on it.

They come in every day except Thursday. These kids are coming

back. They are being put in buses, taken to Walter Reed and Bethesda. Now, from battlefield to bed they get the greatest treatment in the world, but the rooms that they go into a 30 year old

hospital are as big as closets. Their families cannot get in there to

see them. This is wrong. We need to fix it and we don’t need to

fix it in 3 years, we need to fix it now. We don’t have to wait 3

years.

When I first got on this Commission and somebody came from

BRAC and told us about the EIS and everything. I hit the ceiling.

This is not right, and I want it changed.

Mr. VAN HOLLEN. Mr. Chairman, may I make a comment?

Mr. TIERNEY. Certainly. Go ahead.

Mr. VAN HOLLEN. I am interested, as well, in an answer to the

other question with respect to the medical hold, but if somebody

told you that the reason—the BRAC Commission recommendation

came recently. If someone told you that the reason it is being held

up is as a result of the EIS, I can tell you they were giving you

a story. That is not what has been holding it up.

Now, what I want to know is if the Commission took a review

of the entire BRAC recommendation process. My colleague here,

and I am sure you will hear from her, Ms. Norton has pointed out

that maybe, if, instead of moving Walter Reed, we spent the time

investing in rehabilitating the facilities that you talked about, that

you would get the result you talked about. So the issue is there are

different ways. I am not going to weigh in to that particular controversy right now, but I don’t know if your Commission reviewed

in detail the BRAC recommendations and reached a conclusion as

to whether or not their original recommendation was the most appropriate in terms of providing medical care.

I happen to think they made a pretty good case, but I am not

sure, during your review, I certainly don’t see that analysis in this

report, a thorough review of whether or not their original decision

was right, given the circumstances we are facing right now.

I think every member of this committee feels exactly like you do,

that our priority has to be making sure that our people get care,

49

the soldiers returning get the care that they need. I don’t think any

member of this committee is going to be second to anybody in

maintaining that objective.

So the question isn’t whether, the question is what is the best

way to do it, and it is not clear to me that your committee had the

time or the resources to undertake a full review of the BRAC recommendations.

Mr. WEST. Mr. Van Hollen, if I may?

Mr. VAN HOLLEN. Mr. Secretary, the time is expired but I would

like you to respond to that.

Mr. WEST. Thank you, Mr. Chairman.

Mr. VAN HOLLEN. Thank you.

Mr. WEST. I will be brief. You are correct. We are not experts in

BRAC. What we are experts in is urgency, the urgency of those

who spoke to us, the urgency, as mentioned by Mr. Fisher, but we

are not experts in BRAC and we realize that others may make,

based on a better understanding, a different choice.

I remember my colleague General Roadman mentioned a minute

ago, he said something about cost. He said that is not our problem.

Actually, they are our problems, but our mechanism for dealing

with it is simply to make a recommendation based on what we

have heard and had a chance to see. But you are right, we did not

undertake a thorough study of the BRAC process. Others have.

What we have to say is this: there has to be no deterioration of

what is happening at Walter Reed as we go through whatever process goes through, because the key thing is the care for these youngsters. There has to be appropriate medical treatment and availability here, at Fort Belvoir, and at Bethesda in such a way as can accommodate that sense of urgency that we have.

But no, we are not the BRAC experts, but we do not claim to be.

Mr. TIERNEY. I thank the gentleman.

Ms. Holmes Norton.

Ms. NORTON. Thank you very much, Mr. Chairman. As a member

of the full committee I appreciate the opportunity to sit in and

question these witnesses. And I very much appreciate the candor

of your report and how rapidly it was concluded.

This committee is singularly interested, first, in stabilizing Walter Reed and other facilities, and then improving them. There is a

tendency on this panel, particularly the last lecture that was given

by my colleague, Mr. Van Hollen, the lecture to the tendency to

conflate what, in fact, has come out of these hearings and out of

the Washington Post stories, to conflate two issues: medical care

and outpatient care. We are not going to allow that to happen here.

We are not going to allow medical care to become a cover for the

problem that the soldiers tell us is the problem they have.

The House has not said that there should be no Walter Reed

built in Bethesda, no new hospital. The House has said that it is

inappropriate in the middle of a war to say that we are going to

close a hospital and build a new one. Let me tell you why. We are

aware that we are in the middle of a war. We are aware of the deficit that has been built up in the last 5 or 6 years. Are you aware

that nobody has appropriated the $2 billion it will take to build a

new Walter Reed?

50

And if you are not, let me tell you this. If, after the testimony

we have had here, the House were to come forward with a bill for

$2 billion for bricks and mortar rather than putting that money

into where the grievance is, in the outpatient system, there would

be bipartisan fury, because we haven’t had one complaint about the

hospital.

I have been into the hospital, sir. I have been into the rooms, and

I don’t recall any closets. I have talked to patients, as have many

on our panel. What we have learned is over and over again now,

not only Walter Reed but veterans’ hospitals all across the country,

we are inundated at not only veterans’ hospitals, sir, but veterans’

hospitals [sic]. We now have an outpouring of complaints because

people now feel they can speak up.

So we have a problem, we in the Congress. When we had our

first hearing I asked the generals—there were four of them—I

asked them a straight question, has the possibility of the closure

of the hospital had any affect on retaining or attracting personnel.

To the last general they said yes. If I can quote one of them, Army

Vice Chief of Staff General Richard Cody—this is only one of the

statements—‘‘We are trying to get the best people to come here to

work, and they know in 3 years that this place will close down, and

they are not sure whether they will be afforded the opportunity to

move to the new Walter Reed National Military Center. That

causes some issues.’’

Your answer apparently is to eliminate the environmental impact statement. If you think that is a problem for the environmentalists, I don’t think you understand the Congress of the

United States, or dispense with the A–76 process and hurry up the

process.

Let me ask you this: if you were in our position, the position of

the U.S. Congress, faced with a war we have to fund no matter

what happens, faced with the rebuilding Iraq that we have to do

no matter what happens, faced with now chronic neglect of domestic issues and pressure from all of our constituents to get to it and

to do something there, faced with a deficit that we are committed

now to halting and breaking down, what would your priority be?

I want the same kind of candor from you that your report shows.

If you had a choice between spending the money on outpatient care

and veterans’ facilities, a new hospital, what would you advise the

Congress to do?

Mr. WEST. Congresswoman Norton, I will give a specific answer

to the question you just asked. I would advise you to look at the

facts that we have gathered, look at the facts that are available to

you, look at the allegations of what is good there at Walter Reed

and what is not, how the maintenance is, how the rooms are. Look

at those facts. Look at the costing of the estimates of what is necessary to be done at Walter Reed to keep it going forward, remodeled, reinvigorated, the facilities fixed and the like. Compare those

with the cost of moving to a new facility and doing that, and make

a judgment on that basis.

Ms. NORTON. But the $2 billion hasn’t even included the cost of

equipment, just the cost of putting the bricks and mortar up.

51

Mr. WEST. I have seen the costs. I have seen a cost workup that

was done for another committee. I have looked at that. I tell you

that is the way I would do it.

