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38–833 2008

[H.A.S.C. No. 110–29]

CHALLENGES AND OBSTACLES WOUNDED

AND INJURED SERVICE MEMBERS FACE

DURING RECOVERY

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

HEARING HELD

MARCH 8, 2007

(II)

HOUSE COMMITTEE ON ARMED SERVICES

ONE HUNDRED TENTH CONGRESS

IKE SKELTON, Missouri

JOHN SPRATT, South Carolina

SOLOMON P. ORTIZ, Texas

GENE TAYLOR, Mississippi

NEIL ABERCROMBIE, Hawaii

MARTY MEEHAN, Massachusetts

SILVESTRE REYES, Texas

VIC SNYDER, Arkansas

ADAM SMITH, Washington

LORETTA SANCHEZ, California

MIKE MCINTYRE, North Carolina

ELLEN O. TAUSCHER, California

ROBERT A. BRADY, Pennsylvania

ROBERT ANDREWS, New Jersey

SUSAN A. DAVIS, California

RICK LARSEN, Washington

JIM COOPER, Tennessee

JIM MARSHALL, Georgia

MADELEINE Z. BORDALLO, Guam

MARK UDALL, Colorado

DAN BOREN, Oklahoma

BRAD ELLSWORTH, Indiana

NANCY BOYDA, Kansas

PATRICK J. MURPHY, Pennsylvania

HANK JOHNSON, Georgia

CAROL SHEA-PORTER, New Hampshire

JOE COURTNEY, Connecticut

DAVID LOEBSACK, Iowa

KIRSTEN GILLIBRAND, New York

JOE SESTAK, Pennsylvania

GABRIELLE GIFFORDS, Arizona

ELIJAH E. CUMMINGS, Maryland

KENDRICK B. MEEK, Florida

KATHY CASTOR, Florida

DUNCAN HUNTER, California

JIM SAXTON, New Jersey

JOHN M. MCHUGH, New York

TERRY EVERETT, Alabama

ROSCOE G. BARTLETT, Maryland

HOWARD P. ‘‘BUCK’’ MCKEON, California

MAC THORNBERRY, Texas

WALTER B. JONES, North Carolina

ROBIN HAYES, North Carolina

KEN CALVERT, California

JO ANN DAVIS, Virginia

W. TODD AKIN, Missouri

J. RANDY FORBES, Virginia

JEFF MILLER, Florida

JOE WILSON, South Carolina

FRANK A. LOBIONDO, New Jersey

TOM COLE, Oklahoma

ROB BISHOP, Utah

MICHAEL TURNER, Ohio

JOHN KLINE, Minnesota

CANDICE S. MILLER, Michigan

PHIL GINGREY, Georgia

MIKE ROGERS, Alabama

TRENT FRANKS, Arizona

THELMA DRAKE, Virginia

CATHY MCMORRIS RODGERS, Washington

K. MICHAEL CONAWAY, Texas

GEOFF DAVIS, Kentucky

ERIN C. CONATON, Staff Director

DEBRA WADA, Professional Staff Member

JEANETTE JAMES, Professional Staff Member

MARGEE MECKSTROTH, Staff Assistant

(III)

C O N T E N T S

CHRONOLOGICAL LIST OF HEARINGS

2007

Page

HEARING:

Thursday, March 8, 2007, Challenges and Obstacles Wounded and Injured

Service Members Face During Recovery ............................................................ 1

APPENDIX:

Thursday, March 8, 2007 ........................................................................................ 63

THURSDAY, MARCH 8, 2007

CHALLENGES AND OBSTACLES WOUNDED AND INJURED SERVICE

MEMBERS FACE DURING RECOVERY

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Hunter, Hon. Duncan, a Representative from California, Ranking Member,

Committee on Armed Services ............................................................................ 1

Skelton, Hon. Ike, a Representative from Missouri, Chairman, Committee

on Armed Services ................................................................................................ 22

Snyder, Hon. Vic, a Representative from Arkansas, Committee on Armed

Services ................................................................................................................. 1

WITNESSES

Chu, Hon. David S.C., Under Secretary of Defense (Personnel and Readiness) 2

Kiley, Lt. Gen. Kevin C., The Surgeon General, U.S. Army ................................ 7

Schoomaker, Gen. Peter J., Chief of Staff, U.S. Army ......................................... 5

Winkenwerder, Hon. William, Jr., MD, MBA, Assistant Secretary of Defense

for Health Affairs ................................................................................................. 3

APPENDIX

PREPARED STATEMENTS:

Chu, Hon. David S.C. ....................................................................................... 72

Kiley, Lt. Gen. Kevin C. ................................................................................... 97

Schoomaker, Gen. Peter J. ............................................................................... 92

Skelton, Hon. Ike .............................................................................................. 67

Winkenwerder, Hon. William, Jr. ................................................................... 86

DOCUMENTS SUBMITTED FOR THE RECORD:

Chart Funding for the Armed Forces Health Longitudinal Technology

Application (AHLTA) submitted by Dr. Chu .............................................. 158

Letter to the Secretary of Defense submitted by Hon. Jeff Miller ............... 156

Memorandum on the Challenges and Obstacles Wounded and Injured

Service Members Face During Recovery ..................................................... 111

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:

Mr. Andrews ..................................................................................................... 167

Mr. Jones ........................................................................................................... 167

Mr. McHugh ...................................................................................................... 165

Mr. Miller .......................................................................................................... 168

Page

IV

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD—CONTINUED

Mr. Ortiz ........................................................................................................... 164

Mr. Skelton ....................................................................................................... 161

Mr. Smith .......................................................................................................... 166

Dr. Snyder ......................................................................................................... 166

(1)

CHALLENGES AND OBSTACLES WOUNDED AND

INJURED SERVICE MEMBERS FACE DURING RECOVERY

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, Washington, DC, Thursday, March 8, 2007.

The committee met, pursuant to call, at 10:03 a.m., in room

2118, Rayburn House Office Building, Hon. Vic Snyder presiding.

OPENING STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM ARKANSAS, COMMITTEE ON ARMED SERVICES

Dr. SNYDER. The hearing will come to order.

We appreciate you all being here on this cold, snowy morning.

Mr. Skelton will be joining us probably in the 10:30, 10:45 range,

but he wanted us to go ahead and begin the meeting.

It is a pleasure once again to have all of you here with us, wellknown to this committee: Dr. Chu, Dr. Winkenwerder, General

Kiley.

And, General Schoomaker, you are a bit like the old pair of slippers that just keeps coming back in the house once it is set outside.

And I think we said goodbye to you the last time that you were

here, thinking it was going to be your last time to testify. But we

appreciate your service and appreciate you being with us.

Yesterday evening, Mr. McHugh and I met with some of our staff

members for an hour or so, because this body, this house, is very

interested in trying to help resolve some of these issues involving

the medical holdovers, the Walter Reed situation, with legislation.

And so, you all may interpret that as bad news. We interpret

that as good news. But the good news part of it is Mr. McHugh and

I really want the legislation to be helpful. And we also recognize

that sometimes legislation may not be helpful.

So I think some of the questions today will try to get at things

that we may at least take a first bite at this here in the next few

weeks, recognizing that there is no one piece of legislation or one

decision by any one of you that is going to solve the kinds of issues

that we are dealing with.

And before going to the witnesses, I will defer to Mr. Hunter for

any comments he would like to make for as much time as he needs.

STATEMENT OF HON. DUNCAN HUNTER, A REPRESENTATIVE

FROM CALIFORNIA, RANKING MEMBER, COMMITTEE ON

ARMED SERVICES

Mr. HUNTER. Thank you, Mr. Chairman.

And, gentlemen, good to be with you. I look forward to your testimony this morning.

2

I think the position of the committee clearly is, let’s figure out

what went wrong and fix it.

One thing that I did want to say to my colleagues on the committee is that we have had a bipartisan team of staff members, Democrat and Republican staff members, attending medical facilities

throughout the country and in other areas where we have American troops for the last several years.

And, Mr. Chairman, we did something several years ago that I

think had never been done by the Armed Services Committee before, and that was to dedicate a staff member from the committee

to simply handle issues that patients of our Department of Defense

(DOD) medical system experienced, and to talk to their families

and try to assist them as they go through the process of coming

back from Landstuhl and other areas to Walter Reed, Bethesda,

and then, ultimately, out to satellite hospitals throughout the DOD

complex.

So, gentlemen, I look forward to your testimony. There certainly

appears to be a lot of work to be done.

And, Mr. Chairman, thank you for calling this important hearing

this morning.

Dr. SNYDER. Thank you, Mr. Hunter.

Our four witnesses today are well-known to this committee and

this Congress and this country for their service: Dr. David Chu, the

undersecretary of defense for personnel and readiness; Dr. William

Winkenwerder, the assistant secretary of defense for health affairs;

General Peter Schoomaker.

Did I pronounce that right, General? Schoomaker?

General SCHOOMAKER. Schoomaker, sir.

Dr. SNYDER. Schoomaker?

General SCHOOMAKER. Yes, sir.

Dr. SNYDER. Okay. At the last hearing, you are entitled to have

your name pronounced right for the first time, perhaps, in your career—Schoomaker, chief of staff of the U.S. Army; and Lieutenant

General Kevin Kiley, the surgeon general of the U.S. Army.

And we will have your opening statements in that order.

Dr. Chu.

STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF

DEFENSE (PERSONNEL AND READINESS)

Dr. CHU. Thank you, Mr. Chairman, Congressman Hunter, members of the committee. My colleagues and I each have prepared

statements which I hope you would accept for the record.

Dr. SNYDER. Without objection, all the statements will be part of

the record.

Dr. CHU. Thank you, sir.

I am deeply chagrined by the events that bring us to this hearing

today. As you appreciate, we set high standards in the Department

for our personnel programs and their administration.

You can see the achievement of those high standards in the conduct of our medical personnel in caring for the wounded on the battlefield, bringing them home to the United States and placing them

on the road to recovery.

3

It is evident in the fact that we have the lowest disease and nonbattle injury rate in the history of the republic and the highest rate

of survival from wounds the American military has ever sustained.

And you can see it also in the generally favorable ratings that

our patient population—active, reserve, retired—gives to the

TRICARE medical program. Indeed, the Congress has added communities to that program over the last several years, as a result

of the high regard in which it is held.

But I wish to apologize this morning on behalf of the Department

to those individuals where we fell short in administration, in

billeting, in how we carry out the disability claims process.

And I apologize likewise to the American public.

I would like to ask my colleagues to speak to medical programs,

per se, and I would return very briefly, if I may, Mr. Chairman,

to speak to the disability evaluation system, which I do think is the

area in which long-term legislative change may be meritorious.

STATEMENT OF HON. WILLIAM WINKENWERDER, JR., MD,

MBA, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

Dr. WINKENWERDER. Thank you, Mr. Chairman. Thank you for

your support to all of our efforts over the year.

Mr. Chairman and distinguished members of this committee,

thank you for the opportunity to be here today to talk about the

serious concerns raised about housing conditions and inappropriate

bureaucratic delays and hurdles for service members at Walter

Reed Army Medical Center while those individuals are receiving

long-term rehabilitation and care.

Our wounded service members and their families expect, and

they deserve, quality housing and family support along with wellcoordinated services. In the case of the incidents at Walter Reed,

we failed them.

Today, I welcome the chance to talk about these issues and what

the Department is doing, even at this time, to move forward.

Corrective action plans in the Army and across the Department

will take the following approach.

One, the top priority is finding problems and fixing them. Where

policy, process, or administrative change is required, the Department will do it.

Second, we welcome public scrutiny, and that—this point—that

is a difficult thing to say, but we do, as painful as it is. The problems cannot be solved and the people properly served if the light

is not shed on the problem, and that is happening.

I endorse the statements of Secretary Gates. He has made it

clear that defensiveness and explanations are not the route to getting things done. Standing up and making things happen to meet

the needs of our service members and their families is our only job

right now.

Let me just assess the problems before us as follows. And I think

Dr. Chu is kind of touched on this.

It relates to physical facility issues, process of disability determination—and there will be a lot more to talk about with that—

and the process of care coordination in the outpatient long-term

setting, not in terms of acute outpatient care.

4

With regard to the housing, I understand that the Army has already begun correcting problems and is reviewing all housing for

wounded service members at other locations. The other services

have also undertaken a review, and that review is ongoing.

With respect to the disability determination process, let me just

say that service members deserve fair, consistent and timely determinations. The complex procedures must be streamlined or removed. The system must not be adversarial, and people should not

have to go through a maze or prove or defend themselves to the

benefits that they deserve.

Likewise, regarding coordination of services, there must be a

higher ratio of case workers to wounded service members, so that

people get personalized care, a better support and communication

system with the families, and simpler administrative processes.

Now let me just address one issue, and I think this is important—we will have more discussion about it today; make that very

clear. The problems sighted in the press reports are not result of

unavailable or insufficient resources. Nor are they in any way related to the base realignment and closure (BRAC) decision to close

the Walter Reed campus as part of the planned consolidation with

the National Naval Medical Center.

Significant resources have always been available, and we continue to invest, even at this day, at Walter Reed for whatever is

needed.

For example, there were some who questioned the decision in 2005 to fund $10 million to construct Walter Reed’s new amputee

center. But we have proceeded with that without hesitation. We

think that is the right thing to do. And we will simply not allow

for plans for a new medical center to interfere with ongoing issues

of care or any needed facility improvements.

Secretary Gates’ decision to establish an independent review

group to evaluate and make recommendations on this matter will

be very beneficial. The group is a highly qualified and, again, bipartisan team of former congressmen, line, medical and enlisted

leaders who have already begun their work. And, of course, in addition to that, there is the commission that the President just announced here within the last couple of days, who will also be looking at these issues even more broadly, including the Veterans Administration (VA).

The entire Department has been informed of the review group’s

charter. Group members can go to any installation, talk to any personnel, review any policy or procedure to get the information and

answers they need. They will have full support of the Department.

The Department will be driven for results in the actions that we

take in the weeks ahead: engaged, action-oriented, and focused on

making real and permanent improvements.

The people we serve—the service members, families, military

leaders, Congress and the President, the secretary, everybody—

they deserve to know that we are getting the job done. We have

attacked problems in the past and solved them and come out

stronger as a result, and I believe that we can do that again.

We have established new standards, as Dr. Chu noted, in virtually every category of wartime medicine. Many people don’t know

that we have established new standards in everyday medicine for

5

America that has a great impact on improving health care in America.

The quality of our medical care for our service members is excellent. No one should question that aspect of this issue. There is no

question about that.

On the other hand, with regard to the quality of life for people

while they are receiving that care, that is where our focus is. That

is where we did not meet our standards.

In the current news reports, the trust that has been earned

through our historic achievements has been damaged. And that

trust was earned through a lot of hard work, but we have got to

work even harder to re-earn that trust.

So, in closing, let me just say that, as we work together on all

these issues, I would like to point out one other important thing,

and that is, I believe it is very important at this time that we

maintain the morale of our medical professionals, of all those who

serve our warriors.

And we need to maintain the confidence of our entire military in

the military health system. It is critically important. People should

not question, should not lose their confidence about the care that

they will receive. And I urge that you work together with us on

that matter.

I look forward to working together with you and with the leaders

within the services in the Department in the remaining weeks of

my tenure, and I am grateful to have had the opportunity to have

worked with selfless and committed and dedicated professionals

and patriots who care for our wounded warriors. They are our Nation’s heroes, and, as such they deserve our very best.

Thank you.

[The prepared statement of Dr. Winkenwerder can be found in

the Appendix on page 86.]

Dr. SNYDER. Thank you.

General Schoomaker.

STATEMENT OF GEN. PETER J. SCHOOMAKER, CHIEF OF

STAFF, U.S. ARMY

General SCHOOMAKER. Mr. Chairman, distinguished members of

the committee, you know, as chief of staff of the Army, as a senior

uniform military officer in the Army, I am responsible for everything that happens and fails to happen in the United States Army.

And so I take full responsibility for the situation that has caused

us to appear before you again today.

As you have already stated, I had hoped that the last appearance

before you would have been my last, and I am disappointed that

these circumstances are the ones that bring me before you again.

But we have worked well together in the past, and we are going

to need your help to fix the things that we have found in this.

I will tell you that one of the things that is disturbing is, with

the amount of attention and the amount of resources that we have

placed into this area, that we find the kinds of conditions and situations that have been reported.

And one of the things we need to find out is why, within the

leadership structure, that these kinds of surprises surface. It

doesn’t make sense. We have had hundreds and hundreds, if not

6

thousands, of visits to all of our medical facilities. You have visited

a great many times. I certainly have. The leadership has. And to

have these kinds of things appear the way they were is—doesn’t

make sense to me.

There is an opportunity here that I hope we take, and that is fix

this comprehensively. This isn’t about painting things and dealing

with mildew and fixing some administrative processes. There needs

to be a really top-down look at the statutes that underpin the kinds

of things that we do, the fact that there are different laws—Title

10 for DOD in terms of compensation, Title 38 for the VA, which

has a different structure for compensation, and I understand even

Social Security/Medicare business is another statute.

We, clearly, have differences in the services and how our administrative procedures are put together. The policies aren’t uniformly

administered.

And so I think that this really, as difficult as it is, is an opportunity to do a comprehensive fix. And I hope that is what we are

all committed to doing, you know, as we look at this.

Again, I would like to remind everybody that every day there are

thousands of very dedicated medical professionals that are tending

to our soldiers and their families.

And I really am concerned that we paint broadly across this entire professional community with some of the things that have been

reported, and we fail to recognize that there are real heroes in our

hospitals—and on the battlefield and everywhere else in the medical community—that, every day, are working against great odds

and great obstacles, great bureaucracy, to tend to our soldiers and

their families well.

And I hope you will keep that in mind as we go through not only

our discussions, but the subsequent fixes to what we do.

I am very, very proud of these people. And, as you know, one of

them happens to be my brother, and so I have some great insights

into it.

Finally, what I would like to say is, we have been aggressively

fixing this and pursuing fixes, not only with massive so-called tiger

team approach, but we are doing surveys all across the country,

going out and inspecting all over the place, not just Walter Reed.

But at Walter Reed, we have appointed a new commander there.

He happens to have the same last name as I have. He is a very

talented individual. And I know that he will go about this.

I want to make it clear that I was recused from participating in

the decision to select him, but in my view, he is the right man to

go into there.

We are going to give him—and it will be announced this week—

a brigadier general combat arms officer who will be his deputy.

And that combat arms officer will help look at the situation at Walter Reed from a perspective of the battlefield and as a leader of

combat soldiers.

We have already appointed a combat arms brigade commander

with experience in the war on terrorism, and he has a command

sergeant major. And we have restructured the entire team out

there to make sure that the soldiers are getting the leadership and

the assistance that they require.

7

We have established a hotline directly into the Army Operations

Center, which means that every call is recorded and is required to

be reported to the very top leadership of the Army on anybody that

has a problem out there. It would be a toll-free number. And that

will occur.

And there are many other things that we are doing to make this

right, to include looking at an ombudsman program so that we

have advocates that are outside this adversarial system that can

assist our soldiers and their families as they go through this very

difficult bureaucratic process.

So I will wrap up with that, because I know the important thing

is that we have a discussion about this and that you pursue those

things that you are interested in.

But, again, I want to make sure that there is no mistake about

it: I accept responsibility for these failures that have occurred, and

we are committed to fixing them. And as long as I am in position,

there will be great energy behind getting this done.

And, again, with your help, I believe that we can fix this in a

very comprehensive fashion that will stand the long test of time.

Because I do believe that this long war is going to require us to

continue to have the very best medical care for our great soldiers

and their families.

Thank you very much.

[The prepared statement of General Schoomaker can be found in

the Appendix on page 92.]

Dr. SNYDER. Thank you, General.

General Kiley.

STATEMENT OF LT. GEN. KEVIN C. KILEY, THE SURGEON

GENERAL, U.S. ARMY

General KILEY. Mr. Chairman, Congressman Hunter, distinguished members of the committee, I am here today to address

your questions about the circumstances at Walter Reed.

A commander is charged with the health and welfare of his soldiers, and a physician is charged with the health and welfare of his

patients. And as you know, in the last few weeks we have failed

in the housing at Walter Reed, and we are addressing that and

many other issues.

I want to offer my personal apology to the soldiers and families,

to the Department of the Army, the Department of Defense, to you

and to the American people for these circumstances.

I am personally and professionally very sorry that we are sitting

here today, and I take full responsibility and accountability as the

Medical Command (MEDCOM) commander.

There are bureaucratic, complex systems associated with the disposition and discharge of soldiers that require and demand urgent

simplification, and I am committed to getting on with fixing this

system. I am dedicated to making sure that soldiers are equitably

and fairly cared for, that they reach their full level of care, and

that they are returned to the force or retired in a manner that

shows respect and dignity for them.

As you have heard, we have taken immediate actions. The chief

has listed some of those.

8

Building 18 is empty as of today, and within weeks we will begin

repair of that building. We have got teams out around our installations checking to make sure that the quality of life, communications, command and control, and infrastructure are in good shape

at our other installations.

You know, a soldier won’t attack an objective in combat out of

the sight of a medic. And our 68W medics are the best in the history of our Army. And they are connected inexorably to Landstuhl

Regional Medical Center and to the great facility at Walter Reed

Army Medical Center, which I think you know provides absolutely

outstanding inpatient and, I would suggest to you, outpatient care.

The doctors, nurses and administrators that are doing that are

doing a superb job. There are clearly questions about our handling

of the soldiers’ quality of life and the processing through the disability system that I would be happy to answer your questions on.

It is a very complex disability system. It is confusing and, frankly, we realize it is adversarial and confrontational. And we have got

to fix that. Soldiers tell us it is as though we don’t respect them

because of the way that they have to work their way through the

disability system.

Secretary Gates is expecting decisive action, and he and our soldiers will get it.

The Walter Reed Army Medical Center has got a magnificent

reputation. The care for soldiers on the battlefield is second to

none. That is a combination of the skill of the staff at our facilities,

who prepare themselves and deploy; the technology that we bring

to bear—new technologies almost every year; and the unwavering

support of the Congress and the American people. We want to reestablish that trust.

It is regrettable that The Washington Post had to bring this to

our attention, but since they have, we are taking immediate action,

as we have already said, to fix the problems.

I have been a physician and a soldier for 30 years. It is an honor

to lead the Army Medical Department, and it is an honor to serve

our soldiers and the nation.

And I look forward to your questions.

[The prepared statement of General Kiley can be found in the

Appendix on page 97.]

Dr. CHU. Mr. Chairman, we recognize, as my colleagues have underscored, that we have a special responsibility to those who have

suffered severe injury in the service of their nation. That is one of

the reasons that we opened, two years ago, a Defense medical injured center as a back-stop to the service programs.

