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38–314 2008

[H.A.S.C. No. 110–45]

THE STATE OF THE MILITARY HEALTH

CARE SYSTEM

HEARING

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

HEARING HELD

MARCH 27, 2007

(II)

MILITARY PERSONNEL SUBCOMMITTEE

VIC SNYDER, Arkansas, Chairman

MARTY MEEHAN, Massachusetts

LORETTA SANCHEZ, California

SUSAN A. DAVIS, California

NANCY BOYDA, Kansas

PATRICK J. MURPHY, Pennsylvania

CAROL SHEA-PORTER, New Hampshire

JOHN M. MCHUGH, New York

JOHN KLINE, Minnesota

THELMA DRAKE, Virginia

WALTER B. JONES, North Carolina

JOE WILSON, South Carolina

DAVID KILDEE, Professional Staff Member

JEANETTE JAMES, Professional Staff Member

JOE HICKEN, Staff Assistant

(III)

C O N T E N T S

CHRONOLOGICAL LIST OF HEARINGS

2007

Page

HEARING:

Tuesday, March 27, 2007, The State of the Military Health Care System ........ 1

APPENDIX:

Tuesday, March 27, 2007 ........................................................................................ 61

TUESDAY, MARCH 27, 2007

THE STATE OF THE MILITARY HEALTH CARE SYSTEM

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

McHugh, Hon. John M., a Representative from New York, Ranking Member,

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

Snyder, Hon. Vic, a Representative from Arkansas, Chairman, Military Personnel Subcommittee ........................................................................................... 1

WITNESSES

Arthur, Vice Adm. Donald C., Surgeon General, Department of the Navy,

U.S. Navy .............................................................................................................. 6

Baker, David J., President and CEO, Humana Military Healthcare Services,

Inc. ......................................................................................................................... 41

McIntyre, David J., Jr., President and CEO, TriWest Healthcare Alliance ....... 38

Pollock, Maj. Gen. Gale S., Acting Surgeon General, Department of the Army,

U.S. Army ............................................................................................................. 3

Roudebush, Lt. Gen. (Dr.) James G., Surgeon General, Department of the

Air Force, U.S. Air Force ..................................................................................... 9

Tough, Steven D., President, Health Net Federal Services ................................. 42

APPENDIX

PREPARED STATEMENTS:

Arthur, Vice Adm. Donald C. .......................................................................... 84

Baker, David J. ................................................................................................. 137

McHugh, Hon. John M. .................................................................................... 65

McIntyre, David J., Jr. ..................................................................................... 118

Pollock, Maj. Gen. Gale S. ............................................................................... 68

Roudebush, Lt. Gen. (Dr.) James G. ............................................................... 103

Tough, Steven D. .............................................................................................. 156

DOCUMENTS SUBMITTED FOR THE RECORD:

Addendum from New York Times Website to March 18, 2007, New York

Times Article on The Women’s War by Sara Corbett ................................ 206

March 18, 2007, New York Times Article on The Women’s War by Sara

Corbett ........................................................................................................... 185

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:

Mrs. Boyda ........................................................................................................ 218

Mrs. Davis of California ................................................................................... 218

Page

IV

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD—CONTINUED

Mr. McHugh ...................................................................................................... 211

Dr. Snyder ......................................................................................................... 209

(1)

THE STATE OF THE MILITARY HEALTH CARE SYSTEM

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Tuesday, March 27, 2007.

The subcommittee met, pursuant to call, at 9:05 a.m., in room

2212, Rayburn House Office Building, Hon. Vic Snyder (chairman

of the subcommittee) presiding.

OPENING STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM ARKANSAS, CHAIRMAN, MILITARY PERSONNEL

SUBCOMMITTEE

Dr. SNYDER. The hearing will come to order.

I want to welcome our guests today and folks attending. We obviously have Major General Pollock, the Acting Surgeon General of

the Army, Vice Admiral Arthur, Surgeon General of the Navy, and

Lieutenant General—I need you to pronounce your last name for

me.

General ROUDEBUSH. Yes, sir, Roudebush.

Dr. SNYDER. Roudebush. I thought that is what it was.

General ROUDEBUSH. Yes, sir.

Dr. SNYDER. But you and I had been friends long enough, I

thought I didn’t want to mess it up here.

General ROUDEBUSH. Thank you, sir.

Dr. SNYDER. Lieutenant General Roudebush, Surgeon General of

the Air Force.

We appreciate you all being here.

This is General Pollock’s first appearance before this committee

in this role. And we appreciate you being here today, General.

And this may be Admiral Arthur’s last time, although the full

committee not long ago bid goodbye to General Schoomaker, and he

returned, like, two weeks later.

So this may be your last time here. We certainly appreciate your

years of service to your country and to the Navy.

And, of course, we can’t discuss the current state of the military

health care system without acknowledging the events of the last

few weeks. The stories that have come, the reports out of Walter

Reed Army Medical Center showed our failure to properly care for

all of our wounded warriors in the way that we all want. And when

I say ‘‘our,’’ it is a joint problem for this country. It is all of our

issue and all of our responsibility.

In order to have an open and honest dialogue, we need to understand both the challenges the system faces and the solutions the

Department of Defense (DOD) and the services have proposed. Our

military medics face growing requirements as far into the future as

2

we can see. They will continue to support operations in Iraq, Afghanistan, and the global war on terror. They will also need to support the expansion of the Army and Marine Corps.

While they are doing all of these things, however, the military

medical departments are being required to cut costs. They are

being tasked to find ‘‘efficiencies’’ in the system to the tune of $248

million in fiscal year 2008. They are further required to convert

military medical positions to civilian ones, frequently reducing the

overall number of medical professionals in the process.

We have no doubt that our dedicated military personnel will devote all of their efforts to accomplish their assigned missions. But

there is concern that they are not being given the resources they

need, not want, but need to fully support our Nation’s military

forces.

And we appreciate you being here. You are the first of two panels

today.

I also want to introduce David Kildee, who this is his first time

in this staff position sitting here.

And please prepare to fire off red flares, Mr. McHugh, if you and

I get in trouble and he doesn’t know what to do. So Jeanette will

come racing over here to——

Mr. MCHUGH. I hope you have got a lot of them. [Laughter.]

Dr. SNYDER. A lot of them.

And with that, I would like to yield to Mr. McHugh for any comments he would like to make.

STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE

FROM NEW YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

Mr. MCHUGH. Thank you, Mr. Chairman. And I would ask my

entire statement be entered into the record in its entirety.

Dr. SNYDER. Without objection.

Mr. MCHUGH. I certainly want to add my words of welcome to

our distinguished guests.

I think, Mr. Chairman, you said an appropriate potential farewell to the good admiral. But whether it is his last or not, I will

certainly add to your comments about our deep appreciation for all

that he has done.

And a word of special welcome to General Pollock, who not only

joins us in her first hearing as the new surgeon general for the

United States Army, but also comes, I am told by Jeanette James,

who was the general’s successor as the Medical Department Activity (MEDAC) medical commander up at Fort Drum for the 10th

Mountain Division, she is also the first nurse to work her way and

earn her way into this esteemed position.

Although, general, very challenging times, we certainly congratulate you on your appointment and look forward to your progress

and cooperation and participation in this partnership, as the chairman said, in the days ahead.

Mr. Chairman, I would echo as well your comments about the

broad range of challenges we face. You mentioned efficiency

wedges, a fine phrase, if you will, for cuts. And it is really just the

proverbial tip of the iceberg. If you look at the expected or anticipated savings placed against other costs in the medical system, we

3

are looking at over $2 billion in efficiency wedges and cuts and savings that all mean we have got a great uphill battle to meet the

demands of the budget.

Civilian conversions from military positions—there are funds for

an additional 2,700-plus positions for conversion at a time when we

have already converted over 5,500. And I think it is appropriate,

we begin to wonder what effect this is going to have on our ability

to continue to provide a robust military health system carry out its

mission. And certainly given our witnesses’ expertise in their medical professions, we look forward to their perspective on those kinds

of things.

And last, Mr. Chairman, you are absolutely right. We need to

focus all of our abilities and resources on Walter Reed and the larger medical hold, medical holdover system in the medical care system for all of our wounded warriors. None of us, no American,

wants to see these brave heroes who have given all of us so much

to get anything less than the quality care that we expect them to

be treated with.

So with that, we look forward to the panels here today. And, Mr.

Chairman, I would yield back.

[The prepared statement of Mr. McHugh can be found in the Appendix on page 65.]

Dr. SNYDER. Thank you, Mr. McHugh.

What we will do, I am going to have David put the five-minute

clock on. But that is just to give you an idea where you are at.

When you see that red light go on, if you have still got more things

that you think we need to know, you go ahead and continue.

We will begin with General Pollock and then go to Admiral Arthur and then to General Roudebush.

So, General Pollock, the floor is yours.

STATEMENT OF MAJ. GEN. GALE S. POLLOCK, ACTING

SURGEON GENERAL, DEPARTMENT OF THE ARMY, U.S. ARMY

General POLLOCK. Mr. Chairman, Congressman McHugh, and

distinguished members of the subcommittee, thank you for the opportunity to discuss the current posture of the Army Medical Department.

Our investments in medical training, equipment, facilities, and

research, which you have strongly supported, have paid tremendous dividends in terms of safeguarding soldiers from the medical

threats of the modern battlefield, restoring their health and

functionality to the maximum extent possible, and reassuring them

that the health of their families is also secure.

Army medicine is an integral part of Army readiness. Army medics are deployed around the world supporting our Army in combat,

participating in humanitarian assistance missions, and training

throughout the world. Like the rest of the Army, this operations

tempo is beginning to take its toll on the people and equipment

who are vital to its success.

The toll has been high in terms of cost and human sacrifice.

Army medics have earned 220 awards for valor and more than 400

Purple Hearts. One hundred and two Army Medical Department

(AMEDD) personnel have given their lives in Iraq or Afghanistan.

These men and women are truly the best our Nation has to offer

4

and will make any sacrifice in defense of their nation and most importantly, for the care of their patients.