What we are after is one thing, and one thing only: whatever resolution will get the best resolution of two things, one, a need for

facilities in which the medical care can be delivered, but also the

resolution of the rehabilitation, as well.

Ms. NORTON. Which is the problem before us. The problem before

us is the outpatient care, I remind the panel.

Mr. WEST. Right.

Ms. NORTON. The problem before us is not the care at Walter

Reed Hospital. To the credit of the hospital, there has not been a

single complaint I know of about the hospital. In fact, it remains

the premiere military hospital on the planet.

Mr. MARSH. Delegate Norton, if I could add to that—and I know

that time is running short—from the standpoint of the Commission, we were tasked with a single task: look at the army medical

services, particularly problems at Walter Reed, and, to a lesser extent at Bethesda, which are much, much less. What we were confronted with, I suspect maybe members of the Commission, if we

had been voting on BRAC might have had a difference of view, and

many might well have agreed with you.

But we were confronted with a BRAC decision, had been accepted by the Congress of the United States, enacted into law, and

signed by the President of the United States, so we had to deal

with the situation. This is a matter of law and it has been directed

by the Congress of the United States that we go forward with it,

and so we made our recommendations that were consistent with

that.

Mr. TIERNEY. Thank you very much.

I want to thank the members of the panel, as well as the Members here. I think it has been very helpful, and certainly the report

that you did was very extremely helpful. We thank all of you, including Admiral Martin, who didn’t get to sit at the table on that,

but we do acknowledge her work and George Schwartz’ work, as

well. We have great admiration for the fact that you were able to

get it done in such a short period of time and have it be so thorough with the significant respect also for the fact that you dedicated your time and energies to this. We know that you are all

busy individuals in your own right, and it is a patriotic and great

act of citizenship that you did this, and we thank you very, very

much.

That will end the testimony from the first witnesses. The second

panel will please take the seats when you get a chance.

Thank you, again.

We will now hear testimony from the second panel of witnesses

before us today. Thank you for your patience and thank you for

taking the time to be here during the first panel’s testimony. I

think it would be helpful as we converse here.

I would like to begin by introducing our panel. On this panel we

have Mr. Michael Dominguez, the Principal Deputy Under Secretary of Defense for Personnel and Readiness; Major General Gale

S. Pollack, the Acting Army Surgeon General and Commander of

52

the U.S. Army Medical Command; and Major General Eric

Schoomaker, Commander of the Walter Reed Army Medical Center.

Welcome to all of you. Thank you for your service to your country

and your willingness to be here today.

It is the policy of the committee to swear you in before you testify, so I ask you to stand and raise your right hands. Anyone else

who is also going to be responding to questions, if they would

please rise, as well.

[Witnesses sworn.]

Mr. TIERNEY. May the record indicate that the witnesses answered in the affirmative.

I am going to provide you the opportunity, if you would, to give

a summary of your testimony. As you know, we provide about 5

minutes for that. We would like you to try to stay within that, if

you could, and summarize. Your statements will be put in full into

the record, and then we would like some time to have a colloquy

and some questions back and forth.

Mr. Dominguez, perhaps you could start.

STATEMENTS OF DEPARTMENT OF DEFENSE AND ARMY OFFICIALS: MICHAEL L. DOMINGUEZ, PRINCIPAL DEPUTY UNDER

SECRETARY OF DEFENSE (PERSONNEL AND READINESS),

U.S. DEPARTMENT OF DEFENSE; MAJOR GENERAL GALE S.

POLLACK, ARMY SURGEON GENERAL (ACTING) AND COMMANDER, U.S. ARMY MEDICAL COMMAND (MEDCOM); AND

MAJOR GENERAL ERIC SCHOOMAKER, COMMANDER, WALTER REED ARMY MEDICAL CENTER

STATEMENT OF MICHAEL L. DOMINGUEZ

Mr. DOMINGUEZ. Thank you, Mr. Chairman, distinguished members of this subcommittee, thank you for this opportunity to discuss

support and care for our wounded soldiers and their families.

As you know, we have just received the draft report of the Independent Review Group established by the Secretary of Defense. We

very much appreciate their work and their recommendations. We

will be working to coordinate the Department’s review of those recommendations for approval by Secretary of Defense Gates.

We are currently staffing the recommendations of the Interagency Task Force chaired by Secretary Nicholson of the Veterans

Affairs Department.

I can’t articulate a clear action plan in response to the Independent Review Group findings until our Departmental review is complete and the Secretary has directed action. I would note that the

Department has not been waiting for the report to address matters

of identified concern.

For example, we have requested an adjustment to the fiscal year

2007 emergency supplemental to provide $50 million so that we

can implement in this fiscal year improvements to support and care

for the wounded.

The Army has taken aggressive action to make improvements at

Walter Reed. I defer to my colleagues at the table to address those

actions.

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The Office of Personnel Management provided direct hire authority for over 100 patient care positions. As a result the Army made

125 job offers at a recent fair.

Our first survey of wounded warriors and their families is being

fielded this month, with results expected in June. We have been

working through our Joint Executive Committee, with the leadership of the Department of Veterans Affairs, on improving the flow

of electronic information and records between VA and DOD.

I have described our efforts in my written statement.

We are thoroughly engaged in seeking the correct configuration

for our disability evaluation system. A joint team of DOD and VA

leaders begins that redesign this afternoon. In addition, in partnership with the VA, we are preparing a comprehensive plan to address TBI. The goal is to coordinate our efforts into a comprehensive program of research, education, treatment, and program evaluation.

We are supporting the President’s Commission on Care for America’s Returning Wounded Warriors, which is taking a comprehensive look at the full life cycle of treatment for wounded veterans returning from the battlefield. We expect their findings in June or

July.

In October we expect the report of the Veterans Disability Commission chaired by Lieutenant General Retired Terry Scott. This

group was chartered by the National Defense Authorization Act of

2004.

Correcting the fundamental issues underlying our failure at Walter Reed will require legislation. Legislation that addresses root

causes, however, will look substantially different than legislation

that treats symptoms. We have been working this problem hard for

several weeks now, but we don’t yet have a clear picture of the legislation needed to correct the root causes. We hope that the IRG’s

report will help us move down the learning curve there. When we

have that picture, we are committed to bringing it quickly to the

Congress for action.

Mr. Chairman, I look forward to your questions.

[The prepared statement of Mr. Dominguez follows:]

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Mr. TIERNEY. Thank you, Mr. Secretary. I do note, however, that

the last hearing we had on March 5th, where we asked the witnesses there from a similar panel how much time we ought to give

for review on where they have been and where they have gone, 45

days was the date given, so I know I have read General Pollack’s

statement. I think she is going to be a little more distinct in what

she says has been done to date. But I am hoping we have some

things accomplished and not just waiting for other people to file reports on that.

Mr. DOMINGUEZ. Yes, sir, we are moving out and we have accomplished many things.

Mr. TIERNEY. Thank you.

General Pollack, please.