In this arena, you need, really, a layered effort to ensure that

you have dealt with all cases adequately. It is the place we bring

together our sister Federal agencies—the Department of Labor, the

Transportation Security Administration and the Veterans Affairs

Department—so we can provide the kinds of services that ought to

be available to our people. And I am pleased to say that the Department of Veterans Affairs has placed representatives in our

major hospitals to help with the disability evaluation process.

It is also the reason that we are proud to partner with others.

Heroes to Hometown is one of those examples, where we are working with the American Legion, with the state Veterans Affairs DeVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
9

partments, to ensure that, when the individual comes back to his

or her hometown, that they are greeted appropriately and the kind

of support they should expect is indeed there.

And we are appreciative that the Congress last year gave us the

statute authority to expand the computer electronics accommodations program in which we can provide those who need assistance

in order to carry out their tasks, particularly as they seek re-employment, have the equipment that they indeed deserve.

As General Schoomaker emphasized, I think one of the central

issues as we move forward here is this question: Do we have the

right paradigm for providing for those who have suffered grievous

injuries in the service of their Nation?

As he indicated, and as you appreciate, we have really three different programs in the Federal Government that provide support,

assistance—especially monetary assistance—to those who have

been injured in the service to the Nation.

There is, of course, the defense disability system, but there is

also the disability payments system in the Department of Veterans

Affairs, and there is the Social Security Administration, which, in

some cases, will also make payments.

As General Schoomaker suggested, Title 38, which covers the

VA, and Chapter 61 of Title 10 take fundamentally different approaches to the basis on which you should rate the individual. It

is, therefore, not surprising that we reach different answers in that

regard.

But from the individual’s perspective, this is surely complex, indeed, as the reports suggest, frustrating in its character.

Pending that large debate, the Department is indeed revitalizing

its own system. We will soon be issuing new instructions for the

governance of that system. The services, in their areas of responsibility, are relooking at their processes. The Army has its transformation initiative for its disability evaluation system.

I am confident that with this energy, this level of attention, and

your support for necessary, statutory stages, that we can replicate,

in the way we administer and the way we run the disability evaluation system, the success we have enjoyed in the clinical area and

that is so properly and widely celebrated in our country.

Thank you, Mr. Chairman.

[The prepared statement of Dr. Chu can be found in the Appendix on page 72.]

Dr. SNYDER. Thank you all for your testimony.

I am going to ask unanimous consent also to have admitted to

the record the committee memo that the staffs worked together on.

And I think it is a good summary of some of the challenges.

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

page 111.]

And for anyone out there who would love to have a copy of it before the transcript of the hearing is made publicly available, just

holler at the staff members, because I think it gives a good summary of the history of some of the problems, but also some of the

involvement of this committee.

The second point I wanted to make—and Mr. Spratt came in

here in a very timely fashion.

10

Dr. Winkenwerder, you specifically stated in your written statement, I think in your oral statement also, that you don’t think it

is a money problem. That conflicts a little bit with what General

Schoomaker says in his written statement, which he thinks there

may be some military construction (MILCON) needs that would

take congressional action.

But I would encourage you all—I mean, the fire is hot right now.

We have got trains revved up and ready to go that can carry some

money in your direction to help solve this problem. And if you

think that there are areas there that some additional funds in specific areas would be helpful, please let us know. Because I think

that this is something the American people want to get solved.

Obviously, we don’t want to put money out there and not have

it be helpful. But if you think there are money problems, then this

is the time to deal with it.

The third point or comment I wanted to make: When I first

heard the interview with Dana Priest, who was one of the reporters

in The Washington Post, she made this comment that when members of Congress would go out there, as a lot of members do just

to see what is going on and visit with families and be supportive—

I can’t speak for everyone on this committee, but we don’t have a

formal notification process when there are—when our constituents

are wounded, or when they are admitted to any of the military

treatment facilities or when they are in a medical hold status.

Now, some of us have made some informal arrangements. I think

it has been a couple years or so since my office has been notified

of any wounded. I think there are some privacy issues, some

Health Insurance Portability and Accountability Act of 1996

(HIPAA) issues.

But the point I want to make is one of the things that Dana

Priest said is that when a member of Congress found out that an

individual was having a problem—I mean, her comment was a lot

of times it would get taken care of. We would get ahold of your

staff and work through these issues.

Now, what I am trying to say is I think you have got about close

to 900 people in a medical holdover status at Walter Reed. That

averages out about two per member of Congress who would be advocates for those people if we can work around some of these privacy issues.

I don’t say that—I thought of that last night to myself, almost

facetiously. I thought about it more today. I thought, ‘‘No, that is

the way this system works.’’ And you all know that is how it works.

We hear things from families and constituents and we get ahold

of your folks, and a lot of times there are legitimate concerns that

you all get straightened out. But we do not get formal notification

because of privacy issues. Any comment on that?

Who should I direct this to? Maybe General Kiley. How many

people today do we think systemwide—or maybe Dr.

Winkenwerder—are in a medical hold or holdover status?

General KILEY. Mr. Chairman, I can take the exact answer for

the record. But in a rounding figure——

Dr. SNYDER. Yes.

11

General KILEY [continuing]. About 900 MedHold, which are active duty, and about 3,200 MedHold Over, which are reserve and

National Guard, across our installations.

And also, in that 3,200 are about 1,800 that are in our CBHCOs,

our community-based health care. So they are living at home, getting care in the community, reporting to their National Guard armories.

Dr. SNYDER. And so how many today are in the Walter Reed status?

General KILEY. At Walter Reed, I believe the number is around

600.

Dr. SNYDER. Around 600 today. Those are about the numbers I

have.

General KILEY. Yes, sir, I can get you exact numbers.

[The information referred to can be found in the Appendix beginning on page 166.]

Dr. SNYDER. Dr. Winkenwerder, do you have——

Dr. WINKENWERDER. And let me add to that, there is another—

again, I don’t have the exact number, but rough order of magnitude

1,000 or so that are Navy, Marine, or a smattering of Air Force.

The bulk is the Army.

Dr. SNYDER. And I think it is important we keep these numbers

in mind, because this is a well-defined universe. It is not a large

group of people for this country to deal with. And there has got to

be a way for us to get a better handle on this.

I am told that you all—that somebody sits down in a weekly

manner with you all, and you can pull up and have a list of everyone on medical hold, hold over status. Is that correct?

General KILEY. Yes, sir, I believe that is correct.

Dr. SNYDER. That doesn’t necessarily mean that you know where

they are at, but you actually have a list of them.

General KILEY. We know where they are at, too.

Dr. SNYDER. You know where they are assigned to. That is not

the same as knowing where they are at, because they may have

walked away on you, or their case managers may have lost track

of them, correct?

General KILEY. Well, I wouldn’t say that it never happens. But

our intent is for us to know where they are, if they are at home

in the CBHCOs. We are keeping contact with them.

Dr. SNYDER. Okay, I understand that.

General KILEY. If they are assigned to the MedHold or MedHold

Over at their installations, they have case managers who are keeping track of them.

Dr. SNYDER. But your formal system doesn’t say that, ‘‘They were

last seen by a medical facility on February 7.’’

General KILEY. No, sir. No.

Dr. SNYDER. Which gets to the case managers. Who pays the case

managers? Are they military personnel, civilian personnel, or both?

General KILEY. I believe they are a combination of both. Most of

them are civilian, a combination of nurses and social workers.

Dr. SNYDER. Who do they work for? Who pays their check?

General KILEY. Well, if they are civilians, I pay their check

through MEDCOM.

12

So if they are working at our facilities as case managers, they

work for the commander of the hospital in managing the cases.

And as I understand it, I would pay through the hospital’s finances

for their salaries as contractor general schedule (GS) employees.

Dr. SNYDER. If I ask these 3,000-plus people today, ‘‘Do you consider your case manager your advocate?’’ what do you think the answer would be?

General KILEY. I think their answer would be that in general

they are. We have surveyed MedHold Over soldiers and directly

asked them the questions about how they feel about the case managers. We are just standing this up. I have just gotten some responses back, and they seem to be very pleased with their case

managers in general.

Dr. SNYDER. Well, ‘‘in general’’ may speak to the heart of the

problem, because—what do you see the job as case managers to be,

Dr. Winkenwerder and General Kiley? Do you see their job as to

be advocates?

General KILEY. Absolutely.

Dr. WINKENWERDER. Yes. Yes, sir.

Dr. SNYDER. You don’t see their job as trying to explain to them

why they are not going to get their appointment for 60 days; you

see their job as to have them get their appointment in 5 days. Is

that correct?

Because that is not anecdotally what we have heard from some

of these warriors. They have not seen their case managers as being

their advocate.

Dr. WINKENWERDER. I think that is unfortunate, where that has

happened. They should be——

Dr. SNYDER. Do you agree that it has happened?

Dr. WINKENWERDER. Well, the reports—I have read about the

same ones that you have, and I think of a case manager, case

worker, social worker, nurse as someone who cares about that individual; is trying to do the best for them, get them in, help them

with their appointments, make sure they are followed up, if they

are not certain or clear about what they need to do next.

They are there to help them. That is the job. It is really personalized attention.

Dr. SNYDER. Mr. Hunter.

Mr. HUNTER. Mr. Chairman, thank you.

And, Mr. Chairman, this is a problem which is especially, I

think, both devastating and significant, because it is one that occurred in a place where there are lots of eyes and lots of folks and

are close to a center of power.

And I can tell you that, in fact, I was at Walter Reed I believe

the same day that this story started to come out, visiting some of

our wounded folks in the inpatient area. All of us have been down

there a lot.

You know, this is one of those things that doesn’t lend itself to

statute and legislation and regulation, because we have got a lot

of that. It lends itself to an answer that focuses on the military

families, that focuses on the ability of a Marine wife, whose husband is severely injured and has two kids in school and just drove

300 miles to get here and doesn’t understand the situation, to be

able to easily find out what the program is and to be able to easily

13

access that program and to have a program that is simple enough

that folks that aren’t experts on military medical law can get taken

care of.

And I think it is important for our committee to know that we

have had a great oversight team, Democrat and Republican, with

Ms. Wada on the Democrat side and Ms. James on the Republican

side, visiting literally dozens and dozens of medical facilities

throughout the country, as well as Walter Reed and Bethesda.

And one thing we did several years ago that we have never done

as a committee, is I appointed one of our professional staff members, Mr. Godwin, to be an ombudsman for the families and for the

people who wear the uniform of the United States who are the patients at Walter Reed and Bethesda.

Mr. Godwin undertook more than 80 visits to Walter Reed, a couple fewer visits to Bethesda. And his job was to go in, sit down

with military families, but almost exclusively in the inpatient area;

talk to them, find out what their problems were, direct them to the

right place, try to make sure that they had housing, that they had

transportation and that the wounded soldiers and Marines were

taken care of.

Now, while we were doing that, we thought that we would do another thing, and that is to start getting jobs for guys that were

transitioning out, and ladies who were transitioning out, who were

going to be moving out into the private sector.

And so we started to have jobs fairs in a couple of the hospitals,

one in California. And I attended one that we put together here at

Walter Reed, where members could come down into the day room,

tell us a little bit about what they did, what their professions were,

and see if we couldn’t hook them up with folks in the government

but also folks in the private sector.

So we started doing that. After we had done that for about a

week and we had actually landed some jobs for a couple of our

wounded folks, I was informed that I was on the verge of breaking

the law because there might be an ethics problem with a member

of Congress or professional staff members helping to get jobs for

wounded soldiers and Marines with the private sector, on the basis

that the private sector would then expect a quid pro quo from the

committee.

So to handle that, we then offered a resolution before the full

House which passed—and I think almost every member of this

committee voted for it—essentially laying the groundwork for the

Ethics Committee and the Administration Committee to approve us

having professional staff members on the committee who would assist wounded people, wounded personnel, who were separating

from the service with getting jobs in the private sector without having an ethics ramification.

That resolution passed the full House. It is awaiting action by

the Ethics Committee, which hasn’t been forthcoming.

So I would just recommend to my colleagues that one great thing

that you can do for folks who are wounded is to make sure that

when they get that transition, if a guy is a generator mechanic and

he is going to go back to Maine, we should be able to contact the

companies in that location and see if we can’t get a good job interVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
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view perhaps put together while he is in Walter Reed or while he

is in Bethesda.

So I thought, Mr. Chairman, it is important for our committee

members to know that we have had a strong oversight team going

throughout the United States, conducting also sensing sessions

with over 1,000 personnel and their families with no brass present

and with no administrators present so they could talk candidly to

us.

Nonetheless, this problem has occurred basically right under our

noses, right here in the center of power.

And I would offer that the key to this thing is to have a system

which is consumer- and customer-friendly. And that means when

that young wife of a wounded Marine comes in and she has got two

kids that she has left with her mom while she drove 300 miles

down here to see her husband, perhaps for the first time, that she

not only has a path of things that she has to do with respect to

applications and filling our forms and waiting, but that she is given

very important person (VIP) treatment—that is, preferential treatment, that she has somebody who leads her through this path that

she has never had to walk down before.

We need to have a system that is customer-friendly, because

there is no family that is more vulnerable, nor in more of a state

of anxiety and, to some degree, confusion, than a military family

whose loved one has been injured. And in 99 percent of the times

of the cases, that means that they have got to travel some distance

so they are away from home. They have major expenses.

Now, I think it is important to note that we have a number of

great organizations, like the Semper Fi organization and a number

of others, that will provide cash and will provide help. And we also

have great on-hospital facilities like the Fisher House and others

where families can put up without paying that 120 bucks a day in

the Washington area for hotel rooms while you are here.

But this a problem, I would just say to my colleagues.

And, you know, if the buck stops here, General Schoomaker, my

gosh, all of us have been down to Walter Reed numerous times. I

think I was there visiting a patient when the story broke. So the

buck stops here also.

But I think that the answer to this question is not going to be

regulations. Regulations got us here. It is the same regulation that

means, when a soldier is carried off the field on a stretcher and

gets to Walter Reed, he ends up receiving a bill for the equipment

that he lost when he was hit with the improvised explosive device

(IED).

It is a bureaucratic system, and you have to keep mowing the

grass to make sure that you keep that from developing a system

that is very unfriendly to the customer. And the customer is the

men and women who wear the uniform of the United States who

are receiving the medical care.

So I think that the answer to this has to start with the people.

It has got to start with the soldier, and it has got to start with the

family. And what we have to have is a simple system.

Now, before you fix all the regulations, or we try to fix something

structurally so that this doesn’t happen again, there is one way to

get through this early.

15

And that is to assign lots of people to the families and to the

wounded personnel, so that when you have that 18-step program

somebody has to go through before they get their compensation or

before they get the next booking for therapy, you have got somebody standing next to them saying, ‘‘I will take care of this,’’ and

they take care of it. And that wife who has driven 300 miles has

the answer and the solution, rather than simply a direction as to

what the second of 35 different steps is going to be.

So I think if we start with the personnel, with the wounded soldier, sailor, airman, Marine, and his family, start with them—let’s

fix them up first, make sure we have got somebody that takes care

of them, just like there is somebody if a VIP comes to Bethesda or

Walter Reed; there is somebody there to walk them through that

system, to get them through the bureaucracy. We need to have a

VIP system attached to every single person that wears the uniform.

Let’s undertake that, because that will give us a result a lot earlier than a series of legislative steps.

And I think largely this is not a solution that requires as much

legislation as it requires a cultural change.

So if we could do that, if we could focus on the wounded American service member and the family first, attach lots of people to

them to get them through this cumbersome system, then fix the

system, I think that will expedite things.

Thank you, Mr. Chairman.

And I am glad that you put into the record the oversight activities that the Democrat and professional staff members have undertaken.

And you know we have a great system. We have all seen the incredible wounds that would not have been survived 10 or 15 or 20

years ago that now are survived because of excellent care, literally,

from that medic on the battlefield right through to the skilled

hands of the surgeons and the medical providers.

What we have to do is match that capability with a streamlined

bureaucracy that is soldier- and Marine- and airmen- and sailorfriendly. If we do that, we will retrieve this great system.

Thank you, Mr. Chairman.

Dr. SNYDER. Thank you, Mr. Hunter.

I think Duncan had such wisdom there that I would like each of

you to respond to what he was talking about in terms of having a

consumer-friendly system.

Because my guess is if we asked you a month ago, ‘‘Do you think

you have a consumer-friendly system?’’ you all would have said,

‘‘Yes, we have been really working at it and we get good feedback.’’

But it is apparent that we don’t.

So starting with you, General Kiley, how do you see where we

are at today and where we are going to get with regard to having

the kind of consumer-friendly—help families and the soldiers walk

through that system.

I suspect this is going to get to what two or three of you said

in your written statement—working on the training and numbers

of case managers as a part of that—but would each of you respond

to what——

General KILEY. Yes, Mr. Chairman.

Dr. SNYDER [continuing]. Mr. Hunter talked about?

16

General KILEY. I think Congressman Hunter is exactly correct.

My assessment is we have come a ways in customer-friendly activity, but I don’t think we are totally there.

I think the turnover of personnel in our facilities is a constant

training program. And I think it only takes one person not being

customer-friendly to potentially ruin the reputation of an organization, even something as big as Walter Reed.

I think we just need to redouble our efforts and refocus on exactly those issues. An ombudsman program is clearly something

that would be of benefit in our installations.

And I think, clearly, if we can put more people helping soldiers

and sailors and their families now, which we can do—we can hire,

and we can call for volunteers. There are several different ways we

can do to take this on. It will clearly expedite some of these stories

we have heard of soldiers being left without knowing what the next

step is.

We have had more than 6,000 combat soldiers come through

Walter Reed since the start of the war, and we have learned a lot

of lessons and made it better. But it still needs more work, needs

to be further improved.

Dr. SNYDER. General Schoomaker.

General SCHOOMAKER. Well, I will probably say something heretical here, but I think that what we need to do is focus on output,

focus on results.

And, you know, in government and in the military, a lot of people

take a lot of pride in complying with processes, checklists, procedures, working real hard, getting up real early, going to bed real

late. And as far as I am concerned, you don’t get any credit for all

that stuff. What we get credit for is what comes out the other end

of the pipe.

And so if we want a customer-friendly system, which we all do,

we need to measure it at the customer end and make sure that

what we are doing is satisfying that.

And, unfortunately, part of our problem here is that as we have

been touching the customer and asking them, we have not been

getting the kind of feedback that we need. And so we got to figure

out why.

And my view is it probably comes down to trust and some other

kinds of things that we need to regenerate. And if we can do that,

get the communications, then I think we will be able to measure

what we need to measure.

Dr. SNYDER. Dr. Winkenwerder.

Dr. WINKENWERDER. Oh, I agree with what Congressman Hunter

had to say. I totally agree with it. I think it is right on their mark,

and I would concur completely with General Kiley and General

Schoomaker.

And, to me, you know, if you have done what you need to do

when the people you are caring for, your customers, tell you that

you have done a good job. And if they don’t, that is your best indication.

So I think it is that communication, and there are tools—surveys

help, but sometimes it is just talking to people. It is focus groups.

It is talking to people, and it is listening. And it is not saying,

‘‘Why can’t you do something?’’ It is turning back to the bureaucVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
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racy and saying, ‘‘Why can’t we do this? Why can’t we do this to

make it easier on the person?’’

That has got to be the mentality. And I agree. Sometimes, in the

military—and even outside the military, with my experience—people get into, ‘‘Well, this is the way we do it. This is the checklist,

you know, and this is supposed to be the right way.’’

Well, if it is not meeting the needs of the customer, it is not getting the job done. And that is the outcome. That is the result. And

that is what we ought to be focused on.

Dr. SNYDER. Dr. Chu.

Dr. CHU. First, I hope Congressman Hunter gets a favorable ruling from the Ethics Committee. Otherwise, we may be in trouble,

too, because we have held a half a dozen of these job fairs, as you

know, Congressman, last year. We are committed to at least half

a dozen this year. I think the most recent was at Fort Dix, if I recall correctly.

On a more serious note, I could not agree more. I do think we

need to look at the structure within which the advocate works.

Let’s come back to case workers for a moment: I think that is the

source of some of the situations described most recently.

From the early days of the conflict, we had too few case workers.

We have beefed it up considerably; I think the Army is now to a

point where the case worker-to-cases ratio is at approximately the

right level.

But the system in which they work is one in which these decisions are all sequential. And one of the things we are looking at

with the new energy, attention that has been focused on this challenge is, why is it sequential? Why can we not gather up all the

decisions in a package for the soldier, sailor, et cetera, to confront

at one time, as opposed to going through this one step at a time?

We are committed to the standard that you advocated. I think

the issue ahead is, how do you get there? How do you get there

quickly? And how do we start making at least the major improvements in the next few weeks and months?

Dr. SNYDER. Thank you, Dr. Chu.

We will now go and start our questions for the committee members. Dr. Winkenwerder has a mid-afternoon plane, but I think everyone else is committed to being here for some distance from now.

So we should get to everyone.

Mr. Ortiz.

Mr. ORTIZ. Thank you, Mr. Chairman.

Welcome to our hearing this morning.

A few years ago, we took a tour, a group of Republicans and

Democrats, because we wanted to see the worst facilities of our

military. And we took a tour. Fort Sill, we saw a new facility, a

big facility, where the young soldiers were taking a shower and the

water was dripping out the walls.

I think that we did that, and I know we did that, because sometimes we feel that the budget is not patient-driven or soldier-driven; it is budget-driven.

Sometimes we give you a bunch of money. We don’t know the

size of the facility if we go. I visited Walter Reed and Bethesda

many times. But unless we know what are the worst facilities that

you have, we won’t be able to fix them for you.

18

Now, when I was touring Building 18 about three, four days ago,

we looked around and I asked some of the people working there,

‘‘What happened here?’’ They said, ‘‘A–76.’’

What happened with A–76? There was a contract, and even

though the civilian workers submitted a better bid, they gave it to

the contractor. Now, correct me if I am wrong. And he says, ‘‘You

know what happened, Congressman? A lot of experienced, knowledgeable workers walked out the door.’’

Now, if I am correct, this facility won’t shut down on 2011. Am

I correct? When is it supposed to—2011?

General SCHOOMAKER. The installation is to close in 2011 under

the BRAC realignment.

Mr. ORTIZ. In the meantime, we have a surge. More soldiers are

going to Iraq and Afghanistan. More wounded soldiers will be coming back. I wanted to ask, General Kiley, do you think that you can

give us a list of your worst facilities so that a group of members

here can go see it so that we can be in a position where we can

help you fix those facilities?

A lot of members might say, ‘‘You know what? We are shutting

it down. Why do we put any more money here?’’ But those lives are

very precious. They are soldiers. They are young sons and daughters.

And at the time, I want to know, did A–76 have an impact as

to what happened in Walter Reed?

General KILEY. Congressman, I will take for the record your request and work with General Wilson to look at worst facilities

across our Army facilities. And I would defer to the chief if he

wants to talk about the larger barracks MILCON issue.

We clearly are looking at the A–76 study. I think the garrison

commander was challenged as the contract was getting ready to

stand up, and some of this workforce was leaving for that exact

reason—probably more about A–76 than BRAC.