We recently hosted a human capital strategy symposium to address growing concerns within Army medicine about accessions, retention, and including well-being issues, which have a direct impact on morale. We have established a 180-day deployment policy

for select specialties, established a physician assistant critical skills

retention bonus, increased the incentive special pay for certified

registered nurse anesthetists, and expanded the use of the health

professions loan repayment program.

Fiscal year 2006 presented Army medicine with challenges in recruiting health care providers. The Army fell short of its goals for

awarding health profession scholarships in both the medical corps

and dental corps. These scholarships are by far the most important

source of accessions for physicians and dentists. And this presents

a long-term manning challenge beginning in fiscal year 2009.

The Reserve Office Training Corps, or ROTC, is a primary accession source for the Army Nurse Corps. In recent years, ROTC has

had challenges in meeting the required number of nurse corps accessions. And as a consequence, the U.S. Army Recruiting Command was asked to recruit a larger number of direct accession

nurses to fill the gap. This has been extremely difficult in a difficult and competitive market. In fiscal year 2006, recruiting command achieved only 84 percent of its mission for Army Nurse Corps

officers.

The reserve components provide over 60 percent of Army medicine’s force structure. And we have relied heavily on these citizen

soldiers during the last four years. And they have performed superbly.

But accessions and retention in the Army National Guard and

Reserve continue to be a challenge. Working with the chief of the

Army Reserve and director of the Army National Guard, we continue to explore ways to improve reserve component accessions and

retention for this important group.

We seek to quickly integrate lessons learned from the battlefield

into health care training and doctrine, not only in military medicine, but throughout civilian facilities as well. Army medicine continues to lead the Nation in adopting new trauma casualty management techniques. Since 2003, we have provided rapid fielding of

improved tourniquets, new pressure dressings, and the use of hemostatic bandages that promote clotting.

I know you are aware that traumatic brain injury (TBI) has

emerged as a common blast-related injury. TBI is a broad grouping

of injuries that range from mild concussions to penetrating head

wounds. An overwhelming majority of TBI patients have mild and

moderate concussion syndromes with symptoms not different from

those experienced by athletes with a history of concussion. Many

of these symptoms are similar to post-traumatic stress symptoms

(PTSD), especially the difficulty concentrating and irritability.

Through your continued support, we will quickly develop a better

understanding of TBI from scientific research, including acute diagnosis, treatment, and long-term rehabilitation. You are well-aware

of the challenges involved in managing this health care delivery

5

system, as highlighted in the recent Washington Post articles about

conditions at Walter Reed Army Medical Center.

The Post series highlighted brick-and-mortar problems that

should have been identified and fixed by our leaders at Walter

Reed. But more challenging, the Post series articulated soldiers’

frustration with a bureaucratic disability evaluation system that

truly needs an overhaul.

We have not waited to correct the problems identified at Walter

Reed. I have a tiger team out assessing all of our facilities to ensure that there is not another Building 18 out there and that any

other concerns are identified and quickly resolved.

Within two weeks of the Washington Post series, every soldier

who had been living in Building 18 had been moved out. And the

Corps of Engineers was awarded a contract to replace the roof on

the building. We will evaluate future uses of the building before we

decide to invest on additional renovations.

We are improving the transition from in-patient care to out-patient care for our warriors at Walter Reed and across Army medicine. We quickly established a wounded warrior transition brigade

led by experienced combat veterans to focus on the unique command and control requirements of patient management as opposed

to the day-to-day command of soldiers assigned to the staff at Walter Reed. The leadership of this brigade down to the platoon sergeant level is supported by the line Army so that now the medics

at Walter Reed can focus on patient care responsibilities they were

assigned to Walter Reed to perform.

We took the painful lessons learned at Walter Reed and implemented an Army-wide action plan for improvement. This plan includes a wounded soldier and family hotline, an 800 number which

began operations last Monday on the 19th. As of the 25th, we had

received 315 calls detailing 179 issues ranging from medical care

to personnel to finance.

We have already researched and resolved 29 of the 56 complaints

received about Army Medical Command areas of responsibility.

Seven of those calls were for information only. But these issues are

quickly elevated to the Army leaders. And calls are returned by an

expert in the topic area within 24 hours.

We are also implementing a one-stop soldier and family assistance center at Walter Reed. This center combines case managers,

family coordinators, personnel and finance experts, and representatives from key support and advocacy organizations such as the

Army Wounded Warrior Program, the Red Cross, Army Community

Services, the Army Relief Fund, and the Department of Veterans

Affairs. We are also hiring patient advocates across the AMED and

establishing an ombudsmen program, first at Walter Reed and then

across the Army.

We are revamping the administrative processes of evaluating and

adjudicating our soldiers’ disabilities. Our goal is to streamline the

process to eliminate confusion among soldiers and families. As we

make these changes, we must not compromise the quality of medical care received or the soldiers’ right to a full and thorough medical evaluation.

We will need Congress’s support to make some of the necessary

changes. As we identify those areas that need legislative change,

6

we will bring them forward for your consideration. We will ensure

that soldiers no longer feel that when they leave the resources and

attention of our health care system behind, when they are discharged from the hospital, that people don’t care.

I am grateful to the Congress for the concern and attention paid

to soldiers and their families. And I will keep Congress informed

as we improve these processes.

In closing, let me emphasize that the service and sacrifice of our

soldiers and their families cannot be measured with dollars and

cents. The truth is we owe far more than we can ever pay to those

who have been wounded and to those who have suffered loss.

Thanks to your support, we have been very successful in developing and sustaining a health care delivery system that honors the

commitment our soldiers, retirees, and their families make to our

Nation.

Thank you again for inviting me to participate in the discussion

today. I look forward to your questions.

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

Appendix on page 68.]

Dr. SNYDER. Thank you, General Pollock.

Admiral Arthur.

STATEMENT OF VICE ADM. DONALD C. ARTHUR, SURGEON

GENERAL, DEPARTMENT OF THE NAVY, U.S. NAVY

Admiral ARTHUR. Yes, good morning.

Dr. SNYDER. Good morning.

Admiral ARTHUR. And, Dr. Snyder, Ranking Member McHugh,

other distinguished members of the panel, thank you very much for

your kind wishes on my announced retirement in August. It has

been an honor to serve for these 33 years and to come and represent the Navy in this committee.

I joined the Navy in the 1970’s when we had some significant

problems with health care quality. We had a draft service. We had

the Berry plan. We had other plans that brought into our service

the top health care providers that we have today.

We suffered through some of those problems in the 1980’s. The

best of our people stayed and made what I think is the best health

care enterprise in the world today. Both Army, Navy, and Air Force

systems, I think, have the highest quality we can have.

In our Medical Treatment Facility (MTF), you can get quality

care that is focused on the patient. I like to say that we never ask

our patients how sick they can afford to be because we give the

right care every single time. And what a pleasure it has been to

have a patient population that is composed of 100 percent patriots.

We have some of the greatest graduate medical, dental, and

nursing education programs in the United States ranking in the

top ten for many of our programs. The quality of the care, the quality of the education is extraordinarily high.

We also deliver the best care in the world where it counts the

most, in combat service support. We have the lowest disease and

non-battle injury rate in history. That is the rate of illnesses and

injury in a combat zone that are not due to combat but to other

illnesses and injuries. We are also resuscitating people from injuries that in prior wars would have been fatal. The average stay for

7

a casualty who comes back to Bethesda in the intensive care unit

is 7.5 days. The average time in a hospital is 109 days.

How people that badly injured are able to get off a battlefield

and survive their injuries is nothing short of miraculous. It is due

to many factors: the quality of care that we have, the surgeons far

up front, the nursing staff that are right there on the battlefield.

But I would say the overwhelming reason why we have the resuscitation rate that we do is the Navy, corpsmen and by extension, the Air Force and Army’s medics who are on the field and

give the first level of care. They have either seen a Marine or soldier who has been injured or they have trained another Marine or

soldier to deliver that combat care.

Unless a wounded veteran gets to a surgeon with a heartbeat, he

will not survive. And it is our corpsmen and by extension the medics who ensure that. They are the best they have ever been.

I want to say a special warm thanks to the Air Force’s critical

care air transport teams that make it possible to get all of these

critically injured patients from the battlefield to Landstuhl and

then Landstuhl back to the states. And a special thank you to the

Army’s wonderful facility at Landstuhl, which we are proud to have

one-quarter of the staff as Navy personnel. This was a recent addition to their armamentarium.

I want to especially recognize Landstuhl because unlike Walter

Reed, Bethesda, and all of our other facilities back at Continental

United States (CONUS), the folks at Landstuhl get to see all of the

casualties in their newly injured states. They don’t have the advantage of seeing them walk out, see their families reunited, and to

see the wonderful cures. They day after day see injured sailors,

Marines, airmen and soldiers and, I think, have extraordinary challenges. My hat is off to the staff of the Landstuhl Army Regional

Medical Center.

We do have special challenges, as General Pollock mentioned, especially in traumatic brain injury, post-traumatic stress. When I

first took this job, someone gave me a brief that said 15 percent

of people who go into combat are significantly affected by the experience. And I said, ‘‘That is wrong. One hundred percent of people

who are in combat are significantly affected by the experience.’’

The closer you are to combat, the closer you are to the actual

fighting, the breaking in of the doors at Fallujah, the more affected

you are. And we have to recognize that this is a debt that all of

these young men and women are gaining in combat that we need

to repay by paying attention to their needs as they come home.

Traumatic brain injury is an especially difficult entity for us to

define right now. We are just coming to the realization that blast

injuries, the concussive injuries, especially multiple concussive injuries, have an affect on the brain, on cognitive function that we

had not anticipated before and that we have to now define what

that is. It is similar to, but not exactly like, the concussive injury

in sports players and other people who have a direct blow to the

head. These concussive injuries can give you very subtle symptoms

that often are not amenable to diagnosis with standard tests.

They can be difficulty with memory, difficulty with mood, inability to make a decision on a menu. And we have veterans who get

lost in supermarkets from their traumatic brain injury effects. We

8

need to do a better job of defining it, to following these people, to

being able to give them the right treatment based on their symptoms.

As good as we are today, we can be better. I think a unified or

joint approach to health care would benefit us all so that we have

common financial systems, common logistics, common communication, common doctrine. And we are working toward that, but I

think we have a long way to go. And we could certainly do better.