STATEMENT OF GENERAL GALE S. POLLACK

General POLLACK. Mr. Chairman, distinguished members of the

subcommittee, I am delighted to have this opportunity to discuss

with you the actions the Army is taking to improve the way that

we care for and support our warriors in transition and their families. I also want to thank the former Secretaries of the Army, Secretary Marsh and Secretary West, for their leadership on the Independent Review Group. The work of the IRG and the other commissions viewing the Department of Defense physical disability evaluation system is very important as we continue to re-engineer the

Army’s medical and physical evaluation system.

Our Army medical action plan is fast-paced and flexible so we

can quickly assimilate the recommendations from these groups into

our ongoing efforts.

On March 5th, Secretary Garon, General Schoomaker, and General Cody testified before this subcommittee at Walter Reed Medical Center and vowed that the Army would work aggressively to

identify and fix the problems at Walter Reed. They told the subcommittee ‘‘we would not wait for reports or recommendations, but

that we would fix things as we go.’’ This is exactly what we have

been doing.

On April 3rd, the Army’s medical holdover Tiger Team included

an exhaustive study of the Army’s 11 key medical treatment facilities. This team included experts in finance, personnel management,

medical care, and representatives from the U.S. Army Installation

Management Command. The Tiger Team not only inspected facilities to identify problems, but also sought best practices in the care

and support of those warriors in transition. These practices can be

applied at Walter Reed and implemented across the Army Medical

Command.

The team found that outstanding and innovative work is being

done by many great Americans, military and civilian, given available resources. There is ample evidence that warriors are receiving

high quality health care and are generally satisfied with our efforts

and their clinical and administrative outcomes.

The team identified several best practices, including the establishment of a deployment health section, dedicated medical evaluation board physicians, and scheduling followup appointments with

the Department of Veterans Affairs prior to their separation.

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On March 19th the Army established a 1–800 hotline for warriors and their families who want to raise their concerns to the

Army leadership. The hotline allows soldiers and their families to

gather information about medical care, as well as to suggest ways

to improve our medical support systems.

The hotline rings in the Army Operations Center and all calls

are logged, tasked for followup within 24 hours, and briefed weekly

to Army leadership.

As of April 9th, the Army had received 848 calls detailing 468

distinct issues. Of this total, only 245 were medical issues, and 162

were tasked to the Army Medical Command for research and resolution.

Last week, in answer to one of the Members’ questions, we

trained 23 soldiers to work as warrior ombudsmen across the Army

Medical Command. The ombudsman is considered another warrior

resource and is not a means of circumventing the soldiers’ chain of

command. The intent of this program is to help cut through the red

tape by linking soldiers and family members with the correct

sources of information in order to answer questions or resolve

issues emanating from a lack of understanding or simply confusion.

This plan ensures that soldiers have additional advocates, while

we correct the administrative process that will require policy or

legislative change.

We have much work to accomplish. We are aggressively improving the existing physical disability evaluation system to minimize

the difficulties soldiers have faced. The system was developed half

a century ago and has become overly bureaucratic and too often adversarial. You have heard that often today.

The Army is developing initiatives to overhaul or replace the current process. Rather than settle for yet another attempt to re-engineer current processes, our goal is to eliminate the bureaucratic

morass altogether and develop a streamlined process to best serve

our soldiers.

As we move forward, there will be areas of policy, process, and

administration requiring full collaboration and coordination between both DOD and VA. We have worked together in the past,

and it is imperative that we expand that partnership to clarify the

issues, fix the problems, and improve the process for our servicemen and women.

We are under no allusions that the work ahead will be easy or

cheap or quick. We have a lot to do to get this right. Fixing the

myriad issues we have recently uncovered will take energy, patience, determination, and, above all, political will. Soldiers are the

centerpiece of your Army and the focus of our efforts. Soldiers

should not return from the battlefield to fight an antiquated bureaucracy. Wounded, injured, and ill service members and their

families expect and deserve quality treatment and support as they

return to their units or their communities.

We know that the President, Secretary Gates, Secretary Nicholson, Secretary Garon, the Congress, and the American public are

committed to this effort, as it is the cornerstone of everything we

are doing. With your help and the help of all the agencies involved,

we are confident that we can match the superb medical care soldiers receive at the point of injury or illness, whether on the battleVerDate 11-MAY-2000 12:35 Aug 15, 2007 Jkt 000000 PO 00000 Frm 00077 Fmt 6633 Sfmt 6633 C:\DOCS\36999.TXT HGOVREF1 PsN: HGOVREF1
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field or during training, with simple, compassionate, and expeditious service that ensures every soldier knows the Army and the

Nation are, indeed, grateful.

Thank you, again, for your invitation to testify. I look forward to

your questions.

[The prepared statement of General Pollack follows:]

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Mr. TIERNEY. Thank you, General.

General Schoomaker, do you have a statement?

STATEMENT OF MAJOR GENERAL ERIC SCHOOMAKER

General SCHOOMAKER. Mr. Chairman, Congressman Shays, distinguished members of the subcommittee, I am Major General Eric

Schoomaker. I command the U.S. Army North Atlantic Regional

Medical Command and the Walter Reed Army Medical Center.

I join Major General Pollack and the Department today in thanking the subcommittee for the opportunity to discuss the many improvements in living conditions for our patients at Walter Reed

campus, our efforts to improve command and control and accountability for soldier welfare, and what we have done to build a warrior-centered and a family centered program at Walter Reed and

throughout my regional medical command and beyond, to the medical command of the whole Army.

First, I want to reassure the committee and the Congress the

Army, the U.S. military, the American people, that the quality of

medical and surgical nursing, psychiatric, rehabilitative, and other

care that is delivered at Walter Reed Army Medical Center, our sister medical treatment facilities within my region that include Fort

Bragg, NC; and Fort Knox, KY; and Fort Drum, NY, and others.

The U.S. Army Medical Command under General Pollack has never

been in question and remains the highest quality. Frankly, it was

heartening to hear Congressman Shays say that we provide an unparalleled level of care within our hospitals, and that survival on

the battlefield has reached unprecedented levels in the history of

American warfare.

Shortly after national attention was drawn to Walter Reed and

our care of wounded warriors, an unannounced inspection of the

hospital was conducted by the Joint Commission. This is the Nation’s leader in accrediting hospitals and health care systems. We

were reassured by their finding of high quality health care overall,

while directing us to areas of improvement, especially in the transition from inpatient to outpatient care. We fully addressed these

areas with a comprehensive program for outpatient warrior care

management, some steps of which I will outline in a few minutes.

The Army and the DOD leadership pledged that we would fix the

problems as they were identified. I think that has been a question

from the subcommittee all morning. Armed with insights derived

from media accounts, your subcommittee’s earlier hearings that

were held at Walter Reed on March 5th, town hall meetings I conducted personally immediately after taking command over a month

ago, and the excellent recommendations provided by the Independent Review Group under former Secretaries of the Army, Marsh

and West, and many others, we have done exactly that. We are eagerly applying best practices from our colleagues in the Army Medical Command and Navy and Air Force medicine, and we are actively seeking new ideas for improving care, for administrative

oversight, and services for patients and families during this important transitional period in their lives. We call these soldiers warriors in transition. They are returning to duty after an injury or

an illness. They are returning to full and productive civilian life

after a recovery. Or they are retiring with a medical disability for

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continued care and rehabilitation, and hopefully employment within their communities.