There were other issues. We have identified some of those, and

we are fixing them.

[The information referred to can be found in the Appendix beginning on page 164.]

Mr. ORTIZ. Do you think that we might be able, for the committee, to get a list of the facilities so that we know exactly how much

money you need and what we need to fix?

I mean, we are at war. And as much as we would like to have

a budget-driven budget, we have got to think about our soldiers

and our families. And I think that this Congress would be willing

to give you the money to fix what is wrong.

And if any of you would like to elaborate on my question——

General SCHOOMAKER. Well, Congressman Ortiz, I couldn’t agree

with you more, and we would be glad to give you a list of what we

consider to be our worst facilities.

With your help, you might remember that over the last three

years, what we have been doing is putting enormous amounts of

money to not only upgrade existing facilities, but to build new facilities where we have languished so long.

You know that our SRM, our sustainment, repair, and maintenance funds, traditionally have always taken a hit, because of priorities and money has had to shift.

19

And I can remember times in my career past where installations

were being funded at less than 50 percent of requirement, which

means that you are fixing things that break, not fixing and staying

ahead of the power curve.

So Secretary Harvey and I made it a priority. And we came to

you and asked for money, and we put hundreds of millions of dollars into both barracks upgrade and the new thing.

On the other hand—and I am going to say this, and this is not

a criticism, but I think we all recognize how difficult it is, through

the budget process.

This year we still don’t have a veterans, MILCON, BRAC budget.

We are six months into the fiscal year and we do not have a bill.

And the amount of energy that this committee and we and everybody else has spent trying to get that through is indicative of how

much energy that senior levels has taken, trying to get things to

come together, that would be better spent, quite frankly, getting

things done, you know, with the resources.

Now, there is no question we are going to get these resources.

But again, we are into this business of half the fiscal year is gone

before we get going on it.

As you know, at Fort Bliss, the MILCON, BRAC business has

called a stall out there in building facilities for the growth of the

Army and for the repositioning of the Army globally. And we have

discussed it, and you have helped us with that.

But I just think that we—you know, it is bigger, and we would

be glad to give you a list, and you can go look, but I think that,

again, what we have to do is systemically look at things and recognize the fact that we are a Nation at war, yet we are trying to overcome what I have testified here many times in the past is the historic underfunding of the United States Army—a significant underfunding and investment in the United States Army.

And we are trying to fill that underinvestment, at the same time

that we are consuming ourselves, at the same time that we are trying to grow. And that is a big challenge. And we need a lot of help

to get that done.

Dr. SNYDER. Mr. Saxton.

Mr. ORTIZ. Let me just say one thing, Mr. Chairman.

We are not here to point fingers at anybody. We are here because

we want to help you. Because these are our soldiers. And we are

not here to point fingers. We want to help you.

Dr. SNYDER. Mr. Saxton.

Mr. SAXTON. Thank you, Mr. Chairman.

Let me just do a couple of things. Let me say a couple of things.

First of all, let me commend you, Mr. Chairman, as chairman of

the Personnel Subcommittee, and Mr. McHugh, as the Ranking

Members of that subcommittee, for the very serious, studious, bipartisan, substantive job you are doing in looking at this issue.

This is an issue that could be fraught with politics and a whole

bunch of stuff that wouldn’t be productive. And your leadership on

this issue is very much appreciated. So, thank you very much.

Second, you know, to listen to this conversation, you would think

the whole system is broke. And I have got to tell you it is not.

I have had some great experiences in observing how this system

works, from Fort Bragg, where medics are highly trained in lifesavVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
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ing procedures that have kept soldiers alive time after time after

time.

I have seen the results of that training in the field. I have been

able to experience the great job that is done in field hospitals incountry, particularly in Iraq. I have been able to visit wounded soldiers in Landstuhl and the great job that is done there, and the

nurse getting me by the arm and saying, ‘‘We need to make this

place bigger.’’ And I have seen the care that is offered here in this

town.

And I am very proud, by the way—Dr. Chu, earlier this week,

I had a conversation with the commander up at Fort Dix, and he

was so proud because Lieutenant General Wilson, the installation

management commander, recently commended him on having one

of the best facilities in the Army to take care of soldiers.

And so, there are good things to be said along with some problems to be pointed out with this system.

And I know that we have tried to fix things as we go along. I

visited Fort Dix I guess two years ago, or three years ago, and I

found out that we didn’t have specialists there to take care of some

of the problems and that soldiers had to be loaded in a van at 5

o’clock in the morning, driven to Walter Reed, wait there to be

treated, and be treated, and drive back to Fort Dix that evening.

I called General Schoomaker and he fixed it.

Still a couple of specialties that we have to use that process, but

the number of soldiers that have to go through that process from

Fort Dix to Walter Reed is a fraction of what it used to be, because

General Schoomaker fixed it.

And so there are good things.

And currently at Fort Dix we don’t have enough space, so the

Army has decided to take a barracks, gut it, remodel it. And that

process is under way as we speak.

So for members who are experiencing this conversation, maybe

in the early stages of their experience with this—need to know that

it is not all negative. There are a lot of very positive things, from

one end of this process to the other.

So I guess that is not a question, but I just wanted to point that

out.

I guess the question that I would ask is, within this system of,

I think, mostly good, what are the things that you need us to concentrate on to help you fix those problems?

Dr. Chu, why don’t we start with you?

Dr. CHU. First of all, sir, thank you for your kind words about

the things that are going right. I do agree with you there are a lot

going right in this system, and I think we do see, back to the earlier issue raised, a large number of satisfied personnel, particularly

with the quality of their clinical care.

I think there are two major areas where you can help. And General Schoomaker has already touched on one: that is, the timely appropriation of funds we need.

I do think the fact that we don’t have the full MILCON appropriation completed is a problem, particularly given the statutory

deadlines for the base realignment and closure actions.

We need to move forward. We need to get those new facilities

built. The Army is expanding. We need to make sure the right faVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
21

cilities are in place, or we will have more nominations for Congressman Ortiz’s list in two years, with people at the expanded installations not able to enjoy the facilities they ought to have.

So I really would hope that when the supplemental is enacted—

I recognize that is not this committee’s lane—but when it is enacted, that there is the full restoration of the BRAC money that

was originally requested.

I think the second place where you can help us—and this is a

little bit further down the road, I don’t think we are ready yet to

make a proposal, but I do think, back to Congressman Hunter’s

standard, if we can streamline this process so that the complexity

that now exists is no longer a problem for the beneficiary, that we

will substantially improve the customer-friendliness of the system.

And that may take some statutory change, because the two

major disability systems, VA and DOD, are operating on different

purpose foundations in the underlying statute that come out of history. Indeed, I think if you look at our major conflicts in American

history, late in or after every conflict there has been great controversy about what is the right place for the Nation in terms of

veterans’ benefits. It was true right after World War II.

But the basic regulations in this regard, the basic statutes in this

regard, really date to 1949. And I do think it is time for a reconsideration, particularly in light—as you have all emphasized, these

are relatively small numbers. We ought to be able to manage this

problem as a nation.

Now, the Department will do everything in the next few weeks

and months within its statutory limitations to get to the goal I

have outlined. But I believe that at the end of the day we will need

some statutory assistance.

Dr. SNYDER. Mr. Smith.

Or does anyone else have a comment in response to Mr. Saxton?

Dr. WINKENWERDER. I will echo—since you asked for a response

from everybody—I would agree exactly with those things. The timeliness of funding is really important. That is particularly relevant

with the base realignment and closure and being able to move forward to do things that we need to do.

I think in addition to that, we can and we will take a look at

medical facilities and come back to you and see if we have any

needs. By and large, from all the feedback we have gotten, our facilities are very good facilities. But I think it is a time to take a

look and to make sure that you and we both agree.

And we really appreciate your offer to help us on this. So thank

you.

General SCHOOMAKER. I would like to reinforce what Congressman Saxton said.

First of all, we have, undoubtedly, the best military health care

system in the world. Everybody else looks at what we have and

they marvel. We have treated Canadians, Brits, Romanians, Poles,

El Salvadoreans, all kinds of folks and soldiers, and they marvel

at it.

Other nations have others solutions. But the issue is not comparing against what others have, but are we as good as we should be

and could be in terms of what we do?

22

And that is why I made that statement up front that I hope that

we recognize the fact that we do have a very good system and we

have a lot of very dedicated professionals in it, but there is a lot

of room for improvement, and we need to look at it, I believe, from

a comprehensive view.

Second, it is not just battlefield medicine we are talking about.

This is an integrated system, from the combat lifesaver, the soldier

on the battlefield; through the medic; through the medevac system,

into the definitive care of the combat surgical hospitals that we

have forward; through the system that regulates them to

Landstuhl; into the Walter Reeds and the Brooke Army Medical

Centers (BAMCs) and all these kinds of places. And everybody is

focused on that.

But we also have a huge mission in providing military medicine

for readiness purposes to the active, guard, and reserve soldiers

and their families. And it is a huge piece of our recruiting and retention of these families and a huge piece of how we compensate

soldiers and families for their service.

And so, I think, you know, as Congressman Hunter said and as

everybody else has talked about, this is very important that we

take a look at this comprehensively and recognize that there is

more than just a battlefield medicine piece of it is important.

And I would remind you that my view in this world today, the

most dangerous world, I believe, that we have faced in a long time,

that our military capacity in the health care business is going to

be important for homeland security, homeland defense; and that

there are unique capabilities inside of military medicine that are

not resident out there in the civilian sector, especially in the area

of chemical, biological, radiological kinds of issues.

And so that is, kind of, how I would come at it. I mean, this is

something. We have an opportunity here to look at this very broadly and to not try to patch things together, but to really make this

and pull it into the 21st century in a way that it should be.

General KILEY. Congressman, I would echo all the other presenters’ comments and simply say that we need to get on with it as

quickly as we can. This can’t be a six-month or one-year solution

set. We have got some opportunity right now to make some of these

changes almost immediately.

STATEMENT OF HON. IKE SKELTON, A REPRESENTATIVE

FROM MISSOURI, CHAIRMAN, COMMITTEE ON ARMED SERVICES

The CHAIRMAN [presiding]. I thank the gentleman.

Before I call on Mr. Smith, let me thank Dr. Snyder for assuming

the chair for me. I was unavoidably detained, working on funding

you folks in the supplemental.

And it appears from my observation that the battlefield through

the acute care gets rave reviews, and from there it seems to be

going downhill. I think we will be discussing that as we go along

in this hearing.

Mr. Smith.

Mr. SMITH. Thank you, Mr. Chairman.

A couple points and a couple of questions.

23

First of all, I think your budget point is outstanding, and we

have got to change the way we do things in Congress. It is not even

really contemplated by members of Congress that we are going to

have our appropriations process done on October 1st, okay? And we

have, sort of, institutionalized and accepted that. The last couple

of Congresses, it is not even contemplated that it was going to be

ready by January 1st.

But October 1st is a huge day, for you guys certainly, but for everybody that we fund and they just, sort of, hang out for two or

three months waiting to see what is going to happen.

And I appreciate you making that point, because I think we need

to change the way we do our structure around here to try, as much

as possible, to get as many of our appropriations bills as possible

done on October 1st because that is when things get really complicated if we don’t do it.

And, now, like I said, it is to the point where we don’t even think

about doing it by that timeframe—maybe by the end of the month,

maybe by November. But we have got to do better on that.

I also will say that I think—you know, I take the point about it

is not necessarily a money issue, and I think in any given situation, you can look at the resources that you have and figure out

how to use them better. No doubt about that, and that has got to

be the first piece.

But based on what I have worked on, it seems like there is at

least a little bit of a dollar issue. I mean, we have had a massive

influx of veterans in the last few years because of Iraq, because of

Afghanistan. I know out in my area, in the Seattle-Tacoma area,

we have waiting lists for the VA. And that is money. That is facilities.

You know, I will tell you a money issue. You can’t park most of

the time at the Seattle VA, okay? So you are obviously injured and

you have got to park blocks away. Building a parking lot: money

issue.

So let’s not go too far down the road of, you know, ‘‘We are fine;

we have got the money we need.’’ Because it sure as heck isn’t the

case out where I come from. And I doubt that that is somehow

unique.

The other piece of this: The casework is critical. And I don’t

know what the numbers are, in terms of what—you need an advocate. Because no matter who you are—I mean, my wife and I are

both lawyers; you know, very attention-to-detail people. And whenever we have to go through a health care situation, it is a nightmare trying to figure out, you know, what forms do you fill out; you

know, what are you covered for; what aren’t you covered for; you

know, let alone an injured service man.

I mean, you need to have case workers who are advocates. And

if, you know, 30 cases for one person isn’t getting it done, then we

have got to figure out a way to cut that in half so that that case

worker is taking care of all that bureaucratic B.S. that is necessary. You can’t just go giving the money away, but you have got

to somebody fighting for that, so the soldier and the family aren’t

going through that.

So, again, I think that, too, is a money issue.

A couple question areas.

24

Guard and reserve, a totally different situation because they are

not active duty. There is the complaint about the level of services;

they have to get services on base. We have had that complaint. On

base isn’t where they live most of the time. It sets up a different

situation.

So I want to hear what you are doing for the challenges for

guard and reserve, particularly on the mental health piece, if they

don’t necessarily get the same care, don’t have the same community, making sure that they are drawn in.

I know, out at Fort Lewis, there is a program, now, where everyone who goes in-theater, when they come back, they have to go in

for a mental health review—I think it is 30 days after they come

back; it is whatever window the psychiatrists think is the best one

to do it—so that they don’t have to volunteer and say, ‘‘Hey, I have

got mental problems; help me out.’’ Because, as you know, most

people, let alone most soldiers, aren’t going to do that. You need

to reach out to them. So I want to know if we are doing that.

And for the record, maybe, if you can’t answer this, I am very

interested in electronic medical records. As part of this, also as you

are moving patients around the system, do the records follow

them? Do we have electronic medical records (EMRs) within the

military, so that we are not losing track of records?

And last, just to make it really complicated, how system-wide is

this?

This was what we have heard. There has been a lot of focus, in

my neck of the woods, on Madigan and what kind of job they are

doing out there.

Is Walter Reed uniquely problematic, or is it more system-wide,

and what is your judgment on that?

And we are down to 30 seconds, so what you can’t answer for me,

if you could—you know, we will submit these questions for the

record and try to get them back. Thank you.

General KILEY. I can attempt to answer.

Congressman, we will take your questions for the record, to include some discussion of guard and reserve and to include some

discussion of mental health. I agree with you completely.

I would like to say one—I have sent teams out with Bob Wilson,

General Wilson, to look at our other installations, to see if there

is any replication there of the issues we found with living conditions at Walter Reed.

I do think that, systemically—we have already alluded to this—

there are issues of the complexity and confusion about the medical

board process.

Even if case manager ratios are low, the medical community attempts to document all the health care. And then the physical disability DOD process has to determine the disability. And therein is

a problem that is systemic in nature and which we are going to attempt to address here in short order.

So that is a short answer. The rest of those questions, we can

take——

[The information referred to can be found in the Appendix beginning on page 166.]

Mr. SMITH. A quick stab at the EMR thing. How is your——

25

General KILEY. We do have one in the DOD. It is ALTA. It is

worldwide. A doctor can pull up a record of a soldier that was cared

for at Landstuhl. But it doesn’t talk yet with the VA system. And

we are working pretty aggressively to get the two, ALTA and Veterans Integrated System Technology Architecture (VISTA), together.

I would defer to——

General SCHOOMAKER. Congressman——

General KILEY. Excuse me, sir.

General SCHOOMAKER. No, go ahead.

General KILEY. No, I was just going to say I would defer to Dr.

Winkenwerder at the DOD level for that.

General SCHOOMAKER. I would like to make just one comment on

the guard and reserve. Because I think we clearly have our emphasis—I mean, our focus right now on the back-side, once they have

served, and going through the process that we are talking about.

But there is huge opportunity, up front, with the guard and reserve, to improve medical readiness. Part of our challenge has

been—during this particular conflict—has been the unreadiness of

guard and reserve, medically, in terms of—because many of them

don’t have health care in their civilian life; there isn’t money in the

system to provide them health care prior to mobilization.

And so we find, once we mobilize them, we are having to deal

with dental issues, things like diabetes, and all kinds of things that

we should have been able to detect and deal with prior to mobilization. Because once they are mobilized, we then must return them

corrected, when they demobilize.

And therefore that is why you see the numbers of guard and reserve in the system that are, right now, compared to active, because we are dealing with that issue and what is required there.

So, again, looking at this comprehensively, this really is a readiness issue, and it really does have to do with how we resource

guard and reserve and prevent some of this stuff, you know, then

we have to deal with in a catastrophic way once they are mobilized.

The CHAIRMAN. Dr. Kiley, when do you think you can get back

to Mr. Smith on that answer?

General KILEY. Sir, within a week, if that is soon enough, Mr.

Chairman.

The CHAIRMAN. That would be fine.

Mr. McHugh.

Mr. MCHUGH. Thank you, Mr. Chairman.

Gentlemen, proper manner suggests I should say how happy I

am you are here. Honesty demands that I tell you I am not. I suspect you are not particularly happy to be here either. It is hard to

tell what the greater emotion is: that of yell in anger or cry in sorrow.

But we all understand the great challenge we have here. And I

want to associate myself with the comments of the gentleman from

New Jersey, my friend Mr. Saxton.

At the point of care—the point of the hypodermic, if you will,

rather than the spear—this is a great system. The doctors, the

nurses, the physician assistants, those folks providing that care on

the hospital floors and the field hospitals that we have all visited

are outstanding, and we are so grateful for their service.

26

But this is a system in its structure is broken. It has turned

what should be a support system, where soldiers view it as a place

of shelter and hope and help, into one of adversaries. And you have

said it yourselves.

And, frankly, it is not a surprise. Dr. Chu mentioned the GAO

report that this committee placed into the 2006 authorization bill,

dealing with the Medical and Physical Evaluation Boards.

Dr. Snyder and I, back when I had the chance to chair the Personnel Subcommittee, had not one but two hearings on medical

holds and medical holdovers.

General Kiley, you sent your deputy; the surgeon general for the

Navy was there. We had soldiers, sailors, Marines in, talking about

their frustrations.

We knew this. We knew it. And yet somehow the kinds of problems we have been reading about and we have been hearing about

in the media came about in any event.

I trust the services, and we are going to watch very carefully—

we are going to find those responsible and take the necessary action. Frankly, I think, you know, companies and military units

tend to do what commanders inspect, so there are command problems here.

But on the broader issues, as I have heard many of my colleagues on both sides of the aisle here this morning say, we as Congress have to be a productive part of that.

Budgets—let’s talk a little bit about budgets.

Dr. Winkenwerder, I believe I heard you say that in your judgment, resourcing has not been a problem. I am concerned about it

nevertheless.

We have a little factor in budgets now called efficiency wedges.

That is a nice way to say, ‘‘You will find savings somewhere. And

we are not going tell you where. The only thing we are going to

tell you is they are going to come out of the medical treatment facilities, the MTFs.’’

And if we go back to when this started, back in 2006, we had an

efficiency wedge of $94 million spread across the Army and the

Navy and the Air Force against the medical treatment facilities.

Then again in 2007, it was $167 million—$167.3 million. In 2008,

$212.3 million has been inserted as an efficiency wedge against the

medical treatment facilities.

Roughly added, that is over $473 million.

Now, we have talked to some folks who are concerned because

these efficiency wedges by the Administration’s budget are documented out through the fiscal year 2013. We have been told that

if the efficiency wedge in 2009 is implemented, the only savings

that are going to be available to probably both the Army and the

Navy will be the actual closure of facilities, a facility in each.

General Kiley, do you have any opinion on where that efficiency

wedge might take us by 2009 and that statement that others have

unofficially told us?

General KILEY. I am concerned by 2008 and 2009 we will have

efficiency wedge that, at least as I sit here now, I cannot see efficiencies gained to recover that. I think the number in 2008 of $140 million is about equivalent

to a MEDACS annual operation, and in 2009 it is equivalent to one

27

of our medical centers’ operations at the $200 million to $240 million.

So I have grave concern if we are going to be able to meet those

budgetary cuts in those out-years.

Dr. WINKENWERDER. Let me respond——

Mr. MCHUGH. Yes, Dr. Winkenwerder.

Dr. WINKENWERDER [continuing]. And separate some things out

and try to take a crack at explaining here.

With respect to the matter of Building 18, I think many have

said—and to clarify there—that resources to have avoided that

having happened were not an issue; resources were there. There is

no question about that. Those were judgments——

Mr. MCHUGH. If I may, that probably makes it worse.

Dr. WINKENWERDER. Right.

Mr. MCHUGH. But I understand your point. Thank you.

Dr. WINKENWERDER. With respect to the broader issue about the

so-called efficiency wedge, that was determined as an approach forward three years ago, and planned and agreed upon by the three

services and our office and Dr. Chu and others. It was premised on

the notion that there were ways to be more efficient and more effective with delivering care, but it was also caveated by saying that

we would look at this every year to ensure that this was something

that was achievable.

I believe, no question, that at this point we have got to look at

it. We will look at it. I think that if there is anywhere—and I have

said this many times—that we do not want to stress the system,

it is on the direct care of our beneficiaries, of our soldiers, sailors

and their families—airmen and their families.

So we will look at this. And I think it is a timely point to do that.

If you look from this point backward, I think the dollar amounts

are relatively insignificant, such that they have not had any effect

that we would be concerned about.

In fact, we have returned dollars last year because we didn’t

fully execute our budget. We returned dollars to the services to be

used for whatever was needed. So we really didn’t have an issue

this past year.

Mr. MCHUGH. It was nearly a quarter of a billion dollars.

The CHAIRMAN. Gentlelady from California, Ms. Sanchez.

Ms. SANCHEZ. Thank you, Mr. Chairman.

And thank you, gentlemen, for being before us today.

And I just want to back up the comments that Mr. McHugh just

made with respect to the fact that, sitting on the Personnel Subcommittee, we have been very concerned. And also our current

chairman, Mr. Snyder, being a doctor, I think the medical issues

are really something that we have delved into as a subcommittee

on this overall committee. And it is a real concern. It is a real concern.

As you know Dr. Winkenwerder, when you came before us just

a few—maybe about a month ago and we talked about the $2 billion or $1.8 billion plus $236 million of efficiency costs that you

were trying to shave off of the budget, that when we look at a normal business plan, most businesses anticipate anywhere between 5

and 8 or 10 percent increase in their medical costs for their emVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
28

ployees. And, unfortunately, and what has been the case with spiraling costs, can sometimes be 15, 17, 18 percent a year.

So it is a real issue for us when you are telling that you are holding down costs. And we want to hear that, but the fact of the matter is, there may not be enough money there.

General Kiley, I want to take the opportunity—you were the

commander of Walter Reed between 2002 and 2004. Is that correct?