Another area where we are working very hard and I think we

are making great strides is with DOD and the Department of Veterans Affairs (VA) interface for our veterans. And one of the examples I would give is the facility at Great Lakes. The Naval Hospital

and the VA facility at Great Lakes have combined. They have combined their leadership, their clinical staffs, their laboratory, their

X-ray. And we now have as close as we can get at the moment a

joint facility with the Veterans Administration.

We do have some challenges that I would be happy to discuss.

Dr. Snyder, you mentioned the efficiency wedges. We have other

wedges and reductions. And by what other name you want to call

them, they are reductions in our funding. For us in fiscal year 2008

is $343 million out of a $2.7 billion budget.

We have challenges in personnel. We have program budget decision 712 that you know well, that has asked us to make military

to civilian conversions. We are only able to make about 83 percent

of those conversions at the moment, despite an intense effort to do

so.

We also have the program decision memorandum number 4 that

mandated 901 additional cuts, not conversions. And this year, we

will have 489 people that we will cut from our roles beginning October 1, 2007. In addition to those cuts, the budget wedges, efficiencies, reductions will necessarily result in a decrease in our contracting funds, further adding to our challenges with providing the

right personnel to staff our facilities and be ready to support combat operations.

We have gone through the quadrennial defense review and its

medical readiness requirements review. And in that process, many

of our future requirements were minimized, especially in areas of

homeland defense and humanitarian assistance. That concerns me.

We also addressed fatigue of our deployers. We have a great

number of our corpsmen, doctors, nurses, dentists who are deploying and not just once or twice, but three, four times. And this operational tempo for a very combat trauma resuscitative, intensive

war does cause fatigue in our providers.

Mr. Chairman, thank you very much for the honor of being here

today. It has been a pleasure to serve. And I thank you for allowing

me to give my statement.

[The prepared statement of Admiral Arthur can be found in the

Appendix on page 84.]

Dr. SNYDER. Thank you, Admiral Arthur.

General Roudebush.

9

STATEMENT OF LT. GEN. (DR.) JAMES G. ROUDEBUSH, SURGEON GENERAL, DEPARTMENT OF THE AIR FORCE, U.S. AIR

FORCE

General ROUDEBUSH. Mr. Chairman, Congressman McHugh, distinguished members of the committee, it is really a privilege and

honor for me to be here today to tell you about Air Force medicine

on the battlefield and at home station.

Up front, I would like to note that Air Force medicine is not simply about support. And it is not simply about reacting to illness

and injury. Air Force medicine is a highly adaptive capability tightly integrated into Air Force expeditionary capability and culture.

We build a healthy, fit force fully prepared to execute the mission

from each of our bases whether deployed or here in the states because every Air Force base is, in fact, an operational platform.

Whether launching bombers from Whiteman Air Force Base or

sitting alert in a missile control facility at F.E. Warren Air Force

Base, or providing close air support from Balad Air Base in Iraq,

we protect our power for our joint forces and provide sovereign options for our national leadership from our bases. Air Force medicine supports that warfighting capability at each of our bases and

is, in fact, designed to prevent casualties and sustain our fighting

strength. The result is the lowest disease non-battle injury rate in

the history of warfare.

But when there are casualties, whether they be airmen, soldiers,

sailors or Marines, your Air Force medics are there with worldclass

care. In the deployed arena, our medical teams operate closer to

the front than ever before allowing us to provide our warfighters

advanced medical care within minutes. Underpinning this

worldclass health care for our joint warfighters is our system of

joint en route care.

It begins with a Navy corpsman or an Army medic providing lifesaving first aid at that point of injury. The casualty is then moved

to the next level of care for us at our theater hospital at Balad Air

Base, the hub of the joint theater trauma system where life-saving

damage control surgery is performed by Air Force surgeons and on

occasion, teaming with Army surgeons. The casualty is then prepared for safe and rapid movement in our Air Force air medical

evaluation system to Landstuhl, an Army hospital manned by

Army, Navy, and Air Force medics.

Re-triage and restabilization is accomplished. And the casualty is

prepared for air evacuation back to definitive care at Walter Reed,

Bethesda, Wolford Hall, Book Army, Navy Balboa, or perhaps a VA

hospital. These capabilities combined to create an average patient

movement time of three days from battlefield to stateside care.

That is truly remarkable when compared to the 10 to 14 days required during the Gulf War or an average of 45 days it took in

Vietnam. And it is especially remarkable when you consider the severity and complexity of the wounds that our forces are sustaining.

In short, Air Force medicine is a key and central player in the

most effective joint casualty care and management system in military history. Having just returned from Afghanistan and Iraq, I

have personally observed this capability from that far forward care

all the way home to the states. And it is truly life-saving care.

10

As our casualties move back through Landstuhl and on to our

stateside military medical centers, our Air Force casualties are followed closely by their unit through an assigned family liaison officer, a member of their unit, to ensure that the needs of the casualty and their family are met. And if going through the disability

evaluation process is the next step for our wounded airmen, the Air

Force HEART program ensures the commander, the medics and

the family liaison officer continue, eyes on and hands on, throughout the disability process.

Our Air Force medical capabilities go beyond home station care

and support of our warfighters. Our medics are globally engaged in

training our allies, in supporting humanitarian missions, responding to disasters, and winning the hearts and minds in key areas

around the globe.

And as we focus on care for our warfighters, I believe it is also

very important to note that caring for the families of our airmen

is a mission critical factor. Knowing that their loved ones are wellcared for back at home gives our airmen the peace of mind to do

a critical job in a stressful and dangerous environment.

The care we provide is a very important factor in building that

trust that is fundamental to attracting and retraining an all-volunteer force. This demanding operations tempo at home and deployed

also means that we have to take care of our Air Force medics. This

requires finding a balance between these extraordinarily demanding duties, time for personal recovery and growth, and time for

family.

And it means developing the next generation of Air Force medics.

My charge is to ensure that we recruit the best and brightest, prepare them to expertly execute our mission, and sustain and retain

them to support and lead these important efforts in the months

and years to come.

In summary, the talent and dedication of our military medics ensure an incredible 97 percent of the casualties that we see in our

deployed and joint theater hospitals will survive today. For our

part in this extraordinary system, Air Force medics have treated

and safety evacuated more than 40,000 patients since the beginning of Operations Iraqi Freedom and Enduring Freedom.

Globally, we have provided compassionate care to 1.5 million people on humanitarian missions over the past six years. And at home

station we continue to provide high-quality health care for three

million patients every year.

It is clear that we have challenges. But these challenges represent an opportunity. And we have the responsibility to step up

to that opportunity to assure that our processes and our capabilities are precisely what those who go in harm’s way both need and

deserve and that we take care of their families as well.

Thank you for your support and assistance in meeting this incredibly demanding and critically important mission. I assure you

that we will continue to work hard with you in the months and

years to come to sustain and improve our medical capabilities for

this fight and for the next.

Thank you.

[The prepared statement of General Roudebush can be found in

the Appendix on page 103.]

11

Dr. SNYDER. Thank you, General Roudebush.

What we will do now is David is going to put the five-minute

clock on us, and Mr. McHugh and I follow it pretty closely. And we

will just go down the line here. But I suspect we will go at least

two, if not a third round. So when we get to Ms. Shea-Porter, your

day is not over. We will come back and start over again.

I would like to start.

We appreciate your testimony.

Admiral, you brought up this issue of efficiencies. You had such

an artful sentence in your written statement on page two, in which

you state, ‘‘Fiscal year 2008’’—you need to put the clock on now,

David—‘‘Fiscal year 2008 provides funding challenges in that the

efficiency wedge increases in certain assumptions regarding savings opportunities may not be borne out in execution.’’

I thought that was a very artfully crafted sentence that I think

if I am an enlisted guy or a junior officer and I read that, I think

we are going to get screwed. Something bad is going to happen.

And you brought that up. And I appreciate you acknowledging it

is a problem this committee, as Mr. McHugh articulated very well,

has been very concerned about.

The question for us is, what do we do? You know, we usually say

we are here to help you do your job. But you all are receiving some

mandates, not from us, but from others that are making your mission difficult.

So, I mean, we are here on this committee heading into the defense bill. This is a great committee. We are short some Republican

members. They are having a conference, a very important meeting

today. But we are all unified in our efforts to help you. So what

is our response?

I mean, what do you suggest for us, Admiral Arthur, in terms of

how do we deal with this? In fact, you upped the ante. We thought

it was $248 million. And you said it is $343 million that we are

looking at. That is a lot of pressure on the folks at the lower end

of the chores that you want to get done.

Admiral ARTHUR. Yes, sir. My figure is we have $147 million in

what is called an efficiency wedge, which has no granularity to it.

It is a rough figure that health affairs has given us. We have——

Dr. SNYDER. I don’t know what you mean by no granularity. Do

you mean it is not any detail, nobody has come and just said do

this?

Admiral ARTHUR. No, no. Correct. There is a requirement to fund

the private-sector care. And funds are being removed from the direct care system to fund the private-sector care. Now, the law was

created by this forum to prohibit money from going from direct care

to private-sector care during the year of execution. However, this

is a creative way to do it in the Program Objective Memorandum

(POM).

So in the POM this year we have $147 million in an efficiency

wedge. And it is interesting that whenever we highlight efficiencies, they are taken off and the efficiency wedge still remains

in its $147 million form. We have a reduction in pharmacy services

of $127 million, facility renovation and upkeep reductions of $422

million, and a reduction in our end strength, which results in a

12

900-person cut in our staffing over the next few years. This year

will be $47 million.

So the total for us is $343 million out of our $2.7 billion budget

this year. We cannot maintain the present level of services with a

funding cut that is about 16 percent of our total budget.

Dr. SNYDER. But, I mean, you are heading out the door. Who is

going to get you? But you are being told that you can. Correct? I

mean, somebody must think—I mean, I have no doubt that there

are patriots all the way up and down the line in the Pentagon. But

somebody thinks that you can do this without that money. Is that

a fair statement?

Admiral ARTHUR. Well, somebody thinks we can be a whole lot

smaller than we are today and get the job done.

Dr. SNYDER. Yes.