We are clear to separate those issues which are unique to the

Walter Reed campus for which I am accountable, those that are

Army- and DOD-wide problems, and those for which solutions lie

in the interagency area.

All patients, I can reassure you, were moved out of Building 18

almost immediately. They have been moved into newer barracks on

the installation. Many of you have come and seen those new barracks. The building, Building 18, will never again be used to house

patients or families. The new barracks have been further upgraded

with state-of-the-art computers and communications. The Army has

been extremely forthcoming with that and very aggressive in their

support.

A comprehensive survey of all critical housing and life support

infrastructure on Walter Reed installation is being conducted, and

repairs are being performed on a priority basis as they are identified by this team.

The Acting Secretary of the Army and the new Chief of Staff of

the Army have made it very clear that we should restore Walter

Reed to a standard which makes all of us proud to work and live

on that installation until we build and occupy the new Walter Reed

National Military Medical Center with our Navy colleagues in Bethesda, MD, under the provisions of the BRAC plan.

Among the most important improvements is the infusion of new

leadership officers and non-commissioned officers, beginning with

my new Deputy Commander, Brigadier General Mike Tucker, a

combat veteran and a line commander—he is our bureaucracy buster, as he has been called—and our new Warrior in Transition Brigade Commander, Colonel Terry McKendrick, also a combat veteran, and his Command Sergeant Major, Jeff Heartless, who, as a

combat veteran, has also been a patient in our hospital and is very

savvy about the problems that soldiers and warriors confront.

With my new Command Sergeant Major Althea Dixon, we have

given every warrior in transition a new chain of command with a

smaller span of control for added accountability for their welfare.

Additionally, we have added better trained nurse case managers to

ensure fluid administrative processes, and primary care physicians

for assurance that medical care is coordinated and is of the highest

quality.

I am here today to answer any additional questions you may

have for me or my command about the improvements in care, our

living conditions, and the administration of this critical transitional

period in the lives of our soldiers and their families. Thank you

again for the opportunity to serve in this fashion.

Mr. TIERNEY. Thank you all for your statements.

Mr. Braley, you have 5 minutes.

Mr. BRALEY. Thank you, Mr. Chairman. Thank you to the panel.

Mr. Dominguez, let me start with you. You talked about the supplemental request for $50 million for the medical support fund.

Were you aware that in the supplemental passed by the House

there was $1.7 billion above the President’s budget request for

DOD medical assistance, and also $1.7 billion of additional funding

for the VA?

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Mr. DOMINGUEZ. No, sir.

Mr. BRALEY. I would suggest that you talk to people within the

Department to see what can be done within the parameters of

those additional appropriations to find room for the $50 million,

which I think would be a completely appropriate use of that funding that was added to the supplemental.

Mr. DOMINGUEZ. Congressman, Secretary Gates is committed to

fixing the problem and doing what is right. That is his standard

he has set. As we were talking about before the hearing with the

chairman, the resources are available. It is about making tough

choices. I appreciate that the Congress has made those choices in

enacting the supplementals that you have done. We will make the

tough choices, too, to get the job done.

Mr. BRALEY. One of the issues that seems to come up over and

over again is the whole inconsistency in the disability evaluation

process between the DOD and VA disability system, and one of the

concerns that is identified in the written statements has to do with

that process becoming adversarial, which is something you identified and General Pollack, you also mentioned.

The reason why those systems become adversarial is because patients feel like they aren’t being taken care of and their concerns

aren’t being heard. I did town hall meetings with veterans groups

throughout my District the last 2 weeks when we were back in recess, and this is the No. 1 concern I heard from veterans advocacy

groups is the backlog of disability claims, and that is why at the

March 5th hearing I specifically asked the final panel how many

patient advocates were there to assist people in the disability process at Walter Reed.

It was very disturbing to me that there was a misunderstanding

of the role that case managers and patient advocates play, and one

of the concerns I have about an ombudsman program is typically

an ombudsman is a clearinghouse for complaints that has the authority to hold hearings and take action on behalf of a group of dissatisfied individuals, but when you are dealing with the complex

bureaucracy that exists in the VA and DOD disability systems, you

need someone there by your side helping you on your behalf.

Whether that is an adversarial process or not is going to depend,

in large part, on how the environment is created for the processing

of those claims.

I would like to hear what institutional changes are being made

within the DOD to make sure that adversarial environment is reduced.

Mr. DOMINGUEZ. Congressman, what I will tell you is that these

are works in progress now. We have all heard the same thing that

you have heard, that the process is cumbersome, bureaucratic, unfriendly, and it loses that focus on the soldier and the family

around the wounded warrior. We all recognize we have to turn that

around and we have to re-engineer the processes.

Now, several efforts are going on right now to look at that. Each

of the services, as they have great discretion in how their process

works, is working on that. There is training involved for the people

that we put in to guide the warriors and their families through

that process.

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That is ongoing. We don’t have all the solutions yet. We are

working them aggressively.

As I said in my opening comments, when I leave here today I am

going to join the leadership of the Veterans Administration with

some of my colleagues from DOD, and we are beginning the redesign of the disability process for both our agencies and, again, hope

to have that implemented expeditiously.

Mr. BRALEY. General Schoomaker, at the March 5th hearing I

commended your brother for having the courage to say that PTSD

is real. Part of the concern I have is when we label all of these

measures with the words wounded warrior it brings about a history

that has evolved over centuries of what it means to be a warrior

and doesn’t leave much room for people who suffer from post traumatic distress order or closed-hit injuries that are diagnosed as

mild traumatic brain injuries, and give people the sense that there

isn’t a significant impairment that comes about to those individuals.

I admonished him at that time to make sure that message was

communicated down the chain of command and into the DOD and

VA health care treatment facilities to change that culture. Can you

shed any insights on what is going on under your command to

make sure that those injuries are treated and are perceived just as

real as a penetrating injury?

General SCHOOMAKER. I appreciate the question and I think you

are right on target. I think the Army, especially, has taken a very

active and aggressive role in recognizing that we are in an era

right now of emerging science and medicine in understanding the

nature of injuries in their totality of 21st century war. Some of

these injuries have undoubtedly been with us since warfare began

and hostile conflict began. Others might be elements of the newer

forms of urban warfare and the weapons that are being used

against us and our soldiers, sailors, airmen, and Marines.

But the fact is the DOD has leaned forward as far as we can and

needs to go further in understanding what it means to have mild

traumatic brain injury. I think you heard that from the first panel

here. We need some fast but good science to best understand that,

and many of us have suggested that the new Walter Reed National

Military Medical campus be a warrior care center of excellence to

include work on that.

Fortunately, Congress, in the NDAO–6 legislation gave us language to coordinate, synchronize all research and treatment within

the DOD under a blast injury program which is now being put together through the Army’s Medical Research and Material Command, my last command.

I would have to also say that changing the culture is difficult,

and we again are leaning forward as much as possible by getting

leaders, leaders, themselves, leaders of war-fighting units coming

back in the Marines and the Army, wherever they might be, to

bring their soldiers with them as we do the mandatory screening

for stress disorder-like symptoms, because those symptoms, if recognized and treated early, do not result in a lifelong, we believe,

disability from PTSD and mild traumatic brain injury.