General KILEY. Yes, ma’am.

Ms. SANCHEZ. During your tenure, were you aware of the problems with the adequacy of the housing for the patients at Walter

Reed?

General KILEY. When I was the commander at Walter Reed, all

the patients were on the installation. There were no patients in

Building 18.

Ms. SANCHEZ. Were you aware of the problems with losing paperwork?

General KILEY. I was aware that the process of doing medical

boards, particularly for reserve and National Guard, was complex;

that there were 22 different forms.

Ms. SANCHEZ. But you didn’t know that your staff was losing it

there, the paperwork?

General KILEY. I was not aware of an individual case, no.

Ms. SANCHEZ. Were you aware that there were problems with the

lack of bilingual staff?

General KILEY. I think we recognized that we needed bilingual

support. We didn’t have a robust bilingual staff when I was there

to assist, but we did have cases where we had to find someone to

assist a patient or their family.

Ms. SANCHEZ. So you didn’t think it was a problem? You thought

you could just grab a ten-year-old child who happens to be the son

who could speak English or something like that? I mean——

General KILEY. No, I just—I didn’t address that issue.

Ms. SANCHEZ. And that is what happens in some of the clinics

that we have. I mean, the child, for example, becomes the interpreter between the doctor and the patient which, unfortunately, is

not a very good one, as you can imagine.

General KILEY. That is not typical.

Ms. SANCHEZ. So you knew there was a problem but you didn’t

address it?

General KILEY. I don’t remember that I specifically gave directions to increase bilingual staff. But it is an issue that we are going

to take on and we are fixing.

Ms. SANCHEZ. Were you aware of the problems patients described

with having access to their case workers and access to care?

General KILEY. We have recognized that we needed more case

workers. We had social workers on the staff of the hospital, but it

became obvious, as we have talked about earlier, the value of case

workers. I think what I failed to realize was that a ratio of one case

worker to, say, 50 soldiers was too much. They were attempting to

do too much.

We have taken that on. We have lowered those ratios. And we

are going to reexamine that and probably lower them again.

Ms. SANCHEZ. Gentlemen, I just returned from leading a Congressional Delegation (CODEL) in Iraq this past Monday. And

29

when I spoke with my soldiers, many of them from California, they

had just learned that they were going to be extended—maybe about

a week ago they learned. They were supposed to be going home actually this week. Their morale was, as you can imagine, incredibly

low. And, in fact, most of them, or all of them, said, ‘‘Get us out

of here.’’

Now, we have asked our active duty and our reservists and our

National Guardsmen to sacrifice a lot and we send them on these

multiple tours. Many of them are extended, in particular. Many are

going to find themselves extended because of the President’s surge.

And while our troops haven’t been to Walter Reed, they are reading the newspaper and they are finding out that their buddies who

are returning home are being treated this way: lack of case workers to help them through the process, lack of bilingual staff, lack

of paperwork, losing paperwork, being housed in slum tenant conditions.

What do you think the neglect at Walter Reed and the publicity

of this is going to have on the morale of our troops out there?

General KILEY. I think if we don’t fix it right away it has the potential to negatively impact on the morale, which is why I am committed to fixing it.

Ms. SANCHEZ. And how do we tell our families? Because I know

I am going to go home this weekend and I am going to meet the

families and they are going to tell me, ‘‘How could you have let this

occur?’’

What is the answer? Can someone on the board tell me how

could we have let this occur?

General KILEY. I think we have been very busy across the Army

Medical Department. I think, in this case, we just lost sight of

some of the issues that some of these soldiers were dealing with,

didn’t respond quickly enough. And we have got to fix it.

We understand what the problems are. We are going to redouble

our efforts not just at Walter Reed, but at bases and posts around

the nation.

Ms. SANCHEZ. Thank you, Mr. Chairman. And I see my time has

expired.

The CHAIRMAN. Thank you. Before we go on, as I understand it, Dr. Kiley, you say the $140

million is the Army’s military hospitals’ efficiency wedge, which

means that the Army has to find another $140 million in the budget. Am I correct?

General KILEY. I believe that is correct.

The CHAIRMAN. All right.

Now, as I understand, Dr. Winkenwerder said that he returns

money that was not needed. Now, it is not needed, then why don’t

we give that money to the military hospitals and eliminate the socalled efficiency wedge? This country lawyer has a hard time understand that. Would somebody like to explain that to me?

Dr. Winkenwerder? Anybody? Dr. Chu?

Dr. CHU. Let me, if I may, sir.

I think Dr. Winkenwerder’s statement about returning funds applied to fiscal 2006, the fiscal year already concluded. The numbers

that you cited, the $147 million, that is fiscal 2007. It is different.

The CHAIRMAN. Was money returned in 2007?

30

Dr. CHU. We haven’t finished executing 2007——

The CHAIRMAN. Will money be coming back? Or do you know?

Dr. CHU. I think it depends on execution.

Let me, however, explain how these numbers were derived. We

looked in detail at the efficacy of all our military treatment facilities. In other words, if we pay them on the basis that we pay our

private sector providers, could they cover their costs?

Many of our facilities do very well on that kind of metric. There

are some facilities that perform very poorly. In other words, they

are not doing the level of work they need to do given the level of

resources we have.

So these figures came from a decision to challenge the poor-performing facilities to come up not to the top, but to the average over

a period of years.

The CHAIRMAN. All right.

Dr. CHU. Now, as Dr. Winkenwerder said, it is something we are

going to look at year by year. This is relatively small in the overall

defense health program. I don’t think we ought to overdo it. And

if these are not achievable, we will reverse course.

The CHAIRMAN. Of course, the ones you need to explain all this

to—which is very difficult for this country boy to understand—I am

not sure that the patients sitting out there in Building 18 would

understand it.

Dr. CHU. It should be invisible to the patient. The standard for

the patient should be the same everywhere.

The CHAIRMAN. Thank you.

Mr. Jones.

Mr. JONES. Thank you, Mr. Chairman.

I guess my question is going to be to General Kiley, and also to

you, Dr. Chu.

Along the lines of Ms. Sanchez, what has amazed me, I do not

understand—General Kiley, I guess you would be called the governor or the mayor of Walter Reed, because of your position.

Is there not some ongoing process of some individual or some

committee that goes through these facilities on a regular basis to

make sure that the maintenance is current and do the things that

normally people do around universities—they do it around big businesses, they do it at homes?

I mean, there are people constantly—know, with any facility, you

have got to have an ongoing process to keep it current. I mean,

meaning the repairs, the paint, whatever it is.

And I want to ask you this question. If it had not been for Dana

Priest and the article in The Washington Post, would you have

known there was a problem? I will ask General Kiley, I will ask

Dr. Chu, because time is limited: Would you have known there was

a problem with the substandard living conditions if there were

going to be heroes put in those conditions?

General KILEY. I would not. In my position as the commander of

MEDCOM and the surgeon general, I would not have.

And when I commanded Walter Reed, I had a colonel who was

the city mayor; I had a colonel who was the brigade commander;

I had a colonel who commanded the hospital facility, who reported

to me daily. They had subordinates that were charged with the

31

day-to-day maintenance of buildings. And, of course, I did not have

patients there.

But my successors also had those same command relationships.

I don’t know if that answers your question.

Mr. JONES. Well, it does somewhat.

I guess, again, my question is, if these facilities are so substandard, it just didn’t happen overnight. It has been an existing

problem. Whether you had left the command at that time, I don’t

know, and it doesn’t really matter.

I am just trying to better understand the process that is not

working.

General KILEY. I think there are two factors, quickly.

I think that is an old building. We had renovated it several

times, had put in carpets, et cetera.

And then what I believe may have been part of the problem is

we failed to reprioritize the maintenance of that building as a patient care area versus a standard administrative building. And so

the repairs that the NCO was requesting weren’t put into the

queue like all the other repairs, and it was just an error. We fixed

that.

Of course, the building is empty now, but in retrospect, we could

have done a better job of that.

Mr. JONES. Dr. Chu, when did the Department of Defense make

a decision to privatize this construction work?

Dr. CHU. It wasn’t Department of Defense. This was an Army

proposal within the larger effort to look at who should do what.

I think you are speaking to the A–76 contract at Walter Reed.

Am I correct, sir?

Mr. JONES. I think this is right. My question is, can you tell me

who the IAP construction—who that business is that won the contract?

Dr. CHU. Sir, could you repeat that? I couldn’t hear over the

bells.

Mr. JONES. IAP is the group, the management group, that got

the contract. Do you know anything about them?

Dr. CHU. I would have to defer to the Army on the specific contract.

Mr. JONES. Okay. When you put this out for private bid, then I

assume that the parameter is anyone that can do the work can bid

on the process. Is that right?

Dr. CHU. Again, I would have to turn to the Army on this issue

of the contract.

If you are referring to the A–76 process, as you know, sir, it first

starts as a comparison between in-house best organization, which

allows the in-house entity to reorganize itself and rethink how it

does business. And they receive, actually, an edge in the competition in terms of the calculation. So they are allowed to come in certain higher because we do value the continuity that is there.

And then, yes, sir, under Federal contracting regulation procedures, outside elements are allowed to bid, and the decision is

made which is the better value answer.

I can’t speak to the specifics in this particular competition. We

will have to take that question for the record.

32

[The information referred to can be found in the Appendix beginning on page 167.]

Mr. JONES. Mr. Chairman, could I submit a letter for the record

asking a couple more detailed questions about the contractor process?

The CHAIRMAN. Certainly do it for the record, and hopefully you

get back to us within a week.

Mr. JONES. Thank you, sir.

The CHAIRMAN. Mr. Andrews from New Jersey.

Mr. ANDREWS. Thank you, Mr. Chairman.

General Kiley——

The CHAIRMAN. Excuse me. Just a second, Mr. Andrews.

There are two votes, and we will break shortly. We will ask the

witnesses to stay because this is terribly important that we get

through all of this. So bear with us, gentlemen.

Mr. Andrews.

Mr. ANDREWS. Thank you, Mr. Chairman.

General Kiley, I think I think I heard you just say a minute ago

to Congressman Jones that you would not have known about some

of the reports and conditions had you not read it in The Washington Post. Is that what you said?

General KILEY. What I thought I was answering to Congressman

Jones was that I would not have been aware of some of the maintenance challenges—specifically the mold, the holes in the roof—if I

hadn’t seen that in The Washington Post.

Mr. ANDREWS. How about the rodents? Same——

General KILEY. Same thing.

Mr. ANDREWS. Okay.

Who down the line from you would have been aware of that? If

a soldier who is in that facility says, ‘‘Hey, there was a rat in my

bathroom this morning,’’ who does he tell? Where is that person in

the chain of command? How come you didn’t know that?

I have got to tell you, if I were managing a college—if I were a

college president, and one of my students said to me that there are

rats in the infirmary, and if my subordinates did not know—A,

know that, and B, tell me that was the case, they wouldn’t be my

subordinates much longer.

Who is it that would know that? And why didn’t they tell you

that? What was missing here?

General KILEY. There is a chain of command starting with General Weightman, who manages that installation. There is a colonel,

the garrison commander, city manager, and a brigade commander.

Those soldiers answer to the brigade commander through company

commanders and first sergeants, who are charged with the day-today health and safety of the soldiers, to include inspecting their

rooms. They should have known.

Certainly, any soldier that came to me and said, ‘‘Hey, sir, you

know, you are the commanding general MEDCOM, and there are

rats in my rooms’’—I would have acted on that immediately, as

would have General Weightman.

Mr. ANDREWS. And I take it on faith that you did not know, or

I am sure you would have done——

General KILEY. I did not know.

33

Mr. ANDREWS [continuing]. I know that is the case. I am just

deeply concerned that you didn’t. And I am not suggesting that

that is necessarily your fault.

But based upon what you know here, where did the information

stop flowing upward? When someone found that there were rodents

in these rooms, where did that information stop so it did not reach

you?

General KILEY. Congressman, that is under investigation as we

speak, in a formal investigation, 15–6. I can tell you that the commanding general relieved two first sergeants and a company commander that were involved in MedHold and that holdover. And

that investigation should be closed soon.

Mr. ANDREWS. Okay.

General, I am not sure you are the right person to answer this

question. My information is that there are 1,055 soldiers Armywide who remain in medical hold-over (MHO) for more than 360

days at this point. I would like to know how many of them are in

the community-based program.

[The information referred to can be found in the Appendix beginning on page 167.]

Mr. ANDREWS. With respect to those in the community-based program, what quality assurances, provisions are in place now so we

can be sure that their treatment is appropriate and their conditions

are appropriate?

And then second, for those who are not in CBHCO—if someone

who is not in CBHCO was my constituent, and he or she called me

today and said, ‘‘I am living in a facility here that is subhuman,’’

whom do I call to fix that?

General KILEY. You would call me right now, Congressman,

but——

Mr. ANDREWS. If I can just say, that doesn’t work—and I would

call you—but not everyone has access to their congressman to ask

that question.

If this soldier told his or her spouse that problem, who would he

or she go to? And who would fix the problem?

General KILEY. Those soldiers that are not in the CBHCO are

still on our Army installations. And they have command and control; they have a company commander and a first sergeant; they

have a MedHold Over commander; there is a hospital commander,

the Inspector General (IG). They could talk to a lot of people if they

had an issue that was not being answered.

Mr. ANDREWS. I want to go back to Mr. Smith’s question of a few

minutes ago. Do you they have an ombudsman or an advocate that

is there for them that is not part of the chain of command, but is

their advocate? Do they have such a person?

General KILEY. I don’t believe we have a formal ombudsman program yet that is separate and distinct from either the garrison or

the Medical Command, but——

Mr. ANDREWS. Do you think that we should?

General KILEY. Yes, sir, I do. And we are going to.

Mr. ANDREWS. Thank you, Mr. Chairman. I appreciate it. I would

also appreciate an answer to my first question for the record when

it becomes available.

General KILEY. Yes, sir.

34

Mr. ANDREWS. Thank you.

The CHAIRMAN. We will take a few minutes’ break. We have two

votes, and we will be back. I appreciate the witnesses staying.

[Recess.]

The CHAIRMAN [presiding]. The committee will come back to

order.

Mr. Miller from Florida.

Mr. MILLER OF FLORIDA. Thank you, Mr. Chairman.

Good afternoon, gentlemen. Thanks for being here and staying

through the extended delay for the votes.

Got several questions and issues that I am going to be submitting to the acting secretary of the Army. And I will also be asking

some of the questions, particularly to General Kiley today.

And we have talked about a wide variety of things, but one of

the things that is most important to me is traumatic brain injury.

I know it is to most everyone else in the health care world. And

the proper care and monitoring of those who suffer from it is of

particular concern, from ensuring our possible traumatic brain injury (TBI) patients receive proper initial cognitive screening to

crafting legislation that changes the International Statistical Classification of Diseases and Related Health Problems (ICD) codes associated with TBI and psychiatric disorders.

We as a government need to do all we can, and we need to do

it quick.

General Kiley, as many members say to our men and women in

uniform, I appreciate your service, certainly your patriotism, and

in no way do I doubt your dedication to the Army or to our wounded soldiers.

However, it is important that we have trust and confidence in

our leaders. And I, along with many of my colleagues, have lost

that trust and confidence in you, sir.

And I think it is only fair before I begin questioning that I inform you that I have written a letter to the secretary of defense

asking that he know my wishes that you should be relieved of your

command.

And, Mr. Chairman, with your permission, I would like to enter

that letter into the record.

The CHAIRMAN. Without objection.

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

page 156.]

Mr. MILLER OF FLORIDA. Frankly, I have been amazed even at

your public comments prior to this hearing and even some of them

here today.

And I want to associate myself with my colleague Congressman

Bill Young’s comments and frustrations that he made. I know in

a hearing yesterday—I believe Mr. Young and his wife are uniquely

qualified to talk about the issues as they relate particularly to Walter Reed.

And also, one of things you said in your opening statement, that

we had failed in the last few weeks—actually I know you probably

meant we failed for quite some time. I think it is the last few

weeks that it has actually been brought to our attention by The

Post.

35

Some of the questions that I have are, again, about the codes

that are currently being used. And I know you are familiar—I

think it is ICD–9 that is currently being used.

And please correct me if I am wrong, but it is my understanding

that that designation, without any other description going along

with it, medically translates to an organic, psychiatric disorder,

and that an IED victim who suffers TBI and has obvious brain

damage and neurological issues is actually assigned that particular

code.

My question is, is that true, and why are we still using ICD–9?

I understand that it may also be congressionally required, but

should we go to the ICD–11 that the private medical fields are

going to?

General KILEY. Congressman, to my knowledge, the ICD–9 codes

for diagnosis—you are correct, as I understand it, sitting here

today. There is no specific code number for traumatic brain injury,

and so our medical personnel, as they codify the health care that

we are delivering, have to find a code that is close.

And, frankly, that is not acceptable. I don’t control ICD–9 coding.

We have to find a solution to that right away.

Our TBI task force, which I launched last fall, I am sure will be

making recommendations to me in that regard.

Mr. MILLER OF FLORIDA. Any other comments from anybody?

Dr. Winkenwerder.

Dr. WINKENWERDER. I agree that that is a concern. As I understand it, the ICD–9 and ICD–11 is managed by the American Medical Association. I think we and others should be and will be working with them to look at this issue.

You know, the whole matter of traumatic brain injury, whether

it is occurring in the context of our kinds of experiences with warriors or in athletics or other, is really a new, emerging field, underrecognized in the past.

And I just want to assure you, because I know that is probably

on the minds of others, that we are moving very aggressively on

that area. We have a field screening tool that has been in place

since last fall to screen people out on the field when these events

happen. We are beefing up our screening afterwards. We are increasing our research. And I think the overall awareness has gone

way up, as it should.

But we need to do more. And there is just no question about

that. And we will be.

Mr. MILLER OF FLORIDA. And certainly there are field tests and

other tests that are given to determine whether a person suffers

from a traumatic brain injury.

Is it true that if a person takes these cognitive tests and receives

anything in the average range, whether being above average or

below average in cognitive function, that they, in fact, do not get

designated as TBI, if they are still within that average range? So

if you are below average, you still don’t get told you have TBI?

Dr. WINKENWERDER. Again, I am learning about this because the

disability system, again, is something that is driven out of the personnel community, but from what I have learned it sounds like

that system is behind the times, so to speak, with respect to how

it looks at people with these kinds of injuries, which are not—you

36

know, they are not visible, and they are subtle sometimes, and they

may be varying in terms of their symptoms.

And so I think—and Dr. Chu and I were just talking about this

recently—that we may need a new paradigm; we may need a different way to think about how to look at disability for somebody

who has that kind of injury.

The CHAIRMAN. I thank the gentleman.

The subcommittee chairman of Personnel has a couple of inquiries at this moment.

Dr. SNYDER. Thank you, Mr. Chairman.

Mr. McHugh had to leave, but we still got a little confused about

case manager and case manager ratios.

General Kiley, maybe you can answer these questions here, and

then one for the record, if you need a bit more detail.

What is the current case manager ratio, system-wide, in the

Army? What is the current case manager ratio at Walter Reed?

And what should the case manager ratio be? And when I asked you

before about who paid the case managers, are they all employees,

or are any of those contracted out?

General KILEY. I believe the case ratio at Walter Reed is approximately 1:30—25 to 30. And I will take all these questions for the

record.

I can’t give you, as I sit here, a case manager-to-soldier ratio

across the MEDCOM. I do believe it varies, that some of the data

I have looked at—it can be as low as 1:17 to 1:35, depending on

the installation.

I will come back. I can give you those numbers.

[The information referred to can be found in the Appendix beginning on page 166.]

Dr. SNYDER. And what is your goal? What do you think it ought

to be?

General KILEY. Well, we thought our goal was 1:30, 1:25. We are

reassessing that now. It may be 1:15.

And at some point, you reach a point of potential diminishing returns, in the sense that you are expending resources and then, all

of a sudden, the case managers don’t have much to do because they

have taken care of the 10 or 15 soldiers. But we are not there yet.

We don’t have an answer for that yet.

They are made up of GS employees. There are activated reservists, case managers that work for us, also, at our installations. I

will take it for the record, to give you a lay-down, across every installation.

Dr. SNYDER. Thank you. If you can share that with——

General KILEY. And it would not surprise me, although I do not

know, sitting here, now, do I have some nurse case managers at

one of my installations that we have brought on board under a contract? It could be all three combinations.

Dr. SNYDER. If we could have that within a week, two?

General KILEY. Yes.

Dr. SNYDER. Thank you.

Thank you, Mr. Chairman.

The CHAIRMAN. Ms. Bordallo, please.

Ms. BORDALLO. Thank you very much, Mr. Chairman.

37

Mr. Secretary Winkenwerder and also Dr. Chu, I spoke to you

briefly during the recess. I want to thank you all for your testimony.

Like my colleagues, I am concerned to learn that service members who have been wounded as a result of their service in Iraq

and Afghanistan or elsewhere may not be receiving the quality of

care they need. And I trust that the DOD shares this committee’s

concern and desire for prompt action to fix the problems at Walter

Reed.

I want to make sure that the Department is aware that problems

at Walter Reed are indicative of problems that exist across the Department’s entire health care system.

For example, many times in the past, including in committee

hearings and in meetings at my office, I have raised with you, Mr.

Secretary, and others in the Department—I have some of the correspondence here with me here that I have inquired about this,

and you have written back—the health care needs of retirees who

are reliant on the TRICARE system for health care. That is, a U.S.,

20-year, military retiree who lives on Guam, who are referred offisland for specialty care or emergency care, are forced to travel to

those locations at their own expense.

These trips to access referred specialty care in Hawaii or California cost in the thousands of dollars, unless, of course, they are

going military air travel. In 2005, the Department suddenly

changed policy to no longer reimburse retirees for travel expenses.

On Guam, Mr. Secretary, and to the other witnesses here, we

cannot travel across the states to another hospital. We are the only

U.S. jurisdiction in the Pacific, thousands of miles away from specialty care. So as a result, these costs are born solely by the retiree.

Mr. Secretary, I have met with you, and I have written to you,

as I have said. And I have addressed this issue more than once in

hearings. The committee included report language on this matter

in 2005. The retirees deserve resolution. From what I can gather,

no measurable action has been taken by you or anyone else on this

matter since we met and discussed this issue last year.

If my proposed legislative remedies continue to be unacceptable

to you or the Administration, then I respectfully request that you

propose alternative solutions for the committee to consider if a fix

cannot be made administratively.

So during this hearing, I will ask, once again, will you work to

rectify this problem to reassess your policy of discontinuing reimbursement of travel for these 20-year U.S. veterans?

Dr. CHU. Congresswoman, yes, we will look at it. And I will take

another look at it. And as I have said, I am sensitive to that concern. We are sensitive to that concern.

It wasn’t a discontinuance of payment for that. It related to the

fact that there had been, in the prior years, flights that had occurred where people could go on those flights and that it is no

longer possible because of the flight schedules and so forth.