Admiral ARTHUR. And if we are going to make these kinds of

cuts, we will be delivering care to active-duty only. We will be having pharmacy services that are provided not in our military treatment facilities, but in the private-sector care. And this, in my opinion, will increase the bill overall.

Dr. SNYDER. Right.

Admiral ARTHUR. Because it will force more care out into the private sector where on the margin it is more costly to provide. And

the only mechanism that the Pentagon has to influence private-sector care is a bill because there aren’t the kind of programs and efficiencies that we can enact within the MTFs that we can display in

the private-sector care.

Dr. SNYDER. The point you just made concerns me because on

your list was some maintenance monies. Is that correct?

Admiral ARTHUR. $22 million in facility maintenance.

Dr. SNYDER. I think the Air Force was doing this a few years ago

overall. And it is shortsighted budgeting because things that you

ignore in maintenance bites you sometime down the line. And, I

mean, any home owner knows that. You ignore the small leak, and

pretty soon you are replastering walls. So that seems pretty shortsighted.

With regard of the personnel cuts or conversions, is it also fair

to say—I mean, General Roudebush doesn’t submit an invoice for

the overtime hours he has worked last month. A civilian employee

is obligated. I mean, you are obligated to pay those kinds of fees.

It does not become a one to one conversion. Is that a fair statement?

Admiral ARTHUR. That is fair. And at Bethesda this week I was

told of the problem with overtime pay given to the civilians that

we have had on conversion because they are——

Dr. SNYDER. So it is already an issue?

Admiral ARTHUR. They are no nights, no weekends, 40 hours a

week, no deployments.

Dr. SNYDER. Yes.

Admiral ARTHUR. And they take the place and sit right beside a

lesser-paid active-duty member who is doing the same job.

This year in fiscal year 2008 we will convert 1,036 billets, positions. And if we keep the 83 percent rate that we are able to fill

them currently, that means a decrease of 176 more people.

Dr. SNYDER. Mr. McHugh.

13

Mr. MCHUGH. Thank you, Mr. Chairman.

I think it is fair to say what happens on capital costs and maintenance costs is Walter Reed. There were contract problems there

and continuity of contracts, I understand. But certainly, if you

don’t have dollars to maintain facilities, including those places

where the soldiers are housed while under care, those are the kinds

of problems you have.

The good admiral kind of highlighted the concerns he has about

the beginning of the military to civilian conversion plan. I want to

broaden that a little bit. You know, as I mentioned in my opening

comments, we have already converted thousands of these positions,

including at this point 152 physicians, 349 nurses, and 208 dental

positions. And at the same time, this Congress is actively enhancing the recruiting and retention through the medical health care

professional program to try to bring more of these people in.

It just seems kind of at odds to me that we are having trouble,

as General Pollock said, finding some health care specialties and

yet we are cutting them out. I don’t know.

Do either General Pollock or General Roudebush want to comment a little bit about the concerns you may or may not have with

respect to the military to civilian transition program on the medical

health care professions, particularly nurses and physicians?

General? Either general?

General ROUDEBUSH. Yes, sir, it is a concern. As we attempt to

find the right balance within our capabilities—and there are opportunities where we can, in fact, use some civilian physicians in order

to provide the capabilities both for our active-duty and our family

members. That is not a bad thing in and of itself. It is the extent

to which we are being asked to go in terms of making those conversions that causes us great concern.

In the Air Force, we have done a thorough review of our

deployable requirements and our active-duty requirements, identified a body of positions that we thought could make sense to convert and then did a business case analysis on it to see if, in fact,

those capabilities were present, were they cost-effective and could

we acquire them.

We can go that far. But we are concerned about going any further than that because it very quickly gets into the issues that Admiral Arthur describes where we can, in fact, or cannot, in fact,

meet the mission in some regard. So we do have concerns in that

area.

Mr. MCHUGH. I appreciate it.

And if I may add before we will have comments from General

Pollock, beyond, I would argue—and I would like your feedback on

this—what the chairman said. And I agree with him totally.

I mean, you have an overtime situation in the civilian sector you

don’t have under normal circumstances, at least in the military sector. You have also got a deployability, availability to deployability

issue, which I think would be a big issue for all of you, certainly,

but particularly for the Navy and the—well, no, all of you, all of

you, General, across the board.

So, you know, it is kind of a two-edged sword that cuts you both

ways, it seems to me.

General.

14

General ROUDEBUSH. Yes, sir. In fairness, though, I could say we

have tried to convert those billets that are not deploying billets

such as radiation therapists for cancer. We don’t have any deploying billets for them, so we will convert them to civilian positions.

Mr. MCHUGH. Yes, I understand that. And I appreciate that. And

I understand what you are trying to do. But you can only try to

do so much.

General ROUDEBUSH. Yes, sir.

Mr. MCHUGH. And you noted you are able to fill 83 percent. So

try as you might, you have got some real problems there.

General ROUDEBUSH. Yes, sir.

Mr. MCHUGH. That is my point. Thank you.

General.

General POLLOCK. Sir, when the original plans were made, we

did not take into consideration that we could truly be in a long

war. And some of the eliminations that we have done are for staff

now that we realize are absolutely critical. You addressed the physician and nurse issues. I am also concerned about our enlisted soldiers that have been converted to civilians.

Mr. MCHUGH. Yes.

General POLLOCK. We are unable to get the mental health specialists that we are able to train and use as part of that care team.

We have not been able to do the hiring—even those positions were

eliminated—for a number of the nursing positions because of the

national nursing shortage and the challenges that we have in hiring because of the Office of Personnel Management (OPM) restrictions on how we can hire a nurse.

Very, very difficult for us to bring professional nurses back into

our organization. And then when we add the significant pay difference between what a civilian would receive and then the overtime compensation compared to the enlisted or junior officer salaries that are available to them, that is definitely a morale buster.

Mr. MCHUGH. Yes. I appreciate your expanding on that. And you

are absolutely right. It is a critical issue beyond just the health

care professionals. There are other positions that are staffed that

are equally important. So thank you for filling that in.

And, Mr. Chairman, I appreciate it. I yield back.

Dr. SNYDER. Thank you.

I think this line of questions is going to continue here through

the day, I think.

Ms. Davis.

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

And thank you all for being here. You obviously are here at such

a critical time in this discussion.

On the conversion issue, if I can just continue with my colleagues, are we at really a critical point in this? Should we be rethinking what we are doing?

General POLLOCK. We have asked the Army and the Department

of Defense to hold on any additional conversions so that we can do

a renewed look because of the issues that we hadn’t taken into consideration when we made the original suggestions back in 2003 and

2004 for who we thought we could convert. Because the reality is

although we selected specialties that we thought we would be able

15

to hire in the civilian world, we are discovering that we really

can’t.

Mrs. DAVIS OF CALIFORNIA. Yes.

General POLLOCK. And we would like to have that reassessed so

that we are making better decisions and not breaking health care

as a result of a personnel change.

Mrs. DAVIS OF CALIFORNIA. Do you see impacts as well in terms

of individuals who might be in a pool, so to speak, to be moving

into military health provider positions who perhaps would see the

conversions and not consider those positions for the future? Is it

impacting folks in that way?

General POLLOCK. Ma’am, would you be so kind as to ask me the

question again? I am not sure I followed you.

Mrs. DAVIS OF CALIFORNIA. I am just wondering by virtue of a

lot of the conversions that we have made—I am wondering. You

mentioned some of the corpsmen, the tremendous role that they are

playing, the skills that they have developed. I am just wondering

whether in some ways we are not cutting off those opportunities for

them in the future by virtue of what we have done in these conversions, whether that somehow somebody looking at that would say,

‘‘Well, why would I bother?’’

General POLLOCK. Well, we certainly have concerns with that because as we decrease the number of our junior enlisted in different

specialties, then that also decreases the number of non-commissioned officers (NCO). And as you then become top heavy in those

NCO ranks, they stop being promoted.

So then again there is one of those second and third order effects

that people hadn’t anticipated that then people who are then midterm, you know, mid-career NCOs are going, ‘‘Well, if I can’t get

promoted and I have to go start at the bottom of a new specialty,

should I stay in the Army?’’ And that is a concern for us.

I have been working since I took over the position to start to address these concerns.

Mrs. DAVIS OF CALIFORNIA. Yes. I want to turn for a second to

the mental health area because of one of great concern to me personally, but obviously to all of us. And I know that we are going

to have testimony in the second panel from TRICARE.

But I wonder if you have concerns we are cutting—there is a 5.8

percent decrease in behavioral health provider reimbursements.

And do you see that as having an impact?

Obviously, as you are saying, we are not able to even find the

people that we need. And now we are going to be cutting back and

in some ways, discouraging people from treating those who really

need it right now. Can you comment on that?

General ROUDEBUSH. Ma’am, in the Air Force, we have paid close

attention to that. First, training our providers in terms of PTSD,

what to look for, how to identify it, how to support that individual

and treat them as they go through.

And in addition, we have brought on 32 additional mental health

providers to put in those areas where we have the most returning

Air Force airmen that have been deployed that could potentially require that capability. So we are paying close attention to that in

order to maintain the capacity that we need.

16

Mrs. DAVIS OF CALIFORNIA. You are not necessarily seeing any

negative impacts of that decrease at this time?

General ROUDEBUSH. Because of the steps that we have taken,

we have not seen any impacts.

Mrs. DAVIS OF CALIFORNIA. You are not seeing any.

General ROUDEBUSH. However, we continue to watch that very

closely because as we get into this sustained conflict—and I think

we are going to be in this conflict for a very long time—I think the

likelihood and the necessity for continuing to both maintain and

perhaps increase our capabilities will be very real.

Mrs. DAVIS OF CALIFORNIA. Yes.

Admiral ARTHUR. Ma’am, there is a military health—a mental

health task force that is looking at this in a very comprehensive

way from start to finish, involving the service members and their

families, military and civilian mental health services. It should report out to the Secretary of Defense on the 15th of May.

Last week I was made the military chairman of that effort after

General Kiley’s retirement. He was the co-chair before me. So we

are going to look at this.

I have read the material that they have collected so far. And they

are looking at a very broad-based approach to mental health, not

just starting at the time when we identify people who need treatment, but before that and building resilience in our service members and their families anticipating some of the stresses of combat

and other stresses of military life.