Mr. TIERNEY. Thank you.

The gentlewoman from Minnesota, Ms. McCollum.

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Ms. MCCOLLUM. Thank you, Mr. Chairman.

To followup on the PTSD and the traumatic brain injury, how

often do you screen for that? If I have a loved one who comes to

Walter Reed, how often are they evaluated for PTSD or traumatic

brain injury?

General SCHOOMAKER. Well, ma’am, we screen as often as it is

needed as often as symptoms dictate that we should be asking

about that, but it is mandatory that every soldier, sailor, airman,

Marine on deployment is screened prior to that deployment.

Ms. MCCOLLUM. The reason why I ask the question is—and I

don’t know if this is at all the VA centers, but the VA, every time

one of our soldiers comes in now, has a screening that pops up that

does a quick evaluation, not an in-depth, but a quick evaluation to

see if that soldier might be facing post traumatic stress syndrome

or traumatic brain injury that wasn’t diagnosed right away. Are

you doing that at the DOD?

General SCHOOMAKER. We don’t have that tool, but we do

have——

Ms. MCCOLLUM. I have some other questions.

General SCHOOMAKER. Yes, ma’am.

Ms. MCCOLLUM. And I don’t mean to be rude by cutting you off.

General SCHOOMAKER. No, ma’am.

Ms. MCCOLLUM. I realize you are all talking to each other, so I

am sure Mr. Dominguez is going to work with the VA to find out

what they have, because if they have something we don’t need to

reduplicate the wheel.

Who places the DOD service personnel in the VA hospitals?

General SCHOOMAKER. That is on a case by case basis. In the

case of a soldier coming back to Walter Reed or any of our facilities—and General Pollack may want to add to this—we have relationships with VA hospitals across the country in our local communities. We also have four large VA poly trauma centers.

Ms. MCCOLLUM. I wanted to know the DOD personnel—excuse

me, I might have been too brief in asking my question—who is

there to help a soldier who has been transferred to the VA system

who still might be in the Department of Defense payroll, and to

make sure that person has someone there who can answer questions. My understanding, and I will tell you this, is that there was

one individual who was assigned to cover all the different branches

of service, which all have different rules and regulations, at our VA

system in Minneapolis, and the VA greatly appreciated having that

individual there, but through no fault of the VA or the individual

who had been assigned by DOD they rotated out every so many

months. So I want to know do you know who is responsible for having that individual assigned to a hospital?

Mr. DOMINGUEZ. Congresswoman, we will have to look at that.

We don’t have that clear in policy.

Ms. MCCOLLUM. And I bring it up because I think it needs to be

cleared up in policy.

There is a big difference between having a patient who has a

case worker assigned to them, an advocate assigned to them, and

an ombudsperson assigned to them. Those are three different roles.

So you said that you have trained, Ms. Pollack, 23 people in the

Army to be ombudspersons. Now, an ombudsperson is probably not

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the first person you should start with, going through a system, because that person is going to be a pit bull against the Army for the

patient, and I want to know what level this individual is really advocating for, because if they have to report back to the Army, if

their promotion and everything is dependent upon the Army, it

makes it very difficult to put somebody in a position to be at times

aggressively in the face of the Army. So what have we trained

here? More case workers? More general advocates to help with red

tape? Or people who are going to be in the face of the Army on behalf of the patient?

General POLLACK. I think that in this position, ma’am, they will

be in the face of the Army Medical Department, because it is the

Army that wants it done, and therefore the Army will support

them and they will be haranguing us inside the Medical Department if we are failing the soldiers. So I think that for the time

being it is a good option. Many have raised the fact that now there

are so many people engaged in the care of the patient, and that

was one of the complaints that we had from the soldiers, that there

were too many people engaged and they didn’t know who their advocate was. They didn’t know who to turn to. That is why I am

very hopeful that, as we place the nurse case manager into position

so that when the service member arrives at the facility they are assigned to a nurse that will be with them through their inpatient

procedures as far as oversight, not the moment-to-moment care,

but the planning and interaction with the family, and then continue with that service member through their entire transition

process.

Ms. MCCOLLUM. Mr. Chair, can I ask for a qualification?

Mr. TIERNEY. Briefly, sure.

Ms. MCCOLLUM. OK. So what is the job title of these 23 people?

Are they an advanced case manager? I mean, you just described

case managers. Is that the 23 individuals that the Army has

brought on?

General POLLACK. No. No, I was saying that there are people

that are going to be very closely aligned with the service members

as soon as they arrive and will stay with them, and I think that

we are going to see over time that——

Ms. MCCOLLUM. Thank you. The Chair asked us to be brief.

If you could please provide to this committee what you are doing

on these three different levels.

General POLLACK. Certainly.

Ms. MCCOLLUM. And who do they have to report for and how

much autonomy that they have. Thank you.

Mr. TIERNEY. I thank the gentlewoman.

Mr. Shays.

Mr. SHAYS. Thank you, Mr. Chairman. Again, thank you for

holding this hearing.

General Pollack, there is a view that I hold and I think a number

of other people hold that doctors do not really consider medical administration issues as part of their charge. I think you see that

even in private hospitals, as well. In other words, doctors are for

medicine and administration is for case managers.

What I would like to ask you is: what current policies or directives does the Medical Command have for medical administration

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staff that work with patients? First, do you agree with that assessment? Second, if so, how do you want to deal with it?

General POLLACK. I would disagree with that assessment for the

Medical Command, because the men and women that serve as our

physicians are also volunteers, and they would not be there if they

were not interested in caring for the men and women in uniform.

So I have always seen them as advocates for our patients.

The nurse case manager that I raised a moment ago I think is

part of that. What we are developing now is a triad with a physician, a nurse, and a line soldier, a non-commissioned officer, to be

the group of three that is able to manage all the different pieces

to ensure that patient can smoothly go through their transition and

have everything coordinated. By bringing in the different perspectives, I think that we are going to have a much more satisfied population.

Mr. SHAYS. Then what accounts for the problems we have had?

General POLLACK. I’m sorry?

General SCHOOMAKER. What accounts for the problems that we

have had? I mean, we know the problem exists. I was trying to

identify why it might exist. So you tell me why it exists.

General POLLACK. Why does the problem in the dissatisfaction of

the patient in the process?

Mr. SHAYS. Yes. And, well, first off, you can say it that way or

we can say the fact that they deservedly can be dissatisfied because

of what, and then tell me why.

General POLLACK. Well, I think that dissatisfaction is related to

the length of the process. The challenge is in explaining to people

sometimes why rehabilitation and the length of rehabilitation

needs to be in a certain timeframe.

Mr. SHAYS. That is really not the problem. I mean, otherwise,

you are saying that it is just a perception of the patient because

they just don’t understand how difficult this issue is.

General POLLACK. No.

Mr. SHAYS. And we have literally at one time close to 100 cases

that this committee was trying to help with individuals who are

getting lost in this administrative Byzantine process. We are well

beyond that. I was trying to throw out the fact that I think doctors

want to be doctors and they don’t want to be administrators. It

wasn’t meant to be unkind, it was just meant to explain something.