But I think that deserves another look, and I promise that we

will do that and get back to you promptly.

Ms. BORDALLO. Thank you. Thank you, Mr. Secretary.

And, Dr. Chu, I thank you for listening to me, as well, this morning. I want to work together. I want to help our veterans. Just reVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
38

cently I had a town hall meeting on Guam, and this was a major

concern among our veterans. And I hope that we can come to some

solution.

Dr. CHU. Thank you, ma’am.

Ms. BORDALLO. Thank you, Mr. Chairman.

The CHAIRMAN. Mr. LoBiondo.

Mr. LOBIONDO. Thank you, Mr. Chairman.

I want to thank the panel for being here today.

And, General Schoomaker, I had the opportunity to visit earlier

in the week. And I have to tell you I was very impressed by the

hands-on your brother demonstrated with where we are with this.

But as a number of my colleagues have indicated, I am having

a hard time grasping how this came about.

In my visit, I listened to the frustration of a couple of our soldiers who repeatedly attempted through their case worker and

then up the chain of command to have something done. Now,

whether there was frustration about the bureaucracy of the paperwork that was a part of this, as was indicated—but the reality is

that those conditions were horrific, deplorable. And repeatedly,

over a long period of time, we had soldiers trying to point this out.

I don’t understand how this breakdown in the chain of command

could have happened. And I am concerned that there are other situations where this chain of command is broken down in other

areas that we don’t know about yet.

So I would like one more time to try to understand. Because having been on this committee for a few years, there have been isolated incidents—and I will say isolated—where I sense when members of Congress ask questions we are almost dismissed from just

some level of the chain of command—the higher chain of command

that doesn’t want to be asked any questions. And then we have a

situation like this where we are held responsible. Yes, you are

being held responsible, but we are being held responsible.

So I am still failing to understand that through the whole chain

of command this thing was broken down. I mean, whoever was in

charge didn’t have officers underneath that understood the plight

of the veterans who were in their care. The case workers couldn’t

do anything about it. These rooms were on the list and kept getting

bumped off the list.

And what assurances do we have that there isn’t something else

wrong in the system somewhere along the line? I am really trying

to understand this to work with you, but it is very difficult.

I don’t know who wants to take a stab at that.

General SCHOOMAKER. Congressman, are you addressing me on

the issue? I assume by the end of your question you were talking

about Building 18 and how that occurred.

Mr. LOBIONDO. Building 18 and how that occurred.

General SCHOOMAKER. But, of course, there are also obvious

breakdowns in outpatient care in general and the medical evaluation board (MEB)/physical evaluation board (PEB) process. We

have had reports of inpatient care concerns and all the rest of it.

And the Building 18—those soldiers that were in there were outpatients going through this process. Noncommissioned officers were

assigned over them. There was a company commander over them,

a first sergeant. And it goes on up through the, you know, brigade

39

that is there on Walter Reed that answers to the commander of

Walter Reed.

So that is precisely what we are investigating right now, is how

did we get to this? With all of the leadership present that was at

Walter Reed, how is it that something as simple as this—when we

were not constrained in resources to fix this, and where we are fixing it throughout the Army in a very aggressive way—why would

this be a surprise to anybody? And why would we be where we are

today on it?

I think that—and so we are investigating it. As you know, a couple of first sergeants and a company commander have been relieved, and we have put in place a more robust structure with a

better span of control on it. And there is very aggressive action

being taken in making sure that the housing for the barracks for

soldiers are adequate. But we need to find out.

And, you know, the assurance is we have to reinforce the chain

of command. And the chain of command is based upon trust and

confidence in the people that are in that chain of command, and

it requires them to take action—of all of us.

So, you know, the assurance is that we are aggressively pursuing, you know, what happened. We are going to fix whatever the

root causes of it are. And we are putting energy in the system, putting the right leaders in place to make sure that, you know, that

it has continued to be an aggressive program and we move onward.

There is no excuse. And I have consistently said that. There is

absolutely no excuse. But there are some reasons, and we need to

figure out what the reasons are and address them properly.

Mr. LOBIONDO. Mr. Chairman, can we on the committee expect

that we will have a follow-up to this to hear some of these reasons

or conclusions at some point in the future?

The CHAIRMAN. We could very well do that. It hasn’t been determined yet, but we could very well do that.

Mr. LOBIONDO. And what about other facilities across that country? I mean, I am assuming there is some aggressive action being

taken to make sure that nothing like this is taking place anywhere

else.

General SCHOOMAKER. Well, you are correct, and at various levels. We have a tiger team that is going out and looking at it. Immediately upon learning this, we have asked everybody to—the mission commanders out there, as well as the hospitals and other facilities—it is not just limited, you know, to the Medical Command.

We have asked all of our commanders out there to take a look at

what they have and make sure that we know what the challenges

are, because we have been aggressively working these issues.

And that is what is so frustrating. What angers me so much is—

I mean, we have been working now for at least three years very

aggressively, and have pursued the resources to do it, have gotten

the resources, have been applying the resources. And there is really

no reason for it.

Mr. LOBIONDO. Well, that is the way we feel. And obviously, over

the last three years, with what you have done, some folks below

you on the chain of command don’t quite understand it, and I hope

they do get the message.

Thank you, Mr. Chairman.

40

The CHAIRMAN. Thank you.

Ms. Castor from Florida.

Ms. CASTOR. Thank you.

Gentlemen, let me start by saying that I am compelled to convey

to you the moral outrage of the folks I represent in the treatment

of our soldiers.

I represent a community that truly values the contribution of our

young, brave men and women. I represent the Tampa Bay area. We

have the largest VA hospital in Tampa, the Haley Center. It also

is one of the very unique polytrauma centers that focuses on the

critical brain injuries and spinal cord injuries. And just across the

bay, we have the great Bay Pines veterans’ center.

So, in our community, we truly value the service of these young

men and women and many veterans. In Florida, we have the second highest number of veterans.

And, General, I agree with you. It is time for a comprehensive

solution, and I just wanted to point out a couple of cases, in talking

with soldiers there over the past few weeks and, really, over the

past few years, that you can build into your comprehensive solution.

First is information provided to families. Before I was elected to

Congress, I served as a county commissioner, and I was very surprised a year and a half ago to receive a call from a family that

could not get any information on an injured soldier.

He was an Army specialist that was—his unit was attacked.

There were IEDs in the roadway outside Fallujah. He was caught

up in a firefight, shot in the neck, and could not communicate himself. And, of course, flown to—provided excellent care, flown to Germany and then to Walter Reed.

And very surprised as a local government official to get a call,

as a county commissioner. They didn’t have anywhere else to turn.

You know, I was the closest elected official to them. And, fortunately, Senator Bob Graham was on the Veterans Committee then

and provided entree.

And I happened to be going to Washington, just happenstance,

to be able to go to Walter Reed with folks from Senator Graham’s

office, and we had to go to the hospital to get information. We could

not get information by calling anyone in the chain of command, by

calling doctors at Walter Reed.

And at that time, I believe, Senator Graham was a Ranking

Member on the Veterans’ Committee.

We had to go to the hospital and track down the doctor and find

out what this soldier’s condition and then phone the family back

home.

Now, I know since that time there have been improved efforts to

communicate with families, but that is a travesty that you have to

rely on those kind of efforts to get the information back to the family.

And finally the soldier returned back home, and we had said, ‘‘If

you need anything else, you know, don’t hesitate to call,’’ thinking

that certainly there would be no other issues that they would have

to call a county commissioner to get through to the Army and to

military health.

41

But sure enough, a few weeks later, this soldier called. And I

know it took a lot for him to call again and said, ‘‘I can’t get my

rehab appointments scheduled.’’ He was shot through the neck, injured his spinal cord, and he was back at home but could not access

the rehab system.

So this information, information-sharing to the families, and

being sure that these soldiers don’t have to go through that rigmarole to get their rehab appointments—another story: Visiting a

soldier just a couple of weeks ago at the Bay Pines inpatient center, where they deal with drug rehabilitation and post-traumatic

stress disorder, a young soldier said, ‘‘You know, when we come

back and we are going through discharge, we are in such a hurry

to get out that we get in the screening that is done—the medical

screening, especially psychological, they hand us a checklist, and

we go through, and we check it off. And we are tough guys, and

we don’t have any physical wounds, but we know something is not

right, but we are in such a hurry to get out, we just check all the

boxes and then go.’’

And he did that. And then all of the PTSD set in, and his marriage went on the rocks. In discharge, did not have any other prospects for employment. Eventually became homeless, started drinking.

And he said, ‘‘You know, if they had just been a little more

proactive with us upon discharge, that would have made all the difference in the world.’’

So being more active at the time of discharge.

And then let me also mention quickly: Dr. Scott at the

polytrauma center at the VA in Tampa said they are having a lot

of difficulty with residents in training—bringing in the residents

for these type of brain injuries and training the rehab doctors. And

this is at a place where we have a college of medicine right across

the street.

Thank you.

The CHAIRMAN. Thank the gentlelady.

Mr. Kline.

Mr. KLINE. Thank you, Mr. Chairman.

Thank you, gentlemen, for being here. I know all of us wish the

circumstances were a little bit different.

I, like everybody else, find it unexplainable and inexcusable that

we could have the kind of conditions that we did have in Building

18. And I know that action is being taken. We have seen some of

it already pretty visibly. And I know that you are working vigorously to get to the bottom of it and make sure it doesn’t exist elsewhere.

Having said that, I want to identify myself with the remarks

that some of my colleagues have already made—Mr. Saxton, Mr.

McHugh among them—and that is about the terrific soldiers who

work at Walter Reed.

One of my very, very best friends retired from the Marine Corps

about the same time I did, another Marine colonel. He goes out to

Walter Reed with his wife about three times a week. They have

gotten extensive care out there: vascular surgery and other things.

And he called me day before yesterday in a rage, not about the

deplorable conditions, but about what the impact of all of this covVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00045 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
42

erage was on the morale of the personnel at Walter Reed. My wife’s

last duty station as an Army nurse was in Walter Reed. And I

know not just because she worked there—but I know that these are

soldiers too and they care. And they give their all.

And I know that this kind of publicity is damaging to the morale.

And as one of the doctors said to my friend, it is just not fair because this looks to the world like we are a Third World dump out

here with substandard care and substandard facilities everywhere.

And we know that not to be the case.

So I just think it is important as we go through this that we remember that it is not just the soldiers who are being treated there

that we need to care about, but it is those working, in many cases

very selflessly.

I am going to get to a question here, Dr. Chu.

The commandant of the Marine Corps was here testifying last

week or so, and we had a discussion about something that he calls

the wounded warrior regiment, a sort of formalized way of making

sure that Marines aren’t falling through the cracks as they go

through this recovery process.

Some of them are being treated at Camp Lejeune or at Camp

Pendleton or something, and then some of them are being discharged, they have being picked by the VA. And we know many,

many cases where we have had soldiers and Marines who have

dropped through the cracks as they go from defense care to veterans care.

And to most of this country, gentlemen, let’s face it, it is all the

same: It is how are we taking care of our wounded soldiers, whether they are active duty or guard or been discharged.

So my question, I guess to you, General Schoomaker, is, are you

looking at a wounded warrior—I know you have something, sort of,

called a wounded warrior program. But are you looking at this concept that the Marine Corps has to, sort of, formalize this? They

have a regiment, a regimental commander. They have brought an

active duty colonel back from Hawaii to command it. They have

two separate battalions.

Are you looking at something like that to help keep soldiers from

falling through the cracks and taking care of some of these case

management questions we have been talking about?

General SCHOOMAKER. Well, we have, as you correctly stated, in

the Army the Wounded Warrior Program that we started in 2003.

And it really got formalized in early 2004 for exactly this purpose.

And we have had tremendous success with it. We have integrated industry and jobs and the whole idea that this is a soldierfor-life approach to things. And the purpose of it was to ensure that

soldiers didn’t fall through the cracks on the thing.

As you know, the load on this program has increased significantly since 2003. And, you know, that approach that you are talking about there may very well be something that we ought to institute, you know, so that we distribute—kind of, expand the control

over it.

But the purpose of both programs is the same. And that is that

we have got a lifelong commitment to these young men and women

that have worn the Nation’s uniform. And it is our intention—our

true intention to be dedicated to lifelong support of them.

43

Mr. KLINE. Well, I hope that the Army and the Marine Corps—

and it would be a model for other services—we kick those programs

into very high gear, so we have somebody serving in uniform that

the soldiers and marines know how to get in touch with—you know

how to get in touch with them and we know how to get in touch

with them—that is making sure we are not losing these terrific

young men and women.

Thank you, Mr. Chairman.

The CHAIRMAN. Thank you very much.

Ms. Davis.

Ms. DAVIS OF CALIFORNIA. Thank you, Mr. Chairman.

Thank you to all of you for being here. I know this is not of your

choosing, but on the other hand, we have to all be accountable. And

I think it is so important that we get to the heart of this.

As you know, I represent also a great military community. And

we have some of the finest examples of patient care and support

for our service members there. But we also share in those problems

as well.

A number of people have discussed contracting out. And part of

that is for operations and maintenance at Walter Reed.

But I want you to take a look and help me understand the impact of what some people would call the military-to-civilian conversions, where you have service providers have to be bought, really,

in the civilian marketplace, and what impact that is having on our

service members and the care that they receive.

One of the concerns, of course, is that there is not the kind of

continuity that we would hope for. Perhaps someone is an advocate

for many service members at one time, but we can’t keep those people in that job. And so, in fact, there are some changes that occur.

If you could address that, I would appreciate it.

Dr. CHU. I think this is an opportunity for the Department to ensure that there is the best possible care for our service members.

The United States, as you appreciate, has a medical care establishment second to none. People come from overseas to the United

States. This is a long tradition in the Department. Let me take an

example from a different military service, at Newport, Rhode Island.

For some years, the Navy tried to operate its own inpatient facility; decided that really wasn’t the best way to provide first-class

care. The Navy continues to maintain a clinical staff—internists, et

cetera—at the Newport Naval Station.

But for inpatient care, they place the patients in the civilian hospitals in that community. The military physicians attend on those

patients.

So mil-civ conversion, that bumper sticker, in my judgment, is an

opportunity, through the Department, and through each military

service, to rethink how it does business, to make sure we have got

the best possible set of ingredients.

So we use military personnel where it is essential.

The Department has been through a major review of what is the

military content we must have to deal with deployed medicine, on

the battlefield, bring the patients home for the kind of care they

get at Walter Reed. That does not mean we have to staff everyplace

else the same way.

44

There are examples all across the military that have been used

in the past. Take radiology as an example. It is not necessarily the

case that at a smaller installation we should try to have our own

radiologist. It is not professionally satisfying for that person. And

so many installations we have gone to agreeing with a local radiology group, they will read the films, we will reimburse them for the

read, et cetera.

So this is an opportunity, in my judgment, to get it right, to

make sure that we are delivering care in a way that is most effective.

Ms. DAVIS OF CALIFORNIA. And if I can interrupt, Dr. Chu, in

what areas, Secretary Chu, are these not working very well?

And let me just quickly—because we talked about the advocate

issue earlier, and one of the things that was said—and ordinarily

I would certainly support having volunteers in positions, but we all

know that we can’t solve this problem with short-term—whether it

is short-term employment or volunteers for that matter. I mean, if

we are really going to attack it, professionally and in the best way,

we need to do it right.

And so part of my concern is that perhaps there are some areas

in which this hasn’t worked very well.

Dr. CHU. I am sure there are instances where people have tried

new arrangements where they have fallen short. And our policy

would be, let’s back up and rethink those areas and do it differently.

To your question about using volunteers as caseworkers, the

caseworkers that we are talking about here today are paid personnel. These are professional staff members.

At the military injured center, we basically staffed at the master’s degree level, for example, to be sure we have the right kind

of backstop there for the service program. So we understand you

need a high level of professional competence to do this job well.

This is not straightforward.

Ms. DAVIS OF CALIFORNIA. Thank you. And if we can follow up

with that in the future and make sure that those people are highly

qualified and well trained, that would be helpful.

One very quick thing: In San Diego, they have developed a onestop center, which essentially provides employment opportunities

not just for the service member, but also for the family member as

well, housed with the California DOD and educational opportunity

center.

Is that a model that we should duplicate elsewhere, or are there

other models that you think are best practices?

Dr. CHU. On employment for both the member and the family,

we are experimenting with a wide variety of models, ma’am. Let

me send you something separately on that front.

Ms. DAVIS OF CALIFORNIA. Okay. Thank you.

The CHAIRMAN. Before I call on Ms. Drake, General Kiley, General Weightman was recently in charge of Walter Reed.

General KILEY. Yes, sir.

The CHAIRMAN. Prior to him was a General Farmer.

General KILEY. Yes, sir.

The CHAIRMAN. Prior to that was you.

General KILEY. Yes, sir.

45

The CHAIRMAN. Did you have knowledge of any of the shortcomings that have been reported regarding Building 18 when you

were there?

General KILEY. No, sir.

The CHAIRMAN. Was Building 18 being used when you were

there?

General KILEY. Yes, sir. We housed a permanent party and transient student detachment, students that were soldiers that came in

for training at Walter Reed, some for short periods of time.

The CHAIRMAN. So when you were there it was not being used

for patients?

General KILEY. That is correct.

The CHAIRMAN. And when did it begin being used for patients?

General KILEY. If my memory serves me correctly, Mr. Chairman, after about a $270,000 renovation to Building 18, General

Farmer in 2005 began using that, carefully selecting patients who

were ambulatory, getting toward the end of their stay at Walter

Reed, and began assigning them there, as I am told.

The CHAIRMAN. Ms. Drake.

Mrs. DRAKE. Thank you, Mr. Chairman.

Gentlemen, thank you for being here. I am just going to get all

my questions out at once, and then we can get as many answered

as possible.

But I think we have heard overwhelmingly today that truly we

have a wonderful health care system within the military, that it

truly is quality. The problem is the long-term care.

And one of my questions for Secretary Chu and Dr.

Winkenwerder: Is there any process in place that you are having

discussions with the VA? Because, of course, these men and

women, some will be returned to active duty, some won’t.

So what are doing? And can we use what has happened now to

make sure it is not happening over in the VA system just as well?

I will tell you, I have never had a complaint in my office about

Walter Reed. I have had many complaints abut the VA system. So

if we can use this with all of you working together, that could be

helpful.

And I know I was encouraged in 2005, when we put the money

in for the seamless transition; we called it for better information

technology (IT) between VA and DOD.

And maybe, Mr. Chairman, we could do a joint hearing, if that

would be appropriate, with the Veterans Committee to look at the

VA system, as well.

The CHAIRMAN. The chairman of that committee and I have already discussed this possibility.

Mrs. DRAKE. Good.

The CHAIRMAN. Thank you for mentioning it.

Mrs. DRAKE. Thank you.

And I think it is really good today to hear that we are going to

redefine the job of case managers, but I would also encourage

you—I know Duncan Hunter just called it a VIP system. Maybe

even if we had a hotline; that if they felt that case manager wasn’t

listening to what they were saying—and, obviously, they are overworked, as well, but not just for our military men and women, but

for their families.

46

If their families felt they had a way to communicate and say,

‘‘Something isn’t right here.’’

And, General Kiley, you have said it: It is complex. It is confusing. And, you know, we are the hotline. When people call us as

their member of Congress, that is exactly the role that we play.

And, fortunately, we know who to call and are able to get through.

But I would also like to ask specifically about Walter Reed. Since

that decision was made some time ago in the studies that were

done on Walter Reed and with a number of injured men and

women who are returning now from a global war on terror, does

it make sense to relook at Walter Reed, or is this just a done deal?

And is it going to be BRACed? And if it is going to be BRACed—

we have talked a lot about uncertainty of funding. Chairman Smith

talked about it, not having our bills done by October 1st.

And just an aside on that, two paralyzed veterans came to see

me yesterday. The only request they had of me was we get our bills

done by October 1st. And I thought, ‘‘Boy, that is not a lot for us.

It doesn’t cost us anything to do that.’’ And they were stressing

what it meant to them that we don’t get those done on time.

But I am also curious about what is the uncertainty—if we are

BRACing Walter Reed, and we have just reduced, in the 2007 bill,

the $3 billion for BRAC—what the uncertainty is for you now. Are

we moving ahead with Bethesda or do you have to wait to see how

we are going to address that issue?

So thank you for being there. And I know that was a lot, but—

thank you.

Dr. CHU. Let me try to answer them quickly within the allotted

time.

On your first question, yes, we have tried, in this Administration,

to try a new construct. We have a joint executive council where I

and the deputy secretary of the VA and all the affected leaders

meet once a quarter. We have had a special meeting just this last

week or so to start dealing with these issues. We see it as an opportunity to do exactly what you suggested.

On the hotline front, we do have a hotline that is at the severely

injured center. We do field calls there and we open case files on

those cases, just as you suggest——

Mrs. DRAKE. Well, maybe that needs to be more widely public.

Dr. CHU. I think I am hearing you say it does need to be widely

publicized.

Mrs. DRAKE. Okay.

Dr. CHU. Although we do get lots of calls, so it is——

Mrs. DRAKE. And family members as well, because that is——

Dr. CHU. Anybody may call.

Mrs. DRAKE. Okay.

Dr. CHU. And we do not restrict what is ‘‘severely injured.’’ If, in

your perception, you are severely injured, that is good enough for

us; we will take that case. And as I said, we have master’s level

counselors to work that system.

We fully support getting money by October 1st. You have identified a very serious problem for the Department. This is a game of

large-scale musical chairs, unfortunately. If we do not get the $2.3

billion that is at stake in the BRAC shortfall, we have a big problem on our hands because those are statutory deadlines.

47

In the specific case of Walter Reed, Bethesda—also Brooke and

Wilford Hall—the Department is aiming to put at these two premier locations a first-class, 21st-century facility.

Both Walter Reed and, on a slightly longer timescale, Bethesda

as buildings need to be replaced. We should not wait on this issue.

In fact, I was pleased, in the hearing on the Senate, Tuesday, that

Senator Warner urged us to go faster, not slower.

But we do need the funding. And I would urge that members of

this committee join their colleagues in ensuring that funding is in

the supplemental, so we correct this issue as quickly as possible.

So we would like to get on with it. We would like to make sure

it is first-class; it has the capacity and the modernity of facilities

to serve our people well.

Mrs. DRAKE. And do we think that we will re-look at Walter

Reed, or is it going to remain BRACed by 2011?

Dr. CHU. Well, it is a statutory decision, as I—I am not a lawyer,

but I understand the statutory decision. We have no real desire to

reopen this decision.

We want a first-class facility. I don’t think anyone would argue,

though, two tertiary care facilities within five miles of each other—

we should have one first-class space.

The advantage of the Bethesda location is it is the same campus

as our medical school. And it is, as you know, across the street

from the National Institutes of Health (NIH).