Mrs. DAVIS OF CALIFORNIA. Yes.

General POLLOCK. The concern I would have, ma’am, is we have

forward deployed many more members of the behavioral health

team to assist the folks who are deployed. And then as we have requirements for the soldiers as they have returned or their families,

we are dependent on the civilian sector for that support. Mental

health has not been a robust practice arena in the United States.

Although there is demand, we have certainly are under-resourced

across the country. And many of us could speak to the challenges

that we have for a child or adolescent behavioral health care

around the Nation and how difficult it is.

I remember when I was up at Fort Drum how difficult it could

be to move a child perhaps to another state before we were able

to get in-patient care if he needed it. This is certainly an area that

is a national issue, not just one for the military.

Mrs. DAVIS OF CALIFORNIA. Yes. Thank you.

Thank you, Mr. Chairman. I know I certainly want to address

the women in the military issue as well with PTSD. Thank you.

Dr. SNYDER. General Pollock, I need to have you clarify your first

answer to Ms. Davis in which you—I forgot how you phrased it, but

you have asked your senior folks to revisit a certain decision on

their military conversion. Did I understand correctly? Would you

repeat what you said?

General POLLOCK. Yes, yes.

Dr. SNYDER. I thought you had an October 1, 2008, timeline that

you have to meet.

General POLLOCK. Yes, sir, we have the 2008 conversions broken

into different phases. And I have gone back and asked if we could

please relook those to see whether or not we are actually going to

17

be able to hire the folks that we had anticipated that we could

when we did that original assessment.

Dr. SNYDER. And specifically, whose decision is that?

General POLLOCK. That goes up through the Army G–1. And

then it also goes to the Tricare Management Activity (TMA) up to

Department of Defense.

Mr. MCHUGH. Mr. Chairman, if I may?

Dr. SNYDER. Yes, Mr. McHugh?

General POLLOCK. Thank you. Admiral Arthur reminded me it is

for the under secretary for personnel and readiness.

Mr. MCHUGH. Yes. When Dr. Winkenwerder appeared before this

subcommittee in response to a question I had posed, he had said

that they are certainly willing. I don’t think he made a hard commitment they were. But he said they certainly were willing to reevaluate both the efficiency wedges and the military to civilian conversions. But I don’t think a decision has been made on that. And

until a decision is unmade, it remains, it seems to me.

Dr. SNYDER. Ms. Boyda.

Mrs. BOYDA. Thank you, Mr. Chairman.

Let me just say my dad was a medic on a submarine in World

War II. So I have always had good medical care at home where he

thought was he still was, you know, still from 60 years ago. And

thank you very, very much for your service.

May I just ask a question? Did you say you have lost 102 of your

medics? Did I hear you say that?

General POLLOCK. Yes, 102. It is across the health care professions. It is medics. It is physicians. It is physician assistants. It is

medical service corps officers.

Mrs. BOYDA. That was in the Army or it was in the armed services?

General POLLOCK. That is within the Army. That is the Army

medical department.

Mrs. BOYDA. I had no idea. I am sure all of our condolences on

behalf of everyone here.

After the Walter Reed, I went to both of the VA hospitals in my

district and then to Irwin Army Hospital there at Fort Riley, came

back and reported that there is some really ugly green tile in our

VAs, but they are clean and they are safe, which is not surprising.

When I went to Irwin, the guy—and I am going to tear up. The

staff virtually teared up at how much they take care of their soldiers, how much of a team they are and the concept that we are

just turning these into civilian, you know, jobs just alarms me like

no other.

And I am a freshman here. Can you explain how we got here,

how the decision was made, when it was made? I really don’t have

the background. When was this decision made?

Admiral ARTHUR. For the military to civilian conversion?

Mrs. BOYDA. Yes.

Admiral ARTHUR. Every four years we have a quadrennial defense review. And that review takes into consideration all of the

policies and all of the plans that we have to conduct operations in

DOD. And part of that is a medical readiness requirements review

where the Department says these will be the requirements over the

18

next foreseeable future for combat operations and here is how the

medical piece will fit into that support.

They calculate what operations they will have, what number of

casualties, what kind of casualties. And then they plot what the

support will have to be to ensure that those casualties are welltrained. They take into consideration the garrison care, that is the

corpsmen, the doctors on the submarines, the ships and with the

Marines every day. And they roll it all into a figure, and they tell

us that this is what we require of your medical department.

Mrs. BOYDA. Who is ‘‘they’’?

Admiral ARTHUR. The Under Secretary of Defense for Personnel

and Readiness through his plans, analysis and evaluations program, the PA&E, as we call it.

Mrs. BOYDA. Does that come back through Congress then for any

kind of funding or any kind of—again, I am trying to figure out—

and it doesn’t sound like—it is just——

Admiral ARTHUR. No, it does not.

Mrs. BOYDA. And when was this one done then?

Admiral ARTHUR. This one was done just within the last year.

They have taken minimal casualty requirements for future

warfighting scenarios, minimal deployment and redeployment, almost no humanitarian assistance, disaster relief or homeland security.

Mrs. BOYDA. So this conversion—I hate to interrupt, but this conversion that we are talking about that is going to be finished on

October of 2008 was actually directed in what year?

Admiral ARTHUR. Yes. This past year. Well, actually, there are

two components. There is the program budget decision 712. And

that was several years ago. And we are on the track to convert that

number of billets that we had in many ways agreed to.

Mrs. BOYDA. So this conversion started when, again, if you

would?

Admiral ARTHUR. In fiscal year 2006 and will continue to fiscal

year 2011.

Mrs. BOYDA. I guess what I am trying to ask is—and I just sometimes continue to be appalled at some of the decisions that we are

making. This move to convert actually happened while we were at

war?

Admiral ARTHUR. Yes, ma’am.

Mrs. BOYDA. Well, did they start looking at doing this maybe a

few years back?

Admiral ARTHUR. No, this was in the last two or three years.

Mrs. BOYDA. And I am going to have to go to an Ag hearing

meeting. So I am going to go to a different subject right now.

And, you know, we hear that funding for TBI research has been

cut back. Can you address that? Do you know anything about that?

Is that true? And is there something that Congress can do to—

sometimes what you read in the paper doesn’t actually reflect reality. I know that shocks us all.

General POLLOCK. I am glad that someone else thinks that,

ma’am. What I would like to do is provide you a written response

to that question. I am new enough in the job that I can’t remember

all of those numbers for the research. And I would like to make

sure that what I provide you is correct.

19

[The information referred to can be found in the Appendix beginning on page 218.]

Mrs. BOYDA. Are you concerned that funding has been cut? Is

that something that is on your list of things to worry about? Or if

you would like to get back, that is fine.

General POLLOCK. Yes, I am concerned about it because with the

fact that TBI and PTSD are seeming to be connected in some analyses, I think it is very important that we continue that research

so we know exactly how to provide the care so we can return these

men and women to their absolute highest level of functioning.

Admiral ARTHUR. This is a newly emerging entity, a new realization for us. And unless we get the research correct, we are not

going to get the longitudinal studies that tell us whether we are

doing the right thing or not, we are not going to be able to follow

the members and their families.

Mrs. BOYDA. Data are good.

Admiral ARTHUR. Yes, ma’am, data are plural.

Mrs. BOYDA. Thank you very much. And thank you for your service, Admiral.

Admiral ARTHUR. Yes, ma’am. It is an honor.

Mrs. BOYDA. And, General, congratulations and good luck with

your challenges ahead.

General POLLOCK. Thank you.

Mrs. BOYDA. Thank you.

Dr. SNYDER. Ms. Shea-Porter.

Ms. SHEA-PORTER. Thank you, Mr. Chairman.

I would like to pursue that direction that my colleague was going

in. My husband was stationed at Fitzsimons Army Medical Center

in Colorado when it was a major medical center. And I was there

as well. And I saw the incredible work they were doing through a

lot of casualties from Vietnam.

And I am sitting here today. And I, too, am trying to figure out

how we got to this point where we decide to gut the system as I

knew it and wind up with this other system that we are using.

And what I would like to know when they made the decision to

privatize these jobs, was there much input from all of you. Were

you asked to give your opinion about all this? Or was it a unilateral decision?

Admiral ARTHUR. Yes, we were. And, yes, it was a unilateral decision. We made many inputs. And they were carefully considered

and rejected. Some of our inputs had to do with the cost of the civilian conversions, the cost of the people and the overtime, as Dr.

Snyder was saying. Some of it was the culture of the military. And

that is a difficult thing to quantify.

But as I said in my opening statement, I was here in the 1970’s

and saw a very different culture. Every single one of the senior providers in the military now are here because they are volunteers.

And they do not work for money alone.

It is not a reimbursement system. They work to give the right

care to each of our veterans and their families every day. That

keeps the best of our people in.

And I am concerned about people who will come in for a contracted fee and look at the bottom line, the money, work 40 hours,

no nights, no weekends and they will sit right next to someone who

20

makes half as much and the morale impact on that. We have the

kind of quality health care we have today because the system has

evolved over the last 2 or 3 decades.

And I am afraid that some of these conversions, while we will get

some very good people, we will also get people who are not invested

in our military families but in the paycheck that comes from their

contracted services.

Ms. SHEA-PORTER. I share your concern about that. And it is especially poignant to me today because a couple of days ago I got

a call from a relative I am very close to. She lives in North Carolina. And she told me she was in South Carolina because she had

been diagnosed with breast cancer. They use TRICARE, and they

couldn’t find physicians who would provide appropriate care for the

funding.

And I want to pay tribute to all who have worked in the military

health care system. I remember how dedicated they were, and they

are to this day. And I find it deeply disturbing. And I thank you

for your candor about that. And I think as a Nation it is ironic that

we talk about supporting our troops, and then we sit here and we

find out what that translates to if they need medical care.

I did want to talk about the mental health issue for another moment. We have known for a long time that when soldiers go into

combat or have any kind of adverse situations there will be some

mental illness and post-traumatic stress syndrome. What has happened in the past couple of years as we have been receiving these

troops with these brain injuries and post-traumatic stress syndrome that kept us from addressing it at such a heightened level

until now?