So if that is not the answer, is it because everybody is not communicating with each other because of paperwork and technology?

What is it?

General SCHOOMAKER. Could I just make a comment, ma’am?

General POLLACK. Sure.

General SCHOOMAKER. With respect, sir, I think what I hear

General Pollack saying is—and I think I need to say this, as well.

One of the real heartbreaking aspects of everything we have gone

through is that, whether you are a physician in uniform or a nurse

or an administrator or whether you are an NCO, whether you are

a civilian employee, we all like to feel very strongly that we are advocates for the patient. I think it speaks to how badly broken the

system is right now that the patient at the end of the day and his

or her family feels that we are all part of an adversarial system.

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I think we all play a role in every case in trying to do best by

these soldiers, ill and injured, irrespective of what the route of

their injury or their illness is.

What we understand, and I think the point about the ombudsman I think points this out, is that we need as part of that plan

to have, standing aside from the rest of us, because at the end of

the day the patient and his or her family may feel that we are part

of their problem, is to put someone in an ombudsman or a patient

representative’s role. At Walter Reed right now we have four patient representatives who are ombudsmen for patients who can

bust through bureaucracy for them. They were there before. We

didn’t put enough emphasis on that role. We have three new ombudsman that General Pollack has brought in for us to serve in

that capacity.

But I think the causes of what you have seen here, as the IRG

has laid out, are myriad. We start at Walter Reed with the fact

that we didn’t have a primary care base system, and we are working on that.

Mr. SHAYS. My red light is on, and obviously we could probably

go on since there is just three of us, but I would suggest to you

that, you know, an ombudsman is helpful, but an ombudsman is

someone who steps in when the system has broken down.

Could I make my motions now?

Mr. TIERNEY. Yes.

Mr. SHAYS. I mean, one of the things that it seems to me we

need to be doing is we need to create, obviously, a Defense-wide

ombudsman office that people can turn to. This is one of the suggestions that has come out of the work of our committee that you

served on, as well, last time. I would like to submit this for the

record. It is H.R. 1580.

Another one, this was actually advocated by Mr. Bilirakis this

year. Another one is by myself and Mr. Davis, and this establishes

a monitoring and medical hold over for performance standards.

That is H.R. 1578.

Another is 1577, submitted by myself and others, and this is to

create a Department of Defense wide program of patient navigators

for wounded members of the armed forces, people who actually

take on each individual patient and walk them through the process.

Finally, one to create a standard per-soldier patient tracking system that goes from one branch to the other.

I would just like to say I would love a hearing, Mr. Chairman,

and I think that you would be inclined to want to look at it, and

I think the committee is already, but just the hand off from the active armed forces to our veterans, because we are having just an

abysmal time getting records of individuals once they go into the

VA system. It is like somehow there aren’t any records for our military personnel. You are not going to be holding on to these folks

indefinitely. They are ultimately going to be veterans.

I know we are all wrestling with this issue but it actually took

pictures to get the military to want to do something in the way

that they are doing it now. It took pictures. Yet, I think as you

know, Mr. Schoomaker, Building 18 does not define Walter Reed in

one way or the other.

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Thank you, Mr. Chairman.

Mr. TIERNEY. Without objection, copies of those bills will be

added in the record.

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Mr. TIERNEY. Thank you, Mr. Shays.

General Pollack, I don’t want to ask you a question on this but

I just want to make a quick point on that. I think attitude is important, and I think that the report that was filed by the IRG had

some comments to make on what has been happening in the past

and also the leadership issues there. You were on record on March

13th indicating that the media, you sort of attacked the media,

down-played the problems at Walter Reed, and I think your quote

from your e-mail read that the media makes money on negative

stories, not by articulating the positive in life. Then you added that

you then went on to articulate your displeasure with the misinformation about the quality of care.

I hope that is an indication that you were trying to distinguish

between those parts of the service that had been working will, but

an acknowledgment, at least, that much has gone wrong, because

if you are going to be the leader of this situation and now you are

going to sit here and tell us that nothing is wrong in the face of

the IRG report, our March 5th hearing, and the numerous other reports on that, I think I would be a little hard-pressed to think that

you would be the person that should be responsible for fixing it.

General POLLACK. May I make a comment?

Mr. TIERNEY. If you would like, sure.

General POLLACK. The purpose of that e-mail was because the

staff across the MEDCOM were reeling from all of the negativity,

and we have men and women in and out of harm’s way that have

been working very, very hard, and it was my attempt, as one of the

senior leaders, to remind them that they are doing a number of

very good things and not to stop doing those things.

Sir, I joined the Army because my big brother had his leg blown

off in Vietnam. I am very, very committed to the care of the men

and women who serve. I am not going to pretend at any time if

something is broken that it is not. But at the same time, I needed

to reach out to the staff, and that was what the purpose of that

e-mail was.

Mr. TIERNEY. So it is not an attempt at all to fail to acknowledge

that there were things that need correction?

General POLLACK. No, sir.

Mr. TIERNEY. OK.

General POLLACK. No, sir.

Mr. TIERNEY. Thank you.

Mr. Dominguez, in your comments—and I think all three of you

talked about it, as did the first panel—we are talking about senior

leaders of the military departments, of the Office of the Secretary

of State beginning the process of designing a system optimized for

wounded and severely wounded service members, speeding disability determinations, and providing support for their transition to civilian life, which Mr. Shays was just talking about on that. What

is going to be done in the interim for that while we are waiting for

those final reports to come out? Is there anything we can do to

make that transition better in the short run?

Mr. DOMINGUEZ. I think the steps that are being taken by the

individual services are actually quite noteworthy in this regard, because a lot of the discussions that we have had here are about the

patient advocates and case managers and ombudsmen. One of the

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things that we didn’t discuss, which both the Army and the Marine

Corps have done, is put in for the wounded warriors a chain of

command, assign them to a unit, give them a squad leader, give

them a first sergeant, give them a commander. If you want a bulldog advocate for taking care of troops, it is called a first sergeant

or squad leader.

Those are now going into place. Those people will have as their

mission, the command’s mission is helping that wounded warrior

and family transition either back into service or back out to civil

society. That is the kind of thing that closes the seams that Congressman Shays was talking about when he was identifying those

different fixes.

The tragedy that these two officers were just talking about is the

total commitment we have of people working inside their seams,

believing that what they are doing is solving the wounded warriors

problem, but not realizing that to the warrior, who is looking at

this as a seamless process, that it is fragmented and broken and

confusing.

Well, a CO, a first sergeant, and a squad leader can fix that. I

think that is the most significant thing that has been done by both

the Army and Marine Corps since your hearing on March 5th.

Mr. TIERNEY. Let me take it up a notch then on that. On page

6 of your testimony you say that we have invited representatives

from the Veterans Administration to sit on the council to assist the

process as we strive for a seamless transition for our service members from the Department of Defense disability system to the Veterans Administration system. We anticipate a revised Department

of Defense instruction will be completed in May 2007.

Mr. DOMINGUEZ. Yes.

Mr. TIERNEY. So you are talking about the Department of Defense’s instructions.

Mr. DOMINGUEZ. Yes.