And Bill Winkenwerder and I have charged the medical school

dean, as a prelude to this event, to build a stronger relationship

between DOD and NIH, so we bring to bear on our problems the

talent in that institution.

Mrs. DRAKE. Thank you.

And, Mr. Chairman, I would just like to reiterate what Chairman

Snyder said. If you could tell us if we have a constituent that is

there. I think even just contacting them and letting them know we

know that they were injured and thank them for what they have

done for our country.

Dr. CHU. Thank you, ma’am.

Mr. LARSEN [presiding]. Thank you, Ms. Drake.

Actually, I am next in line, so I will—I don’t know that I have

a question, but just a comment. Sometimes I show up at these

hearings with a set of questions I really need to ask. Sometimes

I need to come and listen in and hear what I need to hear and develop some thoughts.

I first just want to underscore Mr. Miller from Florida’s comments earlier about traumatic brain injury, combat traumatic brain

injury. That is something of great importance who have contacted

my office—ensuring that we don’t wait too long before we try to

screen some of these folks—not wait till something shows up. But

if, you know, the science needs to advance faster than it has, let

us know what we can do to help out with that so we can screen

faster and catch it sooner.

As you leave at some point today, I do not want you to think that

the morale issue at Walter Reed is a function of media exposure,

okay? It is a function of, from my perspective, a disastrous and horrendous failure in leadership; not because it got covered in some

newspaper and is being covered all over the country now. It

48

wouldn’t have happened—it wouldn’t be covered unless things

weren’t getting taken care of. And so I really have to emphasize

that from my perspective.

Let me tell you a fun story, a high school football story. We got

shellacked one game. And we didn’t get beat by a lot, but we had

done pretty well all year except this one game. Our defense—all

the gaps showed up, all the weaknesses showed up. We hung in

there, but all the weaknesses showed up. We ended up losing the

game.

And our football coaches asked after the game, he said, ‘‘What do

you think of the execution of your defense?’’ He said, ‘‘Well, I think

it might be a little too early for that extreme of an action. We will

see how they do next week.’’

The point I am making is that—and Dr. Chu, you talked about

execution, how things were done—the execution on this has been

terrible as well. And not just how you have handled it since it has

been covered, but we are here because we need to ask: Why did

this happen in the first place? Why did this occur in the first place?

Now, Secretary Gates, to his credit, has come down like a ton of

bricks on this issue. And, frankly, I hope he has a few more tons

of bricks to bring on this issue as well—before, during or after the

independent review group is done. Because this is a problem that

is going to—it is costing us now.

But we debate about Iraq. We debate about Afghanistan. If we

lose hearts and minds of the folks who are coming home, people

who are active duty and become veterans, if we lose hearts and

minds of the families because we aren’t treating those folks well

when they come home, that is when we lose, in the minds of the

American people, what we are doing overseas. And that is a great

frustration of mine.

If we aren’t taking care of these folks when they are coming

home, if we aren’t taking care of these folks as active duty in our

military health care system, and then—as they become veterans—

then it doesn’t matter how well we do sometimes overseas, because

the people who have fought are going to be critical of how they

were treated when they got home.

So on the positive side, we want to help improve that. We have

to. We can’t be fighting this one 30 years from now. We can’t be

fighting how we treated our veterans today 30 years from now like

we are fighting another war 30 years ago because how we treated

veterans then. We got to get it right.

And that is why we are here today. And if we are frustrated, if

I am frustrated, if some of us are frustrated, it is because we have

got enough work ahead of us. We have enough work ahead of us.

We have to get this right.

So with that, I will end my comments.

And Mr. Turner from Ohio.

Mr. TURNER. Thank you, Mr. Chairman.

General Schoomaker, General Kiley, as you will recall, I participated in the Government Reform hearing on Monday at Walter

Reed. General Kiley, at that point you were asked several questions that were similar to Ms. Sanchez’s questions of how could this

happen.

49

Today you answered, ‘‘We have been busy.’’ Monday you answered—because I wrote it down, and I asked you about it later,

and I asked General Schoomaker—you said, ‘‘The complexity of the

injuries of these soldiers was not fully realized.’’

And my question to you, General Schoomaker, was: Did you find

that an acceptable answer? Because it wasn’t an acceptable answer

to me or the Government Reform, Subcommittee of National Security.

Because I think we could easily have anticipated the type and

level of injuries that were described to us in the hearing or that

were described to the patients. I understand you have 371 outpatient rooms at Walter Reed. That was part of the testimony on

Monday.

And, General Schoomaker, you told me that you were not aware

of General Kiley having made that statement and that you would

check on that statement and what he meant by it and get back to

me.

And now I am back in front of you, and you are back in front

of us, so I would like to know your comments on whether or not

you think that General Kiley’s statement is an acceptable answer

of, ‘‘The complexities of these soldiers’ injuries were not fully realized,’’ as an answer to how this could have happened.

General SCHOOMAKER. Well, I am not sure I remember the context in which this was—as I listened to this, what you just described, I take it we are talking about the complexity of the injuries

that we are seeing come off the battlefield today.

Mr. TURNER. We were asking the question as to how this could

have happened. And just like General Kiley today said to Congresswoman Sanchez, ‘‘We have been busy,’’ his answer on Monday was,

‘‘The complexities of these soldiers’ injuries were not fully realized.’’

And what I asked you on Monday was, it would seem to me and

the other members of the Committee of Government Reform that

when we heard that, that that was not acceptable; that in fact the

injuries could easily be anticipated and the complexity of their injuries would have been very easily anticipated. And we asked General Kiley, ‘‘Well, what type of injuries did you prepare for then,

if it wasn’t these?’’

Because what we saw in that hearing, the three individuals we

had testify, a family member and two soldiers, we had a machinegun wound, an explosion and a vehicular accident, which don’t

seem to me to be very unexpected in a conflict.

And you indicated when I asked you the question that you would

check with General Kiley about that answer and get back to me.

I wonder what your thoughts were today.

General SCHOOMAKER. My thoughts today are that I think we

are seeing soldiers survive injuries in combat we haven’t seen before. And I think things like TBI and PTSD and the multiple

things that we had, that is the context in which I understood the

question.

Mr. TURNER. Okay. They are surviving, though, as a result—

General, they are surviving, though, as a result of the actions that

you have taken and others have taken——

General SCHOOMAKER. That is correct.

50

Mr. TURNER [continuing]. On the battlefield that clearly—I

mean, it is not an unexpected result—if you are taking action to

increase the survivability, certainly your expectation would be that

the medical system would be receiving these individuals and be required to step to the plate for their care.

General SCHOOMAKER. As a non-medical person, my understanding is that what we are seeing, though, are injuries that aren’t visible injuries; that we understand differently today than we understood even two or three years ago in terms of TBI, PTSD, some of

these kinds of things that—yes, soldiers survive an IED attack and

they may not even be wounded in the typical sense——

Mr. TURNER. General, I understand that. My time is just expiring soon, so I want to ask you—because I asked you that then. I

understand your further explanation of that, that it has taken a

while for you guys to understand what you are going to be receiving.

But this problem arose in the past couple weeks. It came to light

in the last couple weeks, but it has been ongoing.

So at what point was it—because it wouldn’t have been just

when The Washington Post started the article of the difficulty that

soldiers are having. At what point was it that the complexities of

these injuries were fully realized? Because it wouldn’t have been

two weeks ago.

General SCHOOMAKER. From my standpoint, I think we have

been learning every day. Every day we learn something different—

I certainly do—in the soldiers that I visit and the things that I

hear on this. And so I don’t know. I think it has been a learning

process, a process of adaptation all along.

And, again, I am not a medical professional. I think that the

complexity that I am talking about is the results of survivability

rates and unseen injuries that we are starting to understand now

that are a lot different than anything I have experienced in my career.

Mr. TURNER. Thank you, Mr. Chairman.

The CHAIRMAN [presiding]. Thank the gentleman.

Before I call Ms. Shea-Porter, do I understand correctly, Dr.

Winkenwerder, that you must leave? We have three——

Dr. WINKENWERDER. Yes, sir——

The CHAIRMAN [continuing]. Four members——

Dr. WINKENWERDER. Yes, sir. I am going to try to stay another

15 or so minutes——

The CHAIRMAN. I think we will get everybody in if we stick by

the five-minute rule well.

Ms. Shea-Porter.

Ms. SHEA-PORTER. Thank you, Mr. Chairman.

I have several questions. At first I want to preface those questions by telling you that I was at Fitzsimons Army Medical Center

with my husband during the 1970’s. And it is so discouraging to

see the same kinds of issues and the same problems and the same

surprise that things aren’t going so well.

And I wonder where the breakdown is. And it is hard for me to

buy into any of this, because my feeling is that you know that

these soldiers are going into combat. You know that some of them

are going to have their bodies and their spirits broken. And who

51

has been looking out for them? And I can’t answer that. And I am

going to ask you a couple questions to see if you could answer that

for me.

The first one I wanted to ask was General Kiley, please.

I have it that you said when you did the initial review of Walter

Reed, ‘‘I do not consider Building 18 to be substandard. We needed

to do a better job on some of those rooms, and those of you that

got in today saw that we, frankly, fixed all those problems. They

weren’t serious and there weren’t a lot of them.’’

Is that accurate?

General KILEY. Well, obviously, the rooms that had the mold and

the holes in them were clearly below standard. And subsequent to

those comments, I have said that.

It is an old building. It requires constant maintenance. We have

failed to do that. So, as an organization, we have failed, but recognize that and we are fixing that now.

Ms. SHEA-PORTER. Well, I even want to get past the buildings,

although I do believe that any time you are in command of anything for anyone, part of your responsibility is to make sure that

you talk to people on the bottom of the rung and not just on the

top, and that you walk around your facilities and you look for yourselves.

You must never, ever lose that hands-on, have-a-look touch. Because this is what happens when we do this.

But what about the people in those rooms? Even if the rooms

looked okay to you, at that point, you must have heard something

about the people who were occupying those rooms, and the problems they were having?

General KILEY. No, ma’am. When I made rounds and talked to

soldiers at Walter Reed, I was never approached that there was a

problem in Building 18—‘‘Hey, sir, you should see my room; it has

mold.’’ I would have taken immediate action.

And subsequently to that, talking to soldiers, the ones that were

in those rooms were asking to get those repaired, and we failed to

do that. We screwed that up, and we need to fix it.

And it is not just Building 18. I take your point. We need to

make sure that is not happening anywhere else in MEDCOM.

Ms. SHEA-PORTER. Well, you know, when my husband was a

lowly lieutenant, I am not sure that I would have walked up to a

four-star general—although I might have—or a three-star general

or even a colonel and said anything about it. It is really your responsibility to have a look, instead of expecting that.

Now I would like to talk to Secretary Chu for a moment, please.

You are the undersecretary of defense for personnel and readiness. Did you ever go out to visit any of these facilities? Have you

talked to any of those who have these brain injuries and other horrific injuries? Who do you depend on to find out if we are doing

what we need to do for these troops?

Dr. CHU. I depend both on the top and the bottom. Wherever possible, I do try to visit our various facilities, although I have not

been to Building 18, I should acknowledge. But I also depend on

the Department’s various reporting sources to look at, overall, how

are we doing on this front.

52

And I do think, as several members have said, the clinical care

that the Department delivers to these individuals is first-rate. And

I do think we do want to make sure we thank the commissions and

the clinical staff at places like Walter Reed for what they are

doing.

As General Kiley has testified, the Department did not do a good

enough job in terms of the billeting for these troops. We accept that

responsibility.

We accept the responsibility for the complexity of the Disability

Evaluation System. I think this debate is a terrific opportunity to

reconsider that entire system.

And we are at the beginning stages of doing that. I think we

would like to have a different kind of system for the future; one

that, from the family’s perspective, from the injured’s perspective,

is simple to use, even if the back office elements, the statutory

foundations, are complex.

Let’s let the specialists deal with that; present the family with

a simpler and more easily explained set of choices so that they understand what their selection might be and how they might best

proceed in the next stages of their lives.

So, yes, ma’am, we do understand that we did not perform well,

in terms of how we cared for some of these troops. We do set a

higher standard for our people. I accept my responsibility in that

regard.

What we are dedicated to is changing the system, changing the

outcomes that we get for these individuals. These are terrific Americans, and they deserve good outcomes.

Ms. SHEA-PORTER. I would like to say that I have nothing but admiration for those clinicians and others who work to help our

troops. And this has absolutely nothing to do with them, but it

really has a lot to do with the leadership right here.

And so I want to ask you again, where have you gone to visit the

troops that are injured?

And do you have plans, now—because you are relying on layers

and layers and layers of bureaucracy, whereas, since it is your job,

how are you going to reach out and actually—I realize you are very

busy, but at some point during the year, you have to go out and

actually talk to a couple of families to get the stories.

Have you done that, and do you have any plans to do that?

Dr. CHU. When I visit an installation, I make it a point to visit

a barracks, to visit the housing for families, to sit down, if possible,

and have lunch with a few of our soldiers or sailors or airmen or

Marines, or junior officers, whatever the case might be——

Ms. SHEA-PORTER. Injured ones—have you gone and——

Dr. CHU. And I have, in my career, ma’am, visited, I think, every

major military medical installation in this Department.

Now, have I done every one in the last week? No, of course not.

But I do make it a point to visit the bottom as well. Because I

agree with you: It is up to us to take a look, on a random basis,

as to how the program is actually working, as the Navy would

phrase it, at the deck-plate level.

Ms. SHEA-PORTER. Well, I think the only way you are ever going

to really know is to actually talk to those—is that it? I thank you.

The CHAIRMAN. Thank you very much.

53

Mr. Wilson.

Mr. WILSON. Thank you, Mr. Chairman.

And, Secretaries, Generals, thank you for being here today.

I have actually seen the good. I have visited the casualty hospital

in Baghdad. I have been to Landstuhl, seen the dedicated people

there. I have been to Bethesda, seen the dedicated personnel. I am

really grateful we have the highest survivability rate in history.

There have been advances in prosthetics that are history-making. In fact, I have got two sons that were born at Bethesda National Hospital. So I know the military medical system. But that

makes it even more of a disappointment that people could fall

through the cracks.

The Washington Post article was actually pretty explanatory

that—in terms of a military unit—that there are two companies,

one for active duty and one for reserve components. And then it is

divided into platoons, with sergeants. And, indeed, I have such

faith in the NCOs of our military, it was described that sergeants

know everything about soldiers: vices and talents, moods and bad

habits, even family stresses.

Then I was reading about the military supervisors and case managers, and that there has been an extraordinary increase in the

number of these. How do the case managers and the sergeants and

the military structure and the civilian structure—how do they work

together, or do they not? Because it seems like people have fallen

through the crack, through this system.

General KILEY. Sir, the relationship between the case managers

and platoon sergeants is an important one. The platoon sergeants

have official military accountability for the soldiers, know where

they are, make sure—or should be making sure that their health

and safety on a day-to-day basis is met to include the condition of

their rooms. And the case managers worry about the medical conditions, the recovery from medical conditions, the coordination for examinations and for appointments.

There is a third piece of this that closes out the episode of a soldier being at Walter Reed, which is the medical board process. And

in some cases it appears that records have been lost. That is totally

unacceptable—very frustrating, both to the case managers and the

soldiers. And that is a Patient Administration Division and a Physical Evaluation Board liaison responsibility.

And all of those are being very vigorously examined under another AR 15–6 investigation at Walter Reed to try to determine exactly where the breakdowns were.

It is a very complex process, as I was asked a little earlier. And

working your way through the medical board process with these

complex, multiple, often unseen injuries—TBI, PTSD—sometimes

the PTSD starts to manifest itself a month or two after some of the

other injuries have started to heal. In a MEB and PEB system that

goes back not only to the 1970’s, but to the 1950’s, it can be very

trying and very daunting for the soldiers.

Mr. WILSON. And I am glad you brought up about the paperwork,

because that seems to be the next step: how these different layers

of persons work together. But Secretary Chu has identified the

complexity in med boards; I am familiar how difficult that can be.

54

I indeed am happy to hear that this is being studied, because the

thought that young people would be lost in some kind of bureaucratic system——

General KILEY. Yes, sir.

Mr. WILSON [continuing]. For month after month is just really

not at all what we as veterans, as members of Congress, as parents

would anticipate for the treatment of our young people.

General KILEY. Yes, sir.

And given the complexity of the medical board process, as the

chief has referenced, we have made iterative improvements, attempted to improve it; for example, designating physicians whose

only job is to do the MEB for soldiers rather than have 10 or 15

or 20 physicians in a facility all trying to figure out how to do the

one medical board they are going to do this year.

We learned the hard way years ago in this process that that

wasn’t working. And so, for example, Walter Reed, there are, I am

told, three and a half fully dedicated physicians in the med board

process. That is the physician piece.

But we have got to keep getting at this. We need to reduce the

paper work. If we could make the entire process an electronic process, we are looking for these kinds of solutions right now. No lanes

or boundaries on getting this thing fixed.

Mr. WILSON. Well, I, again, just have to tell you that those of us

who so much support our troops and so much support our military

are deeply concerned.

General KILEY. Yes, sir.

Mr. WILSON. We appreciate your efforts very, very much.

And I know we have the best in the world, but we want to make

sure our troops do understand that. I want our families to understand that.

General KILEY. So do I.

Mr. WILSON. Thank you.

General KILEY. Yes, sir, thank you. So do I.

The CHAIRMAN. Doctor.

Dr. WINKENWERDER. Yes, sir.

I was just going to say if you would allow—it would be possible

to excuse myself. I am glad to take any question for me for the

record or even call back personally if that would be better for the

member.

The CHAIRMAN. We appreciate you being with us. We noticed you

have stretched your deadline 15 minutes, and thank you——

Dr. WINKENWERDER. Thank you very much. Thank you.

The CHAIRMAN. Mr. Hayes.

Mr. HAYES. Thank you, Mr. Chairman.

General Schoomaker, it pains me a great deal to ask the following question—a lot of criticism leveled. You have got a management problem: Should not General Kiley be relieved from duty because of what has happened here?

General SCHOOMAKER. Well, I will make my recommendations as

appropriate to the authority that has that deal. And I prefer not

to say it here.

As you know, I have officially been recused from dealing with

this because my brother is in the mix. But I can promise you that

this is being investigated, and I can assure you that the proper acVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00058 Fmt 6633 Sfmt 6633 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
55

tion will be taken as a result of this investigation in terms of accountability.

Mr. HAYES. And, again, that is not a question I want to ask, but

as a manager in the private sector, it all ends up in my lap.

At Fort Bragg we have a very active town hall, kind of, a format

to air these kinds of concerns. There is a very aggressive action

plan that has been outlined for Walter Reed. Is that a part of,

again, gathering information to make sure that this doesn’t happen?

General SCHOOMAKER. Well, actually, I had a meeting with other

General Schoomaker and General Kiley this week out at Walter

Reed, addressing and listening to what some of their thoughts are

on how to approach this. And that is clearly part of not only town

hall meetings, but selective meetings with people at various levels

in a personal setting to really have very candid discussions and get

their buy-in and understanding of where we might best improve

things.

But I will tell you, it is very distressing to me that with the

amount of direct contact, hundreds and hundreds of visits all over

our medical facilities, from Landstuhl to Brooke to Walter Reed to

Tripler and everywhere out there, talking to families and talking

to soldiers—which I truly believe are candid discussions where people are not afraid to walk up to a four-star general, where we are

sitting in their room, talking to families, ‘‘Are you being cared for

properly? What are your concerns? What do you think about

things?’’ unanimously, without question, it has been thumbs up on

the kind of care that they are been receiving.

General SCHOOMAKER. Yes, there have been issues that have

been raised, and we fixed them, because they raised the issues.

But to have something like this occur with all of this truly is a

surprise to me, and we are going to find out why. And when we

find out why, we will hold those accountable that are the problem.

Mr. HAYES. Thank you.

Again, to reiterate, Walter Reed is a premier institution. The

good that has been provided is incredible. My brother-in-law 35

years ago went there for some—he was a Marine; even let a Marine

in—for serious cancer surgery.

So, again, hopefully we are past the turning point and we can get

back to focusing on care for the soldiers, which is what we do dayin and day-out.

But, again, I thank you for your efforts, and sorry we are here.

But, as you say, anybody that didn’t get the job done, make sure

that that is taken care of.

Mr. Chairman, thank you. I yield back.

The CHAIRMAN. Thank you so much.

General Kiley, how many rooms are there in Building 18?

General KILEY. Mr. Chairman, I believe there are 54.

The CHAIRMAN. How many rooms are we talking about that are

subject to the inquiry?

General KILEY. Sir, I believe there were a total of seven rooms

that had evidence of mold. Two of them had mold on the walls. The

other four or five had mold around the bathtub and the sinks. And

then there were another 19 or 20 that had some other issue: They

56

had a leaky faucet, a leaking toilet, a switch that didn’t work, as

I understand.

The CHAIRMAN. Mice?

General KILEY. Sir?

The CHAIRMAN. Mice?

General KILEY. Sir, there had been a problem with some mice

and cockroaches last year, in 2006. This was brought to the attention of the command at Walter Reed. The preventive medicine

teams went in. They did an assessment of the extent of it.

The CHAIRMAN. Did they assess cockroaches and mice?

General KILEY. Sir, what they did was take a look through the

rooms and take a look at the condition of the building and determined that they could, one, set mouse traps and roach traps. They

asked——

The CHAIRMAN. They catch them all?

General KILEY [continuing]. Asked the soldiers to clean up any

food that might be in their rooms.

The CHAIRMAN. Did they catch them all?

General KILEY. Sir?

The CHAIRMAN. Did they catch them all?

General KILEY. Sir, as far as I know, they did. They haven’t seen

mice, I am told, for months. I think they policed that up, yes, sir,

in an area where you are in a city, urban area, yes, sir.

The CHAIRMAN. What else, besides the mice, cockroaches and

mold?

General KILEY. Well, some leaky toilets, a leaking faucet here or

there, a couple switches that didn’t work, as I understand it. I can

take that for the record and give you a whole list of the findings.

The CHAIRMAN. No, no. I just want to know, were complaints

made?

General KILEY. Sir, I believe the process at the time was that soldiers would make their concerns——

The CHAIRMAN. No, no, no. Just answer the question: Were complaints made?

General KILEY. Yes, sir.

The CHAIRMAN. To whom?

General KILEY. To the barracks noncommissioned officer.

The CHAIRMAN. And then what happened after that?

General KILEY. He would submit work orders to repair them.

The CHAIRMAN. And were they done?

General KILEY. Some were done last year. I am told that up to

200 of these were fixed over last year. But there were repair work

orders outstanding.

The CHAIRMAN. Are there conditions such as this in hospitals

elsewhere in the United States?

General KILEY. Inside the hospitals, it is a challenge with some

of our older facilities.

The CHAIRMAN. The answer to your question is yes?

General KILEY. I think it is. Yes, sir.

The CHAIRMAN. Now the answer to your question is yes. Would

you then explain where they are, if you know?