In other words, if you could talk to me about two years ago. Was

this an issue that you were addressing? Were you looking at these

troops and their families and saying this is a crisis? And if you did,

who did you talk to in terms of, you know, what department, and

what was the response?

Admiral ARTHUR. Well, yes, ma’am, we did address that. I think

all three services addressed it several years ago. And I think we

are actually doing pretty well. For the Navy and the Marine Corps,

which we serve in the Navy, we have embedded people in our

OSCAR program.

We have mental health providers, technicians, psychiatrists, psychologists embedded into the units that go into combat. They go

into combat with them. And instead of being sent for evaluation to

some other unit or location, they are treated in theater with personnel that are assigned to their battalions.

So I think that is a very effective way to do it. When they come

back, there are debriefings. There are debriefings before they go.

The senior leadership is involved. And I think we are seeing a low

rate of PTSD compared to what it could be if we weren’t paying attention to it.

We also have the reassessment six months after they come back.

And it is not because we want to wait six months. It is because

that six months is required to get some of the manifestations of

post-traumatic stress and the decompression that they need to really manifest some of the post-traumatic stress symptoms.

21

So we see them. We evaluate all of those assessments. We get

them to see mental health providers whenever it is needed. And

they can self-refer as well.

So I think we are doing a pretty good job. Are we hitting everyone? I am not sure you can always say that we will hit everyone

because it may take a long time for some of these symptoms to

manifest.

General ROUDEBUSH. And, ma’am, it is broader than just the

PTSD. The PTSD is a critically important piece of this. But as we

look at what that means to the family caring for an individual and

to the broader community looking across all the behavioral health

issues with suicide, for example, being a critical concern always as

well as family stress, deployment stress, those sorts of things, and

the fact that TBI and PTSD have some overlap.

And as Admiral Arthur pointed out, there are areas where we do

not have all the information and the data that we need to fully elucidate that. So I think we are moving in that direction. But I think

the on-going research that is required and the attention and the

focus on this is a very good thing to help us move that forward and

be sure that we do cover this and the whole spectrum of stress, if

you will, across the force and the families that we are able to address.

Dr. SNYDER. Mr. Jones.

Mr. JONES. Mr. Chairman, thank you.

And I am going to be very brief. I am sorry I was late getting

here because I am very, very interested in this issue and wanted

to hear you, the first panel, and look forward to hearing the second

panel.

I guess most of the questions since I have been here have been

asked that I might would have pursued. But something just came

to my mind, in talking about family stress.

And I want to give you an example, Admiral Arthur and only because this touched me so greatly and so dearly. Four or five weeks

ago, I was invited to go to Camp Lejeune, which is in my district,

and read a book to six-year-old children at the Johnson Elementary

School. And they had 10 little children there in front of me.

I am sitting in a rocking chair, probably where I deserve to be

anyway, and reading Dr. Seuss, quite an interesting book because

I couldn’t pronounce half the words. But the teacher told me not

to worry about it. The children wouldn’t know if I was right or

wrong with what I said. [Laughter.]

So anyway at the end, I let the little children make statements

or ask me questions. And, of course, everything from, ‘‘Have you

seen the zoo in Washington?’’ to ‘‘Do you know the President?’’ to,

you know, ‘‘Where do you work?’’

But one thing that really bothered me, toward the end two or

three children mentioned that their father or their mom was in

Iraq. And again, these are six-year-old children. But the last child

said to me—and I never will forget it—‘‘My daddy is not dead yet.’’

A six-year-old child, ‘‘My daddy is not dead yet.’’

And, Admiral, I guess my question to you: How far down does

the Navy and the Marine Corps, Army, Air Force—how far down

do you go to try to figure out what services you can offer to the

family?

22

I am not saying that child has a problem. But that was such a

deep statement that I heard, ‘‘My daddy is not dead yet.’’ You cannot go into every family. You cannot evaluate every child. But

where in the world, if this is a problem—not saying this is an emotional problem. But this is a six-year-old child that is thinking that,

‘‘My daddy is not dead yet.’’

How do you reach the family? I mean, does the family in that

kind of situation—and not saying there is a problem. I don’t know

how to evaluate what I am trying to ask you. And I am sure you

can’t make any sense out of what I am trying to say.

Admiral ARTHUR. Well, Congressman Jones, it is good to see you

again.

Mr. JONES. Yes, sir, my pleasure.

Admiral ARTHUR. I think that six-year-old does have a problem.

There is nothing more fundamental to a young person’s life than

the knowledge that the family unit will be there. The insecurity

about the death of a parent is fundamental to the development of

this young man or woman.

We have all sorts of family services. And they go right down to

the children. We involve the teachers in the schools in classes

about what is post-traumatic stress, what should they look for in

the children, how should they help the children cope, especially on

Camp Lejeune, whereas DOD schools—all of or the majority of the

children there of active-duty Marines are cared for on the base, especially with those brand-new schools that are beautiful.

Mr. JONES. Yes, sir.

Admiral ARTHUR. And they pay particular attention because all

of their mothers and fathers are subject to deployment. We have

in the Marine Corps the key volunteers that I think you know very

well. They are the spouses of men and women who are deployed.

And they are very, very active working with the family unit. So I

think they are well-supported.

But that said, you can never get away from the fact that everyone in that school is going to know someone whose mother or father was either very seriously injured or killed in this combat. And

you can’t get away from that.

Mr. JONES. Sure.

Admiral ARTHUR. So I think the key is to be proactive. That said,

we are having a lot of our staff of our military treatment facilities

deployed.

I went to Cherry Point last month. The commander of the base

said, ‘‘You know, we have got longer lines in the pharmacy and

longer waits for clinics.’’ And I said, ‘‘Yes, sir. Twenty percent of

your hospital staff is deployed today.’’

And they are not on vacation. They are deployed in direct combat

service support for their Marines in theater. And saying you can

go 40 minutes for an obstetrical appointment to Craven Medical

Center is not the kind of service that I think our Marine families

deserve.

Mr. JONES. Mr. Chairman, before I close—my time is about up—

I could not say enough about the services provided at Camp

Lejeune and Cherry Point at the hospital. It is outstanding. I

would agree with you that the family support is excellent, I am

sure across every base, Army, Navy, Marine Corps, and Air Force.

23

And I would also say that the DOD schools as long as there is

a military in this country I hope that the Congresses of the future

when I will not be here will always remember that those schools

are an integral part of the quality of life because I have seen so

much good at those schools and at Camp Lejeune and the one I visited.

Admiral ARTHUR. Yes, sir.

Mr. JONES. So I appreciate your comments.

Admiral ARTHUR. If I could say one more thing.

Mr. JONES. Yes, sir.

Admiral ARTHUR. My daughters went to those schools at Camp

Lejeune. And they could ride their bicycles to school and leave

them in a bike rack unlocked in front of that school and know that

they would be there in the afternoon when they returned.

Mr. JONES. That is very important.

Admiral ARTHUR. It is a wonderful culture.

Mr. JONES. Thank you, sir.

Admiral ARTHUR. Yes, sir.

Dr. SNYDER. Congressman Jones, I have been talking with the

staff. And at some point this year I hope that we will have a hearing of this subcommittee on the specific issue of childcare and DOD

schools, both domestically and internationally because it is so important.

Mr. JONES. Thank you, Mr. Chairman.

Dr. SNYDER. We are going to start our—let’s see, I think everybody has been around once. We are going to start our second round

here.

I had said earlier facetiously that General Roudebush, when he

submits his voucher for overtime—it turns out staff corrects me. He

has submitted a voucher for overtime. We owe him $2,873,000.

[Laughter.]

I wanted to get into specifically this—that is not true. For the

record, that is not true, General Roudebush. I made that up.

General Pollock, I want to direct this question to you, General

Pollock and Admiral Arthur. But when your predecessor was here

March 8th, he specifically stated—it was before the full committee—‘‘I am concerned about 2008 and 2009 we will have an efficiency wedge that, at least as I sit here now, I cannot see efficiencies gained to recover that. I have grave concern if we are going

to be able to meet those budgetary cuts in those outyears.’’ That

is the end of his quote.

And when I think about efficiencies, I think about, you know, energy efficiencies in the home. It turns out if you have a front-loading washer, that is much more efficient than a top-loading washer.

And yet the household doesn’t notice anything different.

I can also do energy efficiencies just by dropping the temperature

down three degrees. But that is not an efficiency. That is just a cut

in service. And I think the concern in this committee is not that

you are going to end up with efficiencies. It is just going to be a

cut in service, that somebody is going to see something different in

their lives.

So my specific question to you, General Pollock, and you, Admiral

Arthur, is, as you look ahead for the next calendar year, from this

day until one year from now, if nothing has changed from the manVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
24

dates you have received from above, in terms of civilian conversions

or these efficiencies, what specific services to our military families

and our men and women in uniform do you foresee you will not be

able to provide in the same way that you do now?

General POLLOCK. Unfortunately, sir, that is an issue that my

staff is already working with. The equivalent for us over the next

calendar year is the budget equivalent for one of our large

MEDACS. So basically it means we are going to take an entire

MEDAC out of the ability to contribute to the health care of the

men and women and their families in uniform. There is no way

that I can salami slice that. So it will truly be we will need to make

a decision about what we are going to stop doing.

Dr. SNYDER. So it is not an efficiency. It is a flat-out cut in service at a time our Nation is at war?

General POLLOCK. Sir, it will be a cut in service.

Dr. SNYDER. Admiral Arthur.

Admiral ARTHUR. I echo that. If you recall the words of Portia,

the lawyer in the Merchant of Venice, she said, ‘‘You may have

your pound of flesh, but draw nary a drop of blood.’’ There is no

more flesh to be gained without drawing the blood of the services

that our family members and our active-duty will have.

Our cuts are equivalent to one of our large family practice hospitals like Camp Pendleton and Camp Lejeune, Pensacola, Jacksonville, Bremerton. And we will have to have a serious conversation

about what services we can provide at 16 percent less funding than

the year before.

Dr. SNYDER. As a follow-up to that, Admiral Arthur, you both

equated it to the closing of a large unit. But it is not going to be

the closing of a large unit. It is going to be sprinkled through the

system in a way that this committee, this Congress, you all are

going to have trouble following, I would think, in terms of what the

cuts in services are. You know, every military family that has a

delay in an appointment, instead of one week, it is a month or

whatever it is.