Mr. TIERNEY. My question to you: has the President clearly indicated at his insistence that this be a seamless process, and has he

communicated that to the Veterans Administration as well as to

the Department of Defense, and has he designated somebody from

the White House to so ride herd on this thing? Because you can get

your Department of Defense instructions and the Veterans Administration can get its instructions. The question is: are they going to

be joint instructions and is somebody from higher up going to give

you license to cut across that and, in fact, insist on it?

Mr. DOMINGUEZ. Yes, sir. The President set up two commissions

to advise him. First he put Secretary Nicholson in charge of an

interagency task force and they have spoken on this issue. We are

presently reviewing their recommendations. And then the President’s Commission. So the President——

Mr. TIERNEY. You said a commission, but is there any indication

that the White House has somebody who is going to be riding herd

on this thing, an individual who is responsible, who this committee

can hold accountable for making sure that is done, because I don’t

want to be sitting here criticizing the Department of Defense when

it has done its work and it has given its instructions and the Veterans Administration has done its work and done its instructions.

Mr. DOMINGUEZ. Right.

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Mr. TIERNEY. It will all come down to the White House as to

whether or not they have them working together and giving them

the support to do that.

Mr. DOMINGUEZ. Well, first of all, I conveyed to you Secretary

Gates’ and Secretary Nicholson’s commitment to fixing this problem without regard to where the seams are. The President did put

Secretary Nicholson in charge of the interagency task force, but,

again, you know, the President can’t specify what the answer is

right now.

Mr. TIERNEY. He can sure make sure there is an answer.

Mr. DOMINGUEZ. But he took these two actions to bring to him

the recommendations for how to fix this, and so from that I anticipate, you know, a powerful and strong action by the White House.

In the interim, our two agencies are working very closely together. I am going to join Under Secretary Cooper this afternoon,

and we are working this problem. And Gates and Nicholson are

passionate about getting this right.

Mr. TIERNEY. Do you, sir, agree that the physical evaluation,

physical disability evaluation system should be completely overhauled to implement, one, Department of Defense level Physical

Evaluation Board/Appeals Review Commission with equitable service representation in an expansion of what is currently the Disability Advisory Council, as the IRG recommended?

Mr. DOMINGUEZ. Sir, I would like to withhold my personal judgments on that pending the work that we are going to be doing evaluating the IRG’s recommendations and the work we have already

been doing for the last month or so.

Mr. TIERNEY. How long do you think it will take you to make

that evaluation?

Mr. DOMINGUEZ. Secretary Gates will be back here on April 27th.

I think he is scheduled to see the IRG, like, May 3rd or 4th. I expect he will want the DOD staff’s recommendations to him about

May 5th.

Mr. TIERNEY. Directly after May 5th I am going to ask that you

communicate to the Secretary that one of you get back to the committee with whether or not they agree with that assessment of the

IRG.

Mr. DOMINGUEZ. Yes, sir.

Mr. TIERNEY. And, if they agree that can be done, the process

can be completed within 1 year, as was testified here this morning,

and, if not within 1 year, what would be a reasonable time for us

to expect it to be completed so that we can continue our responsibilities there.

Mr. DOMINGUEZ. Mr. Chair, if I might, one of the things that we

are thinking about and just beginning the dialog inside the Department is for authority for the Congress to pilot on a subset of the

population just that kind of thing. This is a complex system. We

feel like if we could take something, put it in place, operate it for

several months, that by this time next year we would have concrete, hard evidence from a process that worked that we could

learn from and that we could come back to the Congress with very

clear and detailed findings leading to legislation.

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Mr. TIERNEY. I hope that, pilot or no pilot, that within a year or

so we have some firm answers on that, but I hear what you are

saying.

We have received reports, we have seen articles about some injured soldiers being given lowered disability ratings they say because the Army doesn’t want to pay the 30 percent, the current

maximum compensation, for a large number of permanently

wounded soldiers. Have any of you investigated allegations of that

nature? How are we going to have somebody accountable to make

sure that is not happening?

General POLLACK. There is a review of that process going on

now, sir. I don’t have those specifics in front of me.

Mr. TIERNEY. Will you share them with the committee when you

have a chance to get them?

General POLLACK. Yes, sir.

Mr. DOMINGUEZ. I do, sir, want to say this came up in testimony

that Secretary Garon and Secretary England had before another

committee of the Congress last week, and they were unequivocal in

that our policy instructions are directives to these boards. That is

not part of the calculus that they are supposed to be thinking

about. This is to be what is the disability and how does it rate in

the schedule and make a determination.

Mr. TIERNEY. I will look forward to General Pollack’s response on

that. I appreciate it.

Mr. Shays, if you will just bear with me 1 second, I have some

unfinished business.

General Schoomaker, do you know if Staff Sergeant Dan Shannon had his reconstructive surgery scheduled yet, one of the witnesses in our first panel?

General SCHOOMAKER. Yes. I am trying to recall the status of

him. I know one of the two soldiers has returned to Fort Campbell

on active duty, Sergeant Duncan. I don’t know the status of Shannon, but I can get back to you on that.

Mr. TIERNEY. Would you do that for us?

And can you tell us whether or not the Army has taken any steps

to review the denial of benefits to Corporal McCleod? I recall that

it was determined at one review that his brain function problems

they said were the result of a pre-existing learning disability rather

than a traumatic brain injury.

General SCHOOMAKER. I can check on that, sir.

Mr. TIERNEY. Could you see if that has been re-evaluated?

And Specialist Duncan has been returned to service, has he?

General SCHOOMAKER. As far as I know. I saw him last week or

the week before, and he was on his way back to Fort Campbell.

Yes, sir.

Mr. TIERNEY. Thank you.

Last question I have is about the problem that was testified to

earlier, which I have heard in my District from some people involved with the psychological and psychiatric units, a declining

number of mental health, behavioral staff in the medical system

and some problems about out-sourcing some of that, contracting

out, which these people that were talking to me did not feel was

as good as having people within the service.

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I know that the preliminary findings of the American Psychological Association that 40 percent of the Army and Navy active

duty licensed clinical psychologist billets are presently vacant, and

the IRG, of course, found that has affected the care and treatment

of TBI and post traumatic stress disorder. What are we doing about

that and what are we going to continue to do about that, if you

would?

General POLLACK. Sir, we recently had approved at the Department of Defense level a critical skills retention bonus that we are

implementing in 2007 to retain those officers. We have also established, because the behavioral health profession is so broad, we

have instituted a master’s of social work to assist with the, as well,

and that program will begin in 2007, as well.

Mr. TIERNEY. Thank you. And one of the Secretaries made a

point that if they are recruiting doctors over 50 they might have

some success if they didn’t impose the 8 year commitment rule. Is

that being reviewed at all?

General POLLACK. Yes, sir. The G–1, the personnel community,

is working that as a policy and as a legislative proposal, because

I think we need relief. If I remember correctly, we need relief from

a title 10 requirement.

General SCHOOMAKER. We approve of doctors over 50, sir.

Mr. TIERNEY. I approve of all people over 50. Thank you.

Mr. Shays.

Mr. SHAYS. Thank you. I just have a few questions.