General KILEY. Sir, I have to take that for the record. I have got

an SRM project list of things to fix and improve across all of our

hospitals.

57

[The information referred to can be found in the Appendix beginning on page 161.]

The CHAIRMAN. Right.

Dr. Gingrey.

Dr. GINGREY. Mr. Chairman, thank you.

And I want to thank the witnesses, Secretary Chu, General

Schoomaker, General Kiley. I am sorry that Dr. Winkenwerder had

to leave, but I appreciate you being here for so long.

And, you know, I want to say for the record, Mr. Chairman, that

I have been to Building 18, I have been to Walter Reed on a number of occasions. But specifically in regard to this issue I went to

take a look firsthand, having grown up in a motel when I was

going to medical school and living in one of the rooms.

When I saw this old Walter Reed Motor Inn, it really reminded

me a lot, Mr. Chairman, of the motel that my parents had in Augusta, Georgia. It is not a five-star hotel, make no mistake about

it, but it is not a flop house. It is not a dump. It is not a dive. It

needs some work, no question about it. I am not making excuses,

of course.

And when I read The Washington Post report, I was glad to know

that those cockroaches were belly up. It suggested to me that at

least somebody was spraying for them, Mr. Chairman.

And, of course, if you leave food around in a motel room or a

dorm room at a college, you are going to get some mice to show up

at some point in time.

But there is no question that there is a problem. I have heard

some of my colleagues on both sides of the aisle suggest that specific heads should roll. I was a little bit shocked, quite honestly,

that the secretary of the Army was relieved of his command, and

the commander at Walter Reed, General Weightman, was relieved

of his command, and a change has been made there.

I don’t know what comes next, but I would guess if you ask—

since General Schoomaker has had to recuse himself—ask The

Washington Post whose head should roll, I think it probably would

be the commander in chief—would be the only satisfaction. And

that would be President Bush.

But here again—and let’s try to take the politics aside, and some

of the rhetoric, and try to solve the problem.

As a physician member, I think that we need a lot of things that

would help in regard to, let’s say, going to a complete electronic

medical records system, where these soldiers that are injured, and

the families where they have traumatic brain injury or missing

limbs don’t have to worry about filling out 22 forms and repeating

it four times because somebody has lost it.

I think the impression that I get—and hopefully I won’t use my

entire 5 minutes so you can respond—is that when you have a soldier recovering, whether he or she is at the Mologne House on the

main campus or just across the street at Walter Reed Motor Inn,

Building 18, and they have no mobility problems at that point,

wherever you have them, if you keep them too long—and 360 days

is too long—at some point they are going to be so frustrated over

a missed appointment or a long queue or lost paperwork, maybe a

little unhappy about adjudicating their disability claim, either getting back with their troops or rotating back into civilian life, that

58

they are going to start noticing the mold and the cobwebs and the

dead cockroaches and the rats. And that is part of the problem.

So I would like to suggest to the witnesses that maybe if we can

move in that direction, we will go a long way toward solving this

problem.

Dr. CHU. Let me speak to——

The CHAIRMAN. Does someone have an answer to that—Secretary?

Dr. CHU. Delighted to, sir.

To the electronic record challenge, that is where we are. We have

deployed—I am sorry Dr. Winkenwerder had to leave because I

think he was very proud of it—we have deployed ALTA, as I think

you are aware, which is an electronic outpatient record system,

worldwide availability, so basically your records on a server—actually, more than one—and you can call it up wherever you are.

We have agreed with the Veterans Affairs Department that, for

the future, we should have a common inpatient electronic record.

We have already started what we call bi-directional electronic exchange at certain installations, but that is with the existing systems. And as you appreciate, we have got two different systems designed from different I.T. perspectives for the future, which will

take some years. I don’t want to mislead you.

We are aiming at a common system for the two enterprises,

which will facilitate the long-term care of those who have significant injuries.

I take your point about the length of time that is involved here.

I do think part of it is that the Army, specifically, tries very hard

to allow those soldiers who can continue to serve and wish to continue to serve to recuperate.

And that does take some time, given the nature of these injuries,

as you appreciate—a considerable period of time. And that may

lead to some of the frustrations that you have described.

And I accept your advice that, if we can find ways to shorten

that, consistent with the medical situation, we would be importantly advantaged.

General SCHOOMAKER. Mr. Chair, I would like to say just a couple things here.

First of all, I am no expert at all in the system, but I have had

explained to me—and I have some experience from previous commands and frustrations—with the length of time it takes to process

people through this MEB/PEB process.

And I think a lot of people get confused at the recuperation period, which can go on for as much as a year for some of these soldiers—is not part of the MEB/PEB process.

And it is until the healing is done that the process of going

through the evaluation—there is no use to do it.

If you assume that somebody took an entire year to heal and

then went through the rest of the process as fast as, administratively, you can go through it, it would take another 180 days.

If they never missed an appointment, never appealed a decision,

never did anything, it would take another 140 days plus—180 days

plus 40 days—so 220 more days on top of the healing thing.

And I am exactly in your camp. I think that the bureaucracy and

the length of time it takes to go through this thing is a huge factor

59

in terms of the frustration level and the opportunity for misunderstanding and all of the stuff that we are so frustrated about on

this.

And I really do believe that we have got to figure out a way that

we can, kind of, multi-task and figure out how to get this kind of

a process to appropriately move at a speed that protects the soldiers’ interests, which is what this is about, as well as the institution’s interests, in terms of reconciling what they have.

Second, as I said earlier in the hearing, in my opening statement, I am concerned that we have different public laws that regulate what DOD does in terms of disability ratings, which are different—you know, Title 10 is different than Title 38, which the VA

goes under. And then I guess Social Security has got a different

one.

And so part of the distrust in the system is the fact that somebody may get 40 percent in DOD and turn right around and VA

gives them 70 percent.

And so there is a fundamental inconsistency in it that tends to

lead one to believe that there are some shenanigans in the deal,

combined with the frustration of length of time.

So I think, again, as we have been talking about all day, there

is an opportunity here to come down comprehensively and reconcile

this system. Because this is not going to go away. We are in a long

war. We are going to continue to see and learn more about what

we are doing. And we must fix this thing comprehensively. And I

think that is the opportunity we have.

Dr. GINGREY. Mr. Chairman, thank you. You have been most

generous with allowing me extra time, and I really appreciate your

allowing——

The CHAIRMAN. I thank the gentleman. Let me follow through on

your inquiry.

Regarding electronic medical records—I am not sure who to address the question to, probably Dr. Kiley.

General KILEY. I will take a stab at it, Mr. Chairman.

The CHAIRMAN. We funded this some years ago. Is that correct?

General KILEY. Yes, sir. This has actually been going since 1983.

The CHAIRMAN. Since when?

General KILEY. Sir, since I was a physician at William Beaumont, on the hospital information system in 1983, we were building

new prototypes.

The CHAIRMAN. The outpatient care has been complete. Am I correct? Medical records for outpatient care has been complete.

General KILEY. It is close. There are still some modules we would

like to put in, but it is pretty close, yes, Mr. Chairman.

The CHAIRMAN. The inpatient care has just begun——

General KILEY. That is correct.

The CHAIRMAN [continuing]. With the exception of some specialized cases, as I understand it.

General KILEY. There are some specialized——

The CHAIRMAN. What in the world has taken so long, since 1983?

General KILEY. Well, sir, that was a prototype back in 1983. I

think Dr. Winkenwerder——

The CHAIRMAN. When was it funded?

General KILEY. Sir?

60

The CHAIRMAN. When was it fully funded?

General KILEY. I will have to take that for the record. I don’t

know. It has been 10 to 12 years, Mr. Chairman——

The CHAIRMAN. Dr. Chu, do you know?

Dr. CHU. If I could, Mr. Chairman. This is actually the second

generation. ALTA is the second-generation system the Department

has deployed in this regard.

The CHAIRMAN. When was it funded?

Dr. CHU. Over the last several years. I would have to get you the

numbers for the record.

[The information referred to can be found in the Appendix beginning on page 161.]

The CHAIRMAN. Would you be kind enough to do that——

Dr. CHU. Delighted to.

The CHAIRMAN [continuing]. As to how much and at what dates?

Dr. CHU. Yes, sir.

The CHAIRMAN. Or at least what years?

Dr. CHU. Yes, sir.

The CHAIRMAN. That would help.

Dr. Chu, the other day, during the Navy presentation, the Navy

is proposing to cut an additional 900 medical providers out in 2008,

100 of which are doctors. And as I understand it, the Navy medical

system is being challenged quite a bit.

At what point was this approved in the Pentagon?

Dr. CHU. Sir, I presume you are referring to the Navy’s militarycivilian conversion plan.

The CHAIRMAN. No, no, no.

Dr. CHU. I am sorry.

The CHAIRMAN. No. It is just old-fashioned Navy—it was spelled

out for us: Navy medical providers.

Dr. CHU. The Navy as a whole is shrinking in terms of personnel.

The CHAIRMAN. We know that. We know that.

Dr. CHU. The Navy medical establishment is taking significant

steps to rebalance its staffing between uniform personnel and civil

personnel; the issue that Congresswoman Davis raised.

That came out of a broad-scale review for the Department as a

whole as to what is the size of the uniformed establishment we

need to have in order to sustain deployed operations now and in

the future.

But beyond that, I am not familiar with the specific numbers

that you just read.

The CHAIRMAN. Those are the Navy numbers that were provided

to us recently.

Without objection, my statement at the beginning, which I was

unable to deliver, will be put—Dr. Kiley, does the Army inform

members of Congress when there is a wounded soldier from his or

her district?

[The prepared statement of Mr. Skelton can be found in the Appendix on page 67.]

General KILEY. Mr. Chairman, I am going to have to take the

question for the record.

But if my memory serves me, we ask each soldier if they would

like their representative to be notified. And I believe that we pull

61

a roster together once a week to notify. But I will have to doublecheck that; I don’t want to go on the record incorrectly.

The CHAIRMAN. We would appreciate that. I know full well that

we are notified if there is a death or a casualty——

General KILEY. Yes, sir.

The CHAIRMAN [continuing]. Like that.

Yes?

General SCHOOMAKER. Sir, I believe that there is a weekly notification made to Congress on soldiers——

The CHAIRMAN. On wounding?

General SCHOOMAKER. On wounded soldiers. But the soldier

must agree to have his name——

The CHAIRMAN. Oh, I see.

General KILEY. Right. Yes, sir, that is the privacy thing.

The CHAIRMAN. Yes, I understand. Thank you.

I might mention, it has been a little while ago, but I was able

to see one of your medical facilities from the inside out. Congressman Tim Murphy and I were in a vehicle mishap just outside

Baghdad and we were taken by ambulance to the Baghdad Army

hospital, where we received excellent treatment and then

medevaced to Landstuhl hospital.

And I cannot say—I know Congressman Murphy would agree

with me—I cannot say enough good things about the people who

treated us there.

As a matter of fact, with Speaker Pelosi—it has been about a

month ago, Secretary Chu, six of us were in the Middle East. We

came back. But we were at Ramstein and Landstuhl hospital.

And I was able to thank, in an upright position, the four nurses

who were so kind to me there. It is a first-class facility, and I can’t

do anything but brag about them.

Dr. CHU. Well, thank you, sir, for saying that. And I know they

deeply appreciate it.

General KILEY. Yes, sir, very much.

The CHAIRMAN. And you went by room number seven in the ICU

unit, where I lingered for over three days. [Laughter.]

Well, gentlemen, thank you.

Dr. Gingrey, do you have any further questions?

Thank you so much for being with us.

This is a major challenge for us. I believe there will be a followthrough hearing at the subcommittee level. That is my understanding, in visiting with these subcommittee chairmen.

Thank you for being with us. And do your best to fix it.

General KILEY. Yes, sir.

The CHAIRMAN. Thank you.

Dr. CHU. Thank you, Mr. Chairman.

General KILEY. Thank you, sir.

[Whereupon, at 1:37 p.m., the committee was adjourned.]

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146

147

148

149

150

151

152

153

154

155

156

157

158

QUESTIONS AND ANSWERS SUBMITTED FOR THE

RECORD

MARCH 8, 2007

(161)

QUESTIONS SUBMITTED BY MR. SKELTON

The CHAIRMAN. What else, besides the mice, cockroaches and mold? Are there conditions such as this in hospitals elsewhere in the United States?

General KILEY. US Army Medical Command currently lists $183,832,000 of

unfinanced requirements for sustainment, repair and maintenance of medical facilities that directly impact the delivery of healthcare to Army beneficiaries. These

projects are listed in the chart below. Additionally, Army Medical Command has

unfinanced requirements for non-healthcare delivery projects totaling $42,878,000.

Those projects support medical research, force protection, quality of life, and preventive and veterinary medicine across the Army.

State Location/Installation Project Title/Description Cost $000

AZ Yuma Renew Yuma Proving Grounds Health Clinic $1,700

CA Ft. Irwin Renovate ER & Main Entrance-Weed ACH $1,670

CA Ft. Irwin Modify Mary Walker Clinic $400

CA Monterey Presidio of Monterey Health Clinic Renewal $7,500

CO Ft. Carson Smith Dental Transition $3,000

CO Ft. Carson Repair Floor Heaving Phase 1 $7,500

DC Walter Reed Army MEDCEN Renovate Intensive Care Unit $2,500

DC Walter Reed Army MEDCEN Install HVAC return air system $350

DC Walter Reed Army MEDCEN Repair Lab Pneumatic Tube System in $210

DC Walter Reed Army MEDCEN Repair Non-Compliant Fire Stop/Smoke Barriers $400

DC Walter Reed Army MEDCEN Repair 34 of 38 Hot water converters $950

DC Walter Reed Army MEDCEN Upgrade restrooms to ADA compliance $2,540

DC Walter Reed Army MEDCEN HVAC Controls and Balancing $450

DC Walter Reed Army MEDCEN Signage—Improve patient travel in facility $1,200

DC Walter Reed Army MEDCEN Replace the worn and torn base cove $120

DC Walter Reed Army MEDCEN Paint Interior Stairwells and handrails $200

DC Walter Reed Army MEDCEN Modify sprinklers to meet NFPA Requirements $275

DC Walter Reed Army MEDCEN Repair Chiller Plant Systems and Valves $1,300

DC Walter Reed Army MEDCEN Bldg. 82, Roof Repair $20

DC Walter Reed Army MEDCEN Replace electrical distribution panels $377

DC Walter Reed Army MEDCEN Convert Delano Hall to Barracks $403

DC Walter Reed Army MEDCEN Modify Soldier Family Assistance Center/SFAC $450

162

State Location/Installation Project Title/Description Cost $000

DC Walter Reed Army MEDCEN Emergency Riser in Heaton Pavilion South $523

DC Walter Reed Army MEDCEN Install revolving door to maintain climate control $250

DC Walter Reed Army MEDCEN Repair/Replace Fire Doors/Frames Phase II $250

DC Walter Reed Army MEDCEN Repair Bldg 178 $920

GA Ft. Benning Patient Tower Perimeter Heating $4,500

GA Ft. Benning Repair Roof, Paint Exterior, Replace Windows $4,200

GA Ft. Benning Replace Operating Room Reheat $450

GA Ft. Benning Repair Radioloy Dept $3,300

GA Ft. Gordon Repair Lightning Protection/Grounding System $500

GA Ft. Gordon Modernize Elevators Building 300 $449

GA Ft. Stewart Warfighter Refractive Eye Surgery Program $2,500

German Hohenfels Hohenfels Health Clinic Exterior Repair $604

German Illsheim Renovate Illsheim Health Clinic $200

German Landstuhl Install direct digital control in Critical Care Tower $1,200

German Landstuhl Renovate Wing 2A/C of the Medical Center $2,200

German Stuttgart Renew Dental Clinic $450

German Stuttgart Renew Stuttgart Dental Clinic $3,750

German Vilseck Dental Clinic Interior Repair $1,050

HI Schofield Barracks Bldg 681, Repairs and Renovation $7,300

HI Tripler Army MEDCEN Correct boiler deficiencies to ASME standards $375

HI Tripler Army MEDCEN Optimize Optometry Clinic $575

HI Tripler Army MEDCEN Optimize Orthopedic Clinic $841

HI Tripler Army MEDCEN Bldg 137, Repair Emergency Generator $950

HI Tripler Army MEDCEN Bldg 161, Repair Fire Sprinkler System $350

HI Tripler Army MEDCEN Clinic Ergonomics, 10 Areas $680

HI Tripler Army MEDCEN Bldg 161, Install Emergency Generator $550

HI Tripler Army MEDCEN Expand Pathology lab capacity $1,080

HI Tripler Army MEDCEN Combine functions in specialty clinics to reduce need

for additional staff

$1,000

HI Tripler Army MEDCEN Renovate Neonatal Intensive Care Unit $700

KS Ft. Leavenworth Central Patient Records Area $1,000

KS Ft. Leavenworth Physical Therapy/Ortho Add/Alt $4,050

KS Ft. Riley Riley Same Day Surgery Clinic $11,000

163

State Location/Installation Project Title/Description Cost $000

KY Ft. Campbell Renovate Bldg 2730 to Satellite Pharmacy $985

KY Ft. Campbell Red and Blue Clinic Renovations $2,500

KY Ft. Knox Repair Jordan Dental Clinic $9,000

KY Ft. Knox Repair deficient Sprinkler System and Standpipe $1,000

LA Ft. Polk Renovate and reconfigure Perioperative Services $8,000

MD Aberdeen E2100 Renewal—Electrical Feasibility Study $99

MD Ft. Meade Renew Patholoy Lab $5,000

MO Ft. Leonard Wood Site Pre for Modular Troop Medical Clinic $750

NC Ft. Bragg Build out Attic Space to free up ward space $1,700

NC Ft. Bragg MASCAL DECON Facility $1,000

NC Ft. Bragg EDIS Building $1,000

OK Ft. Sill Repair Interstitial Lighting $404

OK Ft. Sill Repair Bleak Troop Medical Center $700

OK Ft. Sill Warehouse/Records Conversion for clinical space $1,300

OK Ft. Sill Allen Dental Addition/Alteration $6,000

SC Ft. Jackson Hospital Structural Foundation Repair—East Win $2,900

SC Ft. Jackson Renewal Troop Medical Clinic Optimization $5,400

TX Ft. Bliss Warfighter Refractive Eye Surgery Program $3,000

TX Ft. Bliss Construct Social Work Services Building $700

TX Ft. Bliss Medical Resident Village $2,800

TX Ft. Bliss Repair outlying Building Roof on medical building $350

TX Ft. Hood Upgrade Elevators 1–7 $1209

TX Ft. Hood Replace Emergency Generators $2,900

TX Ft. Sam Houston Renew McWethy Troop Medical Clinic $2,990

TX Ft. Sam Houston Construct temp admin facilities so hospital can be

used for clinical requirements

$3,750

TX Ft. Sam Houston Hospital Orthopedic Clinic Expansion $350

TX Ft. Sam Houston Repair/renovate Budge Dental $7,500

VA Ft. Lee Repair 2nd Floor, ‘‘A’’ Wing $1,186

VA Ft. Lee Renew Bull Dental Clinic $5,000

VA Ft. Lee Renew Kenner Clinic $5,000

VA Ft. Lee Site work for interim Troop Medical and Dental Clinics $1,800

VA Ft. Myer Rader Clinic Transition Space $3,000

164

State Location/Installation Project Title/Description Cost $000

WA Ft. Lewis Construct LDR #8 for Women’s Health Program $750

WA Ft. Lewis Expand Madigan Pediatric Clinic $700

WA Ft. Lewis Renew Labor and Delivery area; recovery area $600

WA Ft. Lewis Renovate Wing 2A/C of the Medical Center $1,000

WA Ft. Lewis Renovate Labor & Deliver Nursing Team Center $450

WA Ft. Lewis Addition to Women’s Health Clinic $750

TOTAL $183,832

The CHAIRMAN. Regarding electronic medical records. We funded this some years

ago. The outpatient care has been complete. Medical records for outpatient care has

been complete. The inpatient care has just begun with the exception of some specialized cases. What has taken so long, since 1983? When was it fully funded?

Dr. CHU. Funding for the Armed Forces Health Longitudinal Technology Application (AHLTA) covering the period fiscal year (FY) 1997 through FY 2013 is $1.9 billion. This funding includes both acquisition and sustainment costs. The $1.2 billion

acquisition costs of AHLTA include the development, integration, initial procurement, and deployment of the system. Sustainment costs include activities such as

software maintenance, program management, and information assurance.

This funding chart shows funding by fiscal year covering the period FY 1997

through FY 2013. AHLTA (formerly known as Composite Health Care System II)

received Milestone Zero Approval in FY 1997. (In other words, funding to build

AHLTA began in FY 1997). Therefore, the FY 1997 through FY 2005 shows actual

funds spent on AHLTA by fiscal year.

Each year a budget request (President’s Budget) is submitted to Congress. This

budget is the biennial budget submission and covers two years. However, the Department of Defense (DoD) builds a budget that is called the Future Years Defense

Plan (FYDP). The FYDP for the latest FY 2008 President’s Budget covers FY 2006

through FY 2013. The chart shows the funding budgeted for AHLTA in the FY 2008

President’s Budget for FY 2006 through FY 2013.

FY 1997 through FY 2005 reflect actual funds spent and the FY 2006 through

FY 2013 reflects the budget request (FY 2006 and FY 2007 are years that still have

active appropriations and therefore are still considered in the budget submission).

[The chart referred to can be found in the Appendix on page 158.]

QUESTIONS SUBMITTED BY MR. ORTIZ

Mr. ORTIZ. Do you think that you can give us a list of your worst facilities so that

a group of members here can go see it so that we can be in a position where we

can help you fix those facilities?

General KILEY. At all but one Army installation with Medical Holdover Soldiers,

the Army Installation Management Command is responsible for the command and

control of Medical Holdover Soldiers, including billeting. The Army Medical Command (MEDCOM) is responsible for providing healthcare at those installations. The

sole exception is Walter Reed Army Medical Center, where MEDCOM is responsible

for both installation management and healthcare delivery.

From a medical facilities assessment, the hospitals at Fort Knox, Kentucky, Fort

Benning, Georgia, Fort Riley, Kansas, and Fort Hood, Texas, are all more than 40

years old and have significant infrastructure concerns. Each of these facilities is in

need of replacement. Tripler Army Medical Center, Hawaii, is also in need of significant renovation or replacement. In the next few years, the inpatient tower at

Landstuhl Regional Medical Center, Germany, will need replacement as will the

health clinic at Fort Rucker, Alabama.

MEDCOM is able to maintain these facilities in accordance with the Life Safety

Standards of the Joint Commission on Accreditation of Healthcare Organizations

through sustainment, repair and maintenance funds. However, a long-term strategy

within the Medical Military Construction appropriation is required to ensure Army

medical treatment facilities are capable of supporting the Army into the future.