Instead of having a service at their normal military treatment facility, they are going to have to drive 25 miles at a civilian facility.

That is very difficult to follow, is it not? How are you going to follow this impact?

Admiral ARTHUR. Well, it is. And I would say we are—with the

magnitude of these cuts, we are beyond the ability to take salami

slices. We are going to have to, in my opinion, close significant

service locations.

General ROUDEBUSH. Sir, if I might add with that.

Dr. SNYDER. Sure.

General ROUDEBUSH. There are several ways to get at that. One

is the diminution or the loss of services. And actually, that requirement never goes away. So those services will be provided, but it

will probably be in the private sector where it could be even more

expensive in some regards. But the other way that we try and mitigate that and taking risk is with our sustainment accounts, our

care of our facilities, our buying our equipment.

Dr. SNYDER. Through seed corn?

General ROUDEBUSH. Yes, sir. And we push things downstream.

Dr. SNYDER. Yes.

25

General ROUDEBUSH. And particularly now with Military Construction (MILCON), those dollars being in such short supply, we

are taking care of older and older facilities. So it is a bow wave of

obsolescence. It is a bow wave of risk because we all work as hard

as we can to keep those services up to the last inch before we have

to say okay, we are going to have to send that care downtown. So

it drives us in a direction that has impact in a variety of ways.

General POLLOCK. Sir?

Dr. SNYDER. Yes.

General POLLOCK. If we cut services and have to send it out to

the private-sector care, we also lose our ability to ensure the continuity of care. We lose our ability to evaluate the quality of care

that our patients are receiving there. Whereas inside the Army

now we are using measures which are national criteria to ensure

that we are providing the absolute best that we can.

And our goal is to not meet those measures, but to grossly exceed

them so we can clearly demonstrate that our care is superior to

that available in the private sector. But we are unable to even

measure that right now in the private sector.

Dr. SNYDER. Of course, I will be a little bit of a devil’s advocate.

The military is always going to have some substantial amount of

care done in the private sector.

And if that is a problem, you need to figure out how it is not a

problem because we are going to have to follow the quality and the

continuity of care that is done in the out-patient civilian sector,

even care that sometimes is mandated on top of you that you just

as soon not——

General ROUDEBUSH. Well, sir, if I might speak to that. We have

good allies in the private sector.

Dr. SNYDER. Right, right. That is right.

General ROUDEBUSH. Our partnership with our TRICARE managed care support contractors is as good now as it has ever been.

Dr. SNYDER. Right.

General ROUDEBUSH. And we need to continue to make that grow

and get better.

Dr. SNYDER. And better.

General ROUDEBUSH. But as that care goes into the private sector, there is also the issue of currency. Our providers need a caseload. They need the complexity. They need to take care of patients

in order to stay current up on the step to be able to go do the deployed mission as well. So it is important that we keep that care

in the direct care system for a variety of reasons.

Dr. SNYDER. We will go to Mr. McHugh. And then we will go to

Mr. Kline, who has joined us.

Mr. MCHUGH. I will be happy to pass to Mr. Kline.

Dr. SNYDER. Mr. Kline. And then we will go to Mr. McHugh.

Mr. KLINE. Thank you, Mr. Chairman. I understand we have already discussed the conflict this morning. I am very much disappointed that I couldn’t be here for the first hour of this hearing

because it is hard to imagine a more pressing issue right now. And

because I did miss the first hour, I will try very hard not to trod

on old territory.

Admiral, I would like to go, if I could, to you. And I understand

you discussed it very briefly. But let’s talk about corpsmen. The

26

Marine Corps is increasing its end strength significantly. And as

I understand, as part of this process, the Navy is looking at reducing the number of corpsmen. Is that correct?

Admiral ARTHUR. That is correct. We have the program budget

decision that this year is going to reduce 283 corpsmen. They will

be gone by October 1st. We are also looking at the Marine Corps’

requirement to increase approximately 800 staff, which includes

some corpsmen. So we are hoping those will balance. However, we

are not including the Marines’ families in that calculation. So I

think we are still going to be left with——

Mr. KLINE. I am sorry. Explain the balance again. We are cutting?

Admiral ARTHUR. Yes, sir. The program decision memorandum

number 4 has required that we cut 901 staff over the next couple

of years. The contribution in fiscal year 2008 starting October 1st

will be 283 corpsmen. And this was calculated based on the Navy

coming down about 30,000 people.

At the same time, the Marine Corps is increasing 28,000 people.

And we are trying to work with the Marine Corps to offset this program decision memorandum so that we can properly fill the health

service needs of those additional Marines, which turns out to be

about 700 or 800. We have yet to have a firm figure on that.

Mr. KLINE. And what would the Marines do to make this offset?

I mean, what do you mean you are working with the Marines?

They don’t have any corpsmen.

Admiral ARTHUR. The program decision memorandum which took

900 staff from us is done. It is in the budget. And those people, the

money are gone. So we have to work with the Marine Corps as they

increase their staffing by 28,000. The Marine Corps must put in a

requirement back to the defense health plan to increase the staff.

They are two separate entities, I am being told. One is a cut. It

is done. The other is an increase, which we now must properly debt

through the system and argue for the corpsmen and doctors,

nurses, dentists to support the Marines and, I hope, also their family members who will come with them.

Mr. KLINE. Well, it is Washington. Thank you. I yield back.

Dr. SNYDER. Mr. McHugh.

Mr. MCHUGH. Let us talk go back to the comments I was making

about physician losses, 162 that have been lost in the military to

civilian conversion but take it from a different perspective. Two of

you noted that you are having trouble recruiting in the doctors and

into the other health care professions. I mentioned what the Congress has done with respect to trying to make increases for the

health profession scholarship program.

We have increased the loan repayment program for officers from $22,000 to $60,000. We have increased the Health Professionals

Scholarship Program (HPSP) scholarship grant from $15,000 to

$45,000, increased the monthly stipend, which was at $579 a

month to no more than $30,000 a year intended, of course, to try

to facilitate those recruiting.

Other than addressing the issue from the conversion part, which

I think is an important component of that challenge, do you have

any suggestions what this Congress can do to help you to be more

effective in recruiting health care professionals into your ranks?

27

Admiral ARTHUR. Sir, I think there are two facets. One is the recruiting, to get young men and women to come into the medical

and dental professions and the nursing professions. I think those

scholarships and other programs are terrific. I hope in the next few

months to be able to announce a program in the Navy to do a medical enlisted commissioning program where we take some bright

young corpsmen and put them through medical or dental schools.

I think another important facet is to retain the talent that we

already have, to craft the bonuses and shape the organizational

rank structure to keep the gray hairs, if you will, the people that

have the most experience in combat service support and trauma

management and have the highest degree of medical skill.

We are seeing, paradoxically, the highest retention rate that we

have had in some time in our general surgeons. And we are seeing

that, I believe, because the quality of the service, the kinds of service, and the rewards they get from the service on these casualties

is so great that they will stay in just for the satisfaction of the

practice.

Mr. MCHUGH. General Pollock.

General POLLOCK. Sir, the retention bonuses and being able to

correct them and level some of the disparity between a military salary and a civilian salary so that we can keep the people that have

already developed the foundation of military health care and not

lose them to the civilian world because they are being very aggressively recruited. And as we look at the multiple deployments and

the year deployment for the Army, the year away from their families knowing that they will face that year again, it is very, very difficult to retain them.

Mr. MCHUGH. General Roudebush, your testimony didn’t mention you were having recruiting problems. Two years ago General

Taylor suggested, in fact, stated that there were some challenges

in that regard. What did you do that has been so successful? Great

leadership, I know. But beyond that?

General ROUDEBUSH. No, sir. The concerns remain. The HPSP

program is a major source for us. And thank you for the increased

authorizations within that pay structure. And now we are working—because those are reserve pay dollars that, in fact, support

that to work to be sure that there are dollars available to move into

that. We have continued to work both on scope and quality of care

to retain the individuals once, in fact, we do recruit them. But we

still have concerns and difficulties in recruiting fully qualified.

The additional bonuses and the authorities in that regard, I believe, will be helpful as we work through that. But we are no less

concerned relative to our ability to do that. And certainly, within

the realm of nursing, a very competitive environment to recruit

nurses.

And I would also suggest that there are also issues within the

reserve realm in terms of being able to recruit reservists of all varieties, whether physicians, nurses, in order to do that as well. And

we look forward to working certainly with Congress on incentives

that will make that both more attractive and more fulfilling for reserve duty as well because they are an important part of what we

do.

28

Mr. MCHUGH. Thank you. Just while I have got a yellow light,

I made a comment earlier that Secretary Winkenwerder suggested

that the efficiency wedges in the military to civilian conversion targets were certainly could be revisited. Are you aware of any revisitation happening in that regard, yes or no?

General ROUDEBUSH. In terms of within the Department revisiting the efficiency wedges, I am not aware of any activity. I will tell

you with the mil-to-civ conversions certainly all the way up

through our secretary, Mr. Wynne, we are concerned what that

means in terms of the 2008 activity, particularly because we have

to certify by virtue of congressional requirement that there will be

no detriment to neither access or quality of care.

So for us to be able to certify at the secretarial level, we do have

some concerns and will be addressing that, sir.

Mr. MCHUGH. That is another issue we will get to.

Okay. Yes or no, any formal re-evaluations?

General POLLOCK. Sir, I have been involved in some discussions

that they were willing to relook it. But I don’t know what specific

steps would be required at the DOD level. As a point of clarification on the earlier question, the original mil-to-civ conversions that

the Army faced was an Army decision because of the operations

tempo (OPTEMPO) they wanted to move more people into the line

and away from the fixed or the garrisoned organizations.

So thinking that they would be compatible with conversion to civilian support so that they would have the military strength in the

line organizations. But again, some of the decisions we need to

relook because what we thought we could hire and what would be

available across America have not borne true.

Dr. SNYDER. Ms. Davis.

Mrs. DAVIS OF CALIFORNIA. Thank you.

I think we are all familiar with unintended consequences. And

we really need to look at that.