Secretary Dominguez, Ellen Embry, the then Deputy Assistant

Secretary of Defense for Force Health Protection and Readiness,

testified before this Committee on Government Reform in 2005 that

DOD would direct all possible resources to address outpatient process. Why did this not happen, No. 1? Who dropped the ball? What

will the Under Secretary do to see that he maintains oversight and

input into policies that affect our war wounded?

Mr. DOMINGUEZ. Sir, unfortunately I am not able to tell you who

dropped the ball. In terms of what we are doing——

Mr. SHAYS. Well, let’s not answer the question who dropped the

ball, but answer this: why did this not happen?

Mr. DOMINGUEZ. Why did this not happen? Well, I think there

is some uncertainty, but many of us believe that a shortage of resources was not the issue, that there were adequate resources in

the system to be able to deal adequately with outpatient care.

There were some real problems at Walter Reed, in particular, as

you heard from the IRG, associated with BRAC and A–76 that, in

the implementation of those program stuff, created a real capability

gap that was noticed by patients and families and resulted in problems that we saw.

So I don’t know that it was a resource problem, and I don’t believe it was a policy direction and policy architecture problem. It

manifested itself in execution at this one facility because of the perfect storm of events.

Mr. SHAYS. This is not a problem at one facility. Outpatient is

a problem throughout.

Mr. DOMINGUEZ. Yes, sir, and as a result of the light shining on

Walter Reed, all of the services sent people out to all of the facilities where they have——

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Mr. SHAYS. I guess the problem that is discouraging is, you

know, this was not a new problem. We documented it was a problem. We had people testify under oath that they would take care

of the problem and the problem was not taken care of. You know,

it makes you wonder.

Let me ask another question. The IRG recommends that the

physical disability evaluation system must be completely overhauled to include changes in the U.S. Code, Department of Defense

policies and service regulations resulting in one integrated solution.

First, I want to know if you agree in one integrated solution. Then

I would like to know your honest assessment of how this will be

done and how long it will take and what resources will be needed.

That is the end of my questions, but I would like an answer.

Mr. DOMINGUEZ. Again, I think one integrated solution is one we

absolutely, positively, clearly have to look at. I thank the IRG for

putting it on the——

Mr. SHAYS. Look at does not mean have.

Mr. DOMINGUEZ. Yes, sir, because we are now evaluating the

IRG’s recommendations.

Mr. SHAYS. So you think you need to look at it, but you are not

sure you need to do it?

Mr. DOMINGUEZ. At the current time I know we have to do something to change this process. It is not working. It is not working

for service members and families. It is not doing what we——

Mr. SHAYS. How long is it going to take for you to decide you

need an integrated system?

Mr. DOMINGUEZ. Sir, I think we are going to evaluate, in collaboration with the VA, we are going to look at designing that system,

we are going to look at the statutory bases for the systems of disability that now work, which are different for the DOD, for the VA,

and for the Social Security Administration.

We will see how you can reconcile those competing or those different policy objectives—they are coded in the statutes enabling

these things—into one system, see how we can make that work, if

we can figure out how to do that, honoring the statutory bases of

the different calls that have to be made—are you fit to serve, or

do we have to terminate your career, have you lost income, and are

you unemployable.

So these different things have to be welded together into the system. We will see if we can make that work, and then we will come

back with a proposal.

Mr. TIERNEY. If the gentleman would yield?

Mr. SHAYS. Yes.

Mr. TIERNEY. I understand from your earlier answer that by May

5th or immediately thereafter you are expecting to get back to us

as to whether or not it can be combined into one, and then how

much time you think it will take you to do that.

Mr. DOMINGUEZ. Yes, sir, we are going to try to move that expeditiously. I am hoping we do that by May 5th, because that is when

we will have our conversation with Secretary Gates, and he will expect us——

Mr. SHAYS. What I would have thought the answer would have

been would have been, one, we know we need to do it, we just don’t

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know how long it is going to take, and this is what we are going

to do to figure out how long it is going to take.

Mr. DOMINGUEZ. Yes, sir.

Mr. SHAYS. But, you know——

Mr. DOMINGUEZ. I have to be able to assure you that in one system I can be true to the purpose that is enshrined in each of the

statutes that provide a piece of the disability continuum that——

Mr. SHAYS. I asked one basic, simple question. How long will it

take for the various hospitals, VA hospitals, to know that they can

get records that are accurate about the servicemen and women that

they are not treating?

Mr. DOMINGUEZ. Sir, if we have shared patients, I believe that

is happening now with the bi-directional health information exchange that has been in place. We are sharing records. There are

problems. There are, you know, many different pieces of a medical

record. These two can be more specific about it, but that is a major

effort, and we are sharing data on millions of patients right now

with the VA back and forth.

General POLLACK. Sir, if I might?

Mr. SHAYS. Sure.

General POLLACK. There is significant progress that is promised

at this time that by the end of the summer the VA and DOD

should be linked. It will not be as clean as a simple click on your

computer to move from one screen to another, because you will

need to go into the other system and query, but General

Schoomaker and I yesterday afternoon were briefed by Mr. Foster

and his team from TMA, because this is a concern for us, as well,

and there seems to be progress on this. But we will need to see it.

Mr. SHAYS. One is being able to share information within DOD

and another to be able to share information between DOD and the

VA.

General POLLACK. Yes, sir.

Mr. SHAYS. And in these United States, with such bright people

and the resources that we should be able to put, it just seems to

me it is more an issue of will rather than of anything else, just the

will.

General SCHOOMAKER. Sir, we are assured that by the end of the

summer that we will have bi-directional exchange of a large

amount of the clinical record available to both the DOD and the VA

system.

Mr. DOMINGUEZ. And there is a significant technological challenge here, Congressman. There is the will. There is actually commitment by the leadership of VA and DOD to make this happen.

It is a challenging problem and we are working on it very hard.

We are not, by any means, where we need to be as a Nation.

Mr. TIERNEY. Before we wrap up, we asked for a number of

records in a previous request back on March 5th, or whatever, and

unfortunately this is all we have received so far, which is obviously

quite inadequate for that, and a considerable amount of time has

passed. Do we have your assurance? And who is going to take responsibility to make sure that those requests are completed in full

and promptly?

Mr. DOMINGUEZ. Yes, sir.

Mr. TIERNEY. General Schoomaker.

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General SCHOOMAKER. I will have the first delivery of those documents to you this week, sir.

Mr. TIERNEY. Well, when is the last delivery going to come? I

mean, this is the first delivery, I guess. When can we expect that

we will have it? Within a reasonable period of time here?

General SCHOOMAKER. Yes, sir. I think I will have——

Mr. TIERNEY. We are already beyond a reasonable period of time,

so now we are going to give you a second reasonable time, if we

can.

General SCHOOMAKER. I understand, sir.

Mr. TIERNEY. Thank you.

Thank you all for your testimony. Thank you for your service to

your country, as well. We don’t mean to be individually tough on

you, specifically, but I think you share our need to be tough on this

issue, and we appreciate your willingness to cooperate. Thank you.

[Whereupon, at 12:55 p.m., the subcommittee was adjourned.]

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