165

QUESTIONS SUBMITTED BY MR. MCHUGH

Mr. MCHUGH. As more information comes to light about the widely publicized

problems at Walter Reed Army Medical Center, it appears that private-public job

competition, referred to by many as the ‘‘A–76 process,’’ sapped the facility of needed

workers at a time when a demand for their skills, based on inpatient and outpatient

population, was growing. Please provide for me the data in a chart form, that (1)

shows month by month how the numbers of workers on hand in functions covered

by the A–76 process changed over time, and (2) how the WRAMC inpatient and outpatient (medical hold and medical holdover) populations changed month to month

over the same period. The period I am interested in begins two months before the

A–76 process was announced and continues through the month when the A–76 contractor was awarded the contract and ends with the month of January 2007.

General KILEY. The requested data is provided below. It shows that personnel

strength levels remained relatively stable throughout the competition. It also shows

that considerable resources continued to be devoted to maintenance during the short

transition period.

Nov

05

Dec

05

Jan

06

Feb

06

Mar

06

Apr

06

May

06

Jun

06

Jul

06

Aug

06

Sep

06

Oct

06

Nov

06

Dec

06

Jan

07

Med Hold/Med

Holdover * * * * * * * 667 * * * * 617 640 625

BASOPS Staff 296 292 292 289 293 294 294 294 250 244 228 228 232 224 209

* Data not

available

Mr. MCHUGH. How many other installations involving medical hold and medical

holdovers since 2001 have undergone A–76 competitions? Please provide me with

the same trend data from the time the A–76 was awarded through the time a contract may have been awarded versus patient workloads.

General KILEY. Below are the titles and associated sites where the Army Medical

Command has conducted A–76 competitions since 2001. None of these competitions

had any impact on patient care. All but two of the conversions occurred after the

start of Operation Iraqi Freedom. Unlike the Walter Reed A–76 competition, none

of these studies involved base operations that effected the sustainment, repair, or

maintenance of medical facilities or billeting of patients.

Title Affected

Site(s) Status Patient CareImpact

Automation

Management

Riley 3 Sep. 01 Contract Award Pre-OIF

Hospital

Housekeeping

Riley 1 Oct. 01 (Government Start

Date)

Pre-OIF

Ambulance

Services

Polk 1 Nov. 01 Contract Award Pre-OIF

Hospital

Housekeeping

Huachuca 3 Dec. 02 In-House Start Date Pre-OIF

Hospital

Housekeeping

Benning 19 Dec. 03 Contract Award 332 Soldiers in

Medical

Holdover

Base Support

Services

Detrick 25 Jan. 04 In-House Start Date No patients

166

QUESTIONS SUBMITTED BY DR. SNYDER

Dr. SNYDER. How many people today do we think systemwide are in a medical

hold or holdover status?

General KILEY. On March 8, 2007, there were 901 Active Component Soldiers assigned to Army Medical Treatment Facilities for Medical Hold Care and 670 attached. There were 1,895 Reserve Component Soldiers assigned to installation-based

Medical Holdover Units and 1,321 Reserve Component Soldiers assigned to Community Based Healthcare Organizations.

Dr. SNYDER. What is the current case manager ratio, system-wide, in the Army?

What is the current case manager ratio at Walter Reed? What should the case manager ratio be? And when I asked you before about who paid the case managers, are

they all employees, or are any of those contracted out?

General KILEY. As of March 8, 2007, US Army Medical Command has one Case

Manager for every 30 Soldiers across the Army. The ratio varies based on the complexity of patients at any particular location. Currently, the ratio ranges from 1:18

at Walter Reed Army Medical Center to 1:36 at smaller community hospitals. This

is 116 case managers for approximately 3,400 Soldiers assigned to Medical Holdover

Units. Community Based Health Care Organizations average one case manager for

every 16 Soldiers (81 case managers for 1,294 Soldiers assigned). The case manager

ratio at Walter Reed Army Medical Center is one case manager per 17 Soldiers. The

total number of case managers across the Army includes 158 military and 51 civilian case managers.

QUESTIONS SUBMITTED BY MR. SMITH

Mr. SMITH. I want to hear what you are doing for the challenges for guard and

reserve, particularly on the mental health piece, if they don’t necessarily get the

same care, don’t have the same community, making sure that they are drawn in.

I am very interested in electronic medical records. As part of this, also as you are

moving patients around the system, do the records follow them? Do we have electronic medical records (EMRs) within the military, so that we are not losing track

of records?

And last, just to make it really complicated, how system-wide is this?

General KILEY. For National Guard Soldiers, the Post-Deployment Health Reassessment (PDHRA) tool offers both physical and mental well-being screening. The

Army National Guard implementation continues as states and territories incorporate PDHRA into training schedules. On average, there are 20 on-site screening

teams available each weekend. Some of the issues facing the PDHRA screening

teams include (1) Geographic dispersion of Soldiers impacts utilization of the teams;

(2) Mobilizations of National Guard units have not maintained unit integrity resulting in wide dispersal of eligible Soldiers, and (3) Units do not train on every weekend of every month. The Army National Guard will continue to focus on on-site

events as the primary method to achieve screening. Call Center processes are being

refined to reduce wait time and increase viability of the screening method. The

Army National Guard is also advocating for an automated method for tracking referral completion.

For the Army Reserve, there are similar challenges. We determined that the previous method of contacting Soldiers for 100% PDHRA screening, via the Call Center,

proved less effective than on-site events. Limited staff availability to schedule

PDHRA screening events was problematic. With the hiring of PDHRA Coordinators

and scheduling more PDHRA on-site events, the Army Reserve projects meeting its

goal of 3,000 monthly screens by March 2007. Funding has been received to hire

a PDHRA Coordinator at each Direct Reporting Command. Monitoring of mobilization and demobilization dates is being undertaken to proactively schedule units

within the 90–180 day window.

We do have an Electronic Medical Record (EMR) under development within the

Military Health System (MHS). Over the past several years, the Army, in conjunction with the MHS, has deployed AHLTA, an outpatient EMR that uses one centralized clinical data repository. By the end of Fiscal Year 2007, AHLTA will make outpatient medical records available across MEDCOM and at combat support hospitals

in Iraq and Afghanistan. What the MHS still lacks is an inpatient EMR that enables the same visibility of inpatient information as AHLTA. We also need to develop an updated system for pharmacy, laboratory, and radiology orders and results.

These two remaining components are under development, but still several years

away. Until they are complete, the Composite Health Care System, originally developed and deployed in the late 1980’s remains the backbone of the ancillary and inpatient EMR for the MHS.

167

Many of the problems with the Physical Disability Evaluation System (PDES) discovered at Walter Reed Army Medical Center exist across the Army. The PDES is

clearly an outdated system that does not meet the 21st century needs of the Army

or our Soldiers. All too often, this system places the Soldier in an adversarial position with the medical and personnel systems. We are working to streamline this system, improve the Soldier’s understanding of the system, and ensure every Soldier

receives a thorough and fair evaluation of their disability.

QUESTIONS SUBMITTED BY MR. JONES

Mr. JONES. IAP is the group, the management group, that got the contract. Do

you know anything about them?

When you put this out for private bid, then I assume that the parameter is anyone that can do the work can bid on the process. Is that right?

Dr. CHU. There was no decision to ‘‘privatize’’ the base support services at Walter

Reed Army Medical Center (WRAMC), nor was there a pre-decision to ‘‘privatize.’’

Privatization is a decision to exit a business line, terminate an activity, or sell government-owned assets to the private sector. Public-private competition subjects recurring, commercial activity type work performed by government personnel to competition with the private sector to determine if the government or contractor is the

most efficient and cost effective source. The Army made a decision to conduct such

a public-private A–76 competition for the base support services at WRAMC under

OMB Circular A–76 procedures. The competition was to determine the lowest-cost,

technically acceptable service provider that could provide base support services at

WRAMC.

The public-private competition was for base support services, not construction.

The outcome of the competition was the private sector offeror, International American Products Worldwide Services, Inc. (iAP). The timeline for the public-private

competition process of the base support services at WRAMC (functions included all

public works-related functions, hospital logistics—hospital warehouse functions, and

administrative/logistics functions) follows:

May 19, 2000—the United States Army Medical Command Assistant Chief of

Staff for Resource Management notified the Assistant Chief of Staff for Installation

Management that the WRAMC Commander intended to compete base support services at WRAMC.

June 13, 2000—WRAMC competition began upon Congressional notification and

public announcement.

September 29, 2004—WRAMC made a tentative decision, which provides due

process for affected parties to dispute the outcome (e.g., appeals and protests).

June 5, 2006—Congressional notification was made via the Final Decision Report

identifying the selected private sector source, iAP.

November 7, 2006—The 90-day transition period (phase-in period) began.

February 4, 2007—iAP contract performance period (first period of full performance) began.

International American Products Worldwide Services, Inc. is one of the largest facility management companies doing business with the Department of Defense

(DoD). iAP purchased Johnson Controls World Services, which was the successful

offeror during the public-private competition process due to their long and successful

history of competing for DoD contracts to provide base support services.

As part of the acquisition process, under Federal Acquisition Regulations, Defense

Acquisition Regulations, and Army Acquisition Regulations, private sector offerors

are subjected to a source selection process where a government source Selection

Evaluation Team evaluates them and the Source Selection Authority determines the

lowest-priced, technically qualified private sector offeror to perform the work. Such

competitions are performed in accordance with regulations, and, when appropriate,

OMB Circular A–76. iAP was selected for the base support services at WRAMC

under these regulations.

QUESTIONS SUBMITTED BY MR. ANDREWS

Mr. ANDREWS. My information is that there are 1,055 soldiers Army-wide who remain in MHO for more than 360 days at this point. I would like to know how many

of them are in the community-based program.

168

General KILEY. There are 1,134 Reserve Component Soldiers who had been assigned to installation-based Medical Holdover units and Community Based

Healthcare Organizations for longer 360 days as of March 8, 2007. 695 of these Soldiers are assigned the Community Based Healthcare Organizations.

QUESTIONS SUBMITTED BY MR. MILLER

Mr. MILLER. I’m sure you are familiar with the ICD–9 designation. It is my understanding that an ICD–9 designation without any accompanying description medically translates to ‘‘an organic psychiatric disorder’’ and that IED victims who suffer

TBI and have obvious brain damage and neurological issues are given this designation.

Dr. WINKENWERDER. The application of the 9th revision of the International Classification of Diseases (ICD)–9 codes to a person’s medical situation is an attempt

to classify, in a standardized manner, each of the individual’s medical conditions or

reasons for seeking care. Every ICD–9 code is associated with a text description of

the diagnosis. There are no codes without such descriptions. In the context of traumatic brain injury TBI, there are numerous ICD–9 codes which may be appropriate

for specifying the patient’s condition. They include:

310.2 Post-concussion syndrome

800 Fracture of vault of skull

801 Fracture of base of skull

802 Fracture of face bones

803 Other and unqualified skull fractures

804 Multiple fractures involving skull or face with other bones

850 Concussion

Fourth digits from .0 to .5 and .9 specify whether or not there was loss of consciousness and, if so, the duration of that loss of consciousness.

851 Cerebral laceration and contusion

852 Subarachnoid, subdural, and extradural hemorrhage, following injury

853 Other and unspecified intracranial hemorrhage following injury

854 Intracranial injury of other and unspecified nature

925 Crushing injury of face, scalp, and neck

959.0 Injury, other and unspecified, of the head, face, and neck

Code 310.2 refers to the presence of impaired mental (i.e., intellectual) function

following a concussion, not to a psychological disease. It is a mental disorder, not

a psychiatric disorder. The category 310 as a whole is specifically for ‘‘non-psychotic

mental disorders due to organic brain damage.’’

The list of ICD–9 codes above includes those traditionally used for potential (TBI)

cases. They do not cover the full clinical spectrum such as the non-specific symptoms for which the codes are in the 780.xx series. Unique codes for military external

causes of injury have been proposed and are being coordinated now with the

TRICARE Management Activity coding office for incorporation into Armed Forces

Health Longitudinal Technology Application and other systems. These codes, if used

consistently and accurately, would add some details and may improve our ability to

study TBI from a clinical perspective.

Mr. MILLER. Why would the Army assign a combat wounded TBI patient with a

psychiatric disorder? Can we in Congress help you to create a new designation specifically for TBI and one that does not carry the stigma some believe exists with

having a ‘‘documented psychiatric disorder?’’

Dr. WINKENWERDER. The International Classification of Diseases (ICD)–9 refers

to the 9th revision of the ICD, a system promulgated by the World Health Organization. It is not a Department of Defense (DoD) or United States Army system.

Changes are made to the disease classification codes every year, but it takes time

and must reflect international acceptance. Traumatic Brain Injury TBI is a recently

introduced medical term that is not used extensively around the world, nor is there

full agreement in the scientific community regarding precise definitions for various

types of TBI, such as mild, moderate, or severe. Consequently, at this time, there

is no specific ICD code for TBI. The closest match is ICD–9 code 310.2, entitled

‘‘post-concussion syndrome.’’

In the ICD rubric, this particular code falls under the major diagnostic classification grouping of ‘‘mental disorders,’’ a reference to dysfunction of the brain from any

cause, including organic diseases, dysfunction due to injury or chemicals, behavioral

issues, and various psychological conditions. Examples of non-psychiatric disorders

in the ‘‘mental disorders’’ category include mental disorders induced by drugs (i.e.,

169

medications), acute alcohol intoxication, tobacco dependence, tension headaches, and

dyslexia.

Code 310.2 refers to the presence of impaired mental (i.e., intellectual) function

following a concussion, not to psychological disease. Combined with the other specific ICD–9 codes that depict the anatomical extent of head injuries, there should

be no stigma associated with 310.2, any more than with the other mental disorders

in the list above. Accurate coding of an individual with a post-concussive syndrome

(also known as TBI), falls in the mental disorders category of codes, but it is not

a code associated with a psychiatric disorder.

Recognizing the limitations of the ICD–9 system, the DoD developed a set of militarily unique codes for external causes of injury related to TBI. This list is in coordination with the TRICARE Management Activity coding office for incorporation into

Armed Forces Health Longitudinal Technology Application and other systems.

These new codes, if used consistently and accurately, will add some details and

should improve our ability to study TBI from a clinical perspective.

Mr. MILLER. Is it true that while waiting for the results of a medical board, a soldier cannot have any needed surgeries because a surgery would change his medical

status? If so, what are you doing to remedy this obviously problematic regulation?

Dr. WINKENWERDER. A medical board is the process of gathering the medical testing and evaluation information on a patient that addresses all of the medical symptoms, concerns, complaints or diagnoses the patient has. After an analysis of this

medical information, the board decides if the Service member meets medical retention standards.

If a patient develops a new medical problem or has a surgery before the medical

analysis is done, then the medical board process is interrupted and the new information needs to be completed and added to the other information.

It is not true that a patient cannot undergo surgery or receive any other needed

medical attention. The health of the patient always comes first, and the processing

time for the medical board will, of necessity, be extended.

The Department of Defense is working with the Department of Veterans Affairs

to re-evaluate the medical disability evaluation systems that are currently in place.

Even with improvements in developing a single, overall process, determination of

disability cannot be accurately made until the patient’s medical condition is fully

evaluated and is stable.

Mr. MILLER. Is it true that all outpatients at Walter Reed are bureaucratically

and administratively transferred from one system or database to another so that if

I were to call the WR switchboard today and ask for a constituent that is an outpatient, the operator would not know if that individual was there or not? Can outpatients receive mail at WR once they are transferred?

Dr. WINKENWERDER. As patients are discharged from inpatient status to outpatient status, the medical center brigade assumes accountability for them. Walter

Reed Army Medical Center (WRAMC) personnel located at the information desk and

other places at WRAMC do not have a personnel roster or database of outpatients.

Outpatients are currently assigned to the medical center brigade and will soon be

assigned to the warrior transition brigade. Outpatient rosters are maintained by the

brigade and can be made available to the WRAMC personnel. The hospital and brigade are partnering together for an optimal solution to this issue.

Outpatients do receive mail once they are in-processed to WRAMC.

Our newly approved hospitality services will include a much more robust information desk and information system for customer service.

Mr. MILLER. What is currently in Building 40? What are it’s future plans and do

you believe there is a better way to use this building?

Dr. WINKENWERDER. Building 40 is the old WRAIR building. This building has

been vacant since 1998. In October 04, HQDA approved and signed a EUL (Enhanced Use Lease) on this property. The original plan was to renovate this historic

structure to create a modern and efficient multiple purpose building capable of providing the Installation adequate and efficient space to support the overall WRAMC

mission. The projected end state was 200,000 square feet of modern office, or lodging

space. The renovation cost was estimated at $62 million, all funded by a private developer. This plan was suspended after the official BRAC announcement.

Mr. MILLER. I’m sure you are familiar with the ICD–9 designation. It is my understanding that an ICD–9 designation without any accompanying description medically translates to ‘‘an organic psychiatric disorder’’ and that IED victims who suffer

TBI and have obvious brain damage and neurological issues are given this designation.

General KILEY. The International Classification of Diseases-9 (ICD) codes all

known diseases. There area wide variety of codes which cover different types of head

trauma. These include fractures, intracranial injuries, including concussion, and unVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00173 Fmt 6601 Sfmt 6621 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
170

specified head injuries. The ICD codes which cover head trauma are 800.0–801.9,

803.0–804.9, 850–854.1 and 959.0.

It is not true that an ICD–9 designation without any accompanying description

medically translates to ‘‘an organic psychiatric disorder’’ and that IED victims who

suffer TBI and have obvious brain damage and neurological issues are given this

designation. Those patients’ conditions should be coded according to the correct diagnosis. However, the term ‘‘organic psychiatric disorders’’ covers a wide range of conditions. Organic psychiatric disorders are those with demonstrable pathology or etiology, or which arise directly from a medical disorder. Therefore a patient with traumatic brain injury could present as an organic psychiatric condition, and could receive several diagnoses. There are also many separate diagnostic codes for organic

psychiatric disorders. For example, organic psychotic conditions are coded as 290–

294.

Mr. MILLER. Why would the Army assign a combat wounded TBI patient with a

psychiatric disorder? Can we in Congress help you to create a new designation specifically for TBI and one that does not carry the stigma some believe exists with

having a ‘‘documented psychiatric disorder?’’

General KILEY. The primary diagnosis for a combat wounded TBI patient should

be one of the ICD–9 codes specific for head trauma. These include fractures,

intracranial injuries, including concussion, and unspecified head injuries. However,

a patient may also have an organic psychiatric disorder, psychiatric symptoms related to his or her injury, or a separate psychiatric disorder. For example: (1) the head

trauma may cause depression directly; (2) they may be very depressed and anxious

over their injuries, or (3) they may have symptoms of post-traumatic stress disorder

or other anxiety unrelated to their injury.

It is part of the task of the clinician to evaluate, diagnose, and treat both the patient’s physical and psychological wounds. In some cases, this evaluation may take

time as the clinical picture changes.

As the war has progressed and the extent of the head injuries became more apparent, our clinicians have received more training in evaluation and diagnosis of

mild traumatic brain injury. Certainly a mild TBI may be confounded with a psychiatric condition. Part of the current challenge is to ensure that civilian practitioners also receive training how to perform this evaluation and diagnosis.

Mr. MILLER. Is it true that while waiting for the results of a medical board, a soldier cannot have any needed surgeries because a surgery would change his medical

status? If so, what are you doing to remedy this obviously problematic regulation?

General KILEY. Clearly, if there is a medical consequence (i.e., a threat to life,

limb or survival) to the timing of the surgery, it will be done at the right time regardless of the administrative process. In short, medically-necessary surgeries are

always performed even if the Medical Evaluation Board (MEB)/Physical Evaluation

Board (PEB) processes must be stopped and subsequently reinitiated.

If the surgery is not going to change the ability to meet retention standards, if

it is associated with prolonged rehabilitation, and it will not change one’s functional

status, then a thorough medical review is performed to see which surgeries are

‘‘elective’’. An ‘‘elective surgery’’ is defined is one that is not life-or-limb threatening

nor required for survival.

Elective surgeries are not performed during a MEB during which the fitness for

duty determination is begun nor during the PEB which is the sole forum within the

Army to determine a Soldier’s unfitness for duty as a result of a physical impairment.

The MEB’s mission is to determine if the physically-impaired Soldier meets retention standards in accordance with AR 40–501, Standards of Medical Fitness. The

MEB process documents the Solder’s medical history, current physical status and

recommended duty limitations. The Solder’s Command prepares a memorandum on

the Commander’s position on the Soldier’s physical abilities to perform his/her primary military occupation specialty (PMOS) or officer specialty (OS). If it is found

that the Soldier does not meet retention standards, the MEB findings are then forwarded to the PEB for adjudication.

The PEB’s underlying mission is to determine whether the Solder can reasonably

perform the duties of his/her primary MOS/OS and grade; and, if not, to determine

the present severity of the Soldier’s physical or mental disability and rate it accordingly.

If the Soldier non-concurs with the decision of the PEB, the case is forwarded to

the Physical Disability Agency (PDA) which may modify the PEB’s findings and recommendations if it concludes that the PEB made an error.

Mr. MILLER. Is it true that all outpatients at Walter Reed are bureaucratically

and administratively transferred from one system or database to another so that if

I were to call the WR switchboard today and ask for a constituent that is an outVerDate 22-MAR-2001 10:59 Oct 21, 2008 Jkt 038833 PO 00000 Frm 00174 Fmt 6601 Sfmt 6621 C:\DOCS\110-29\067000.000 HAS2 PsN: HAS2
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patient, the operator would not know if that individual was there or not? Can outpatients receive mail at WR once they are transferred?

General KILEY. As patients are discharged from inpatient status to outpatient status, the Medical Center Brigade assumes accountability for them. Walter Reed

Army Medical Center (WRAMC) personnel located at the Information Desk and

other places at WRAMC that are called do not have a personnel roster or database

of outpatients. Outpatients are currently assigned to the Medical Center Brigade

and will soon be assigned to the Warrior Transition Brigade. Outpatient rosters are

maintained by the Brigade and can be made available to the WRAMC personnel.

The Hospital and Brigade are partnering together for an optimal solution to this

issue. Finally, outpatients do receive mail once they are inprocessed to WRAMC. For

the long term, our newly approved hospitality services will include a much more robust information desk and information system for customer service. We fully expect

much better information management regarding these issues.

Mr. MILLER. What is currently in Building 40? What are it’s future plans and do

you believe there is a better way to use this building?

General KILEY. Building 40 is the old WRAIR building. This building has been

vacant since 1998. In October 04, HQDA approved and signed a EUL (Enhanced

Use Lease) on this property. The original plan was to renovate this historic structure to create a modern and efficient multiple purpose building capable of providing

the Installation adequate and efficient space to support the overall WRAMC mission. The projected end state was 200,000 square feet of modern office, or lodging

space. The renovation cost was estimated at $62 million, all funded by a private developer. This plan was suspended after the official BRAC announcement.

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