I wanted to just share one of the concerns that I would have from

a number of the families that I have met with. At what point do

we think that this begins to effect retention? As we know, families

feel that the medical benefits that they get are fabulous. And, you

know, they rave about them. And they are very important to them.

But when a mom, you know, can’t see the pediatrician or doesn’t

feel that the pediatrician even understands what it is like to go

through multiple deployments or really relate to the military family because it is a civilian conversion, that begins to change their

on-going decisions.

And so, I think we just need to be aware of that and make sure

that we work to do what we can for those families so they feel that

they are being taken care of. Because otherwise, that benefit, you

know, to the other person who gets a vote in all this doesn’t seem

very important any more.

I appreciate it. I know you understand that.

I wanted to ask you about the article in the New York Times

Magazine the other day by Sara Corbett. I don’t know if you happened to see that about women in combat and women in theater

and the impacts of PTSD on women, particularly as primary care

givers, but also some of the instances that were cited in the article,

abuse to women in theater and how that is being dealt with and

29

how the services are providing the kind of care and support that

the women need and being certain that they get that while in theater and then they certainly get that when they return home.

Could you speak to that?

General POLLOCK. Ma’am, I have not seen that article. But we

have looked at the gender differences to see if there are gender differences for PTSD, for example. And they are comparable. They are

in the 15 to 20 percent reported rates. And there has been some

discussion because women traditionally have been more willing to

talk about their emotions, they are more willing to discuss how

they are feeling and where they are at any one particular time.

But that is still relatively new for us to look at. And it will require more attention and more research as well.

Admiral ARTHUR. I also have not read that article. But I can tell

you that there is a lot more that we need to know about women

in combat, especially direct combat. This is the first conflict where

we have really had substantial numbers, I think, especially as they

come back with significant injuries.

And this was brought to me by one woman who asked me how

am I going to hold my baby with this plastic arm. And I was immediately embarrassed that I had not thought about those special circumstances that we really need to account for. So there is a lot that

we don’t know and that the current cohort of women in combat are

teaching us.

General ROUDEBUSH. Ma’am, I have read the article. And I understand there are some concerns about it. But the issue, I think,

is a very pointed and a very valid one.

Certainly, in terms of sexual assault and harassment, we have

all taken steps to put advocates and a response system both at

home and deployed to be able to attend to that and to be able to

address those needs. But there is also, I think, the commander’s accountability and responsibility to set the tone, set what is acceptable within a realm. And I think the attention is certainly moving

that in the right direction.

Relative to PTSD, there is no gender immunity. And we need to

be as concerned regardless of gender. Every individual who is exposed to that needs to have those resources available. So we are

certainly attending to that.

Mrs. DAVIS OF CALIFORNIA. Yes. I appreciate that. I think we are

all concerned that, you know, for years health studies were done

on men and perhaps didn’t take in the special dynamics that would

affect women. And I think in this same regard, I appreciate your

talking about the research because we need to be proactive. We certainly need to be helping our commanders in the field to have a

high level of consciousness.

But at the same time, you know, there is a lot that perhaps we

don’t know. And so, I would hope that as we see some dollars and,

you know, perhaps siphoning those off in some way, you know, to

be certain that, you know, have we thought about this and make

certain that we are really addressing this issue.

Admiral ARTHUR. Yes, ma’am. I can tell you from my initial read

of the draft of this mental health task force report that I am reviewing now this is given a significant amount of diligence in that

report and looking at not just what are we doing, how can we do

30

it better, but what should we be doing, what is the model and taking into consideration the entire family. So women’s health is highlighted in that report.

General ROUDEBUSH. And given the fact that our combat service

support are at risk in these theaters. There is no front line necessarily. Everyone is certainly at risk.

Mrs. DAVIS OF CALIFORNIA. Yes. You know, the other thing that

we haven’t talked about is that even our health care providers, in

many cases, are susceptible to burnout and trauma as a result of

treating trauma patients. And we need to be thinking about them.

General ROUDEBUSH. Ma’am, we need to take care of our medics

because every time you put a hand on a wounded individual, you

are now part of their life. And there is a cost to that. It can be compassion fatigue. It can be burnout.

As we bring our folks back, we have to pay very close attention

to their recovery and their reconstitution, their ability to deal with

that because in a microcosm, they are giving and giving and giving

in a very fulfilling way to be of service. But it still comes at a cost.

And we need to be attentive to that.

Dr. SNYDER. General Pollock and Admiral Arthur and General

Roudebush, the article that Ms. Davis called to my attention last

week is from the New York Times Magazine March 18, 2007, ‘‘The

Women’s War’’ by Sara Corbett.

And, without objection, Mr. McHugh, let’s include this as part of

our record.

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

page 185.]

Dr. SNYDER. And I have no expectation that you all read everything that is in the press out there about men and women at war

and their families. But if you would respond for the record to this.

And, General Roudebush, you can have another bite at the apple,

too, if you would like, to respond to the record. And hopefully you

can work your way through the approval system of OPM in a way

that it will be timely in giving to this committee and might be helpful.

Mr. Jones.

Mr. JONES. Mr. Chairman, thank you.

General Pollock, I am very interested—it might be in your printed testimony. You might have discussed this before I got here. It

is one of the more difficult specialties to entice graduates of medical schools in the area of orthopedic surgery. Is that a problem in

trying to recruit those who specialize in orthopedic surgery?

General POLLOCK. Well, we recruit very few who are board certified in orthopedic surgery. Generally we educate our own. And as

the other offices have identified, our training programs are often in

the top 10 in the nation. So the men and women that we train as

orthopedic surgeons are truly phenomenal.

Mr. JONES. Right.

Admiral Arthur, it seemed like several months ago I had the

privilege to visit the hospital at Cherry Point. And in talking with

those in the leadership at the hospital and knowing of all these

cuts that you are going to have to deal with and we in the Congress are going to have to deal with, there was a concern. And I

31

don’t know if this has taken care of itself or not. And you can answer this.

That as we began to save monies, instead of being open 24 hours

a day, we would be open 12 hours a day. There was concern down

at Cherry Point that the fact that there would not be a facility

open at night from—I don’t know what the time was. I can’t remember. But let’s say 12:00 a.m. to 6:00 a.m. in the morning, particularly with Marines out training, should someone be injured.

Is this happening at more bases than not, that instead of being

open 24 hours or having some type of urgent-care-type facility?

What is the policy? And I would ask all three this question. And

it can be a very quick answer, if you want to.

Admiral ARTHUR. We are looking at what services we can provide

based on the projected staffing that we are going to have. At Cherry Point, as I mentioned before, 20 percent of the staff is currently

deployed. And we are trying to downsize a bit because, as you

know, it has been base realignment and closure’ed (BRAC’ed). We

have got Carteret and Craven, which are our main sources of care

there. And if an emergency were to occur that requires a surgeon

or higher level trauma care, Cherry Point is not the place to bring

them, whether it is daylight or nighttime.

Mr. JONES. Sure, I understand.

Admiral ARTHUR. They should go to those other facilities. My

concern is obstetrician (OB) care and those other family issues that

as we downsize that facility—and the Marine Corps has plans to

increase the number of aircraft in squadrons on that base—that we

provide those families of deployed Marines a timely access to family level care. And we are working through the issues of the network. I know our TRICARE contractor is being very, very diligent

there in helping to expand that network to support the families.

Mr. JONES. General.

General ROUDEBUSH. Sir, over the last 15 years we have closed

a significant number of small hospitals because they were both inefficient and, frankly, not busy enough to maintain the kind of currency and competency and there was care available in the community. And in working with our managed care support contracting

partners and our community partners we have been able to provide

that care in those circumstances.

And relative to the emergency response, we work that in partnership with the communities in which our bases are part of those

communities. So it is a collaborative association. And on base in

many circumstances, the fire department also has an Emergency

Medical Service (EMS) capability. And we leverage that as well

where that is available.

General POLLOCK. Across the AMED as well, sir, we have looked

at the volume and the competency of the staff that would be there

and made the decision in a number of locations to not call them

emergency rooms any more because they do not have the capacity

that justifies being called an emergency room. But for many folks,

because we have grown up talking about well, if you needed care

quickly, you went to an emergency room, what we need is access

to care when we define we need it. And that is the expectation of

the patients.

32

And that is one of the challenges that we face because they become very frightened when they understand that how they perceive

access to emergency care is changing. So it is very important that

as we make those decisions we have a very aggressive communication and education plan so that people understand that for what

they would need the care is available. We are not eliminating that

care.

Mr. JONES. Thank you.

Thank you, Mr. Chairman.

Dr. SNYDER. I have three more questions which we may be able

to move through fairly quickly. And then we will go to Mr. McHugh

and then to Ms. Davis.

And starting with General Roudebush and going down the line,

do you have a precise number in your mind about the number of

medical holds and medical holdovers that you all are currently following in the Air Force now?

General ROUDEBUSH. Yes, sir. In the Air Force, we are following

52 active-duty and 256 reserve medical hold, if you will. However,

the definition for medical hold for us is somewhat different than

the Army. So there is a small distinction there.

For us our medical hold individuals are those that are at the end

of their term of enlistment or service and they have an issue that

needs to be attended to before they transit either into the VA system or into civilian life. And we work through that before we, in

fact, go ahead and either separate or retire.

Dr. SNYDER. Admiral Arthur.

Admiral ARTHUR. Yes, sir, we have 134 Navy, Marines and one

Coast Guard that are involved in Operation Iraqi Freedom (OIF)

or Operation Enduring Freedom (OEF)-related injuries. We have

an additional 203 who are in medical hold for other reasons such

as cancer and prolonged illnesses. So most of the OIF casualties

are housed at the wounded warrior barracks at either Camp

Lejeune or Camp Pendleton.

Dr. SNYDER. General Pollock.

General POLLOCK. Sir, we have approximately 1,000 active-duty

medical hold soldiers and about 3,200 medical holdover. And so, it

depends on where they are in the country. Some of them will be

co-located at an installation or at one of the Community Based

Health Care Organizations (CBHCO).

Dr. SNYDER. No, I understand that, General Pollock. I just wanted to get a sense of the number.

And then the question for Admiral Arthur and General Pollock.

This specific issue of there has been some activity in Congress

about the events of Walter Reed leading to a proposal to change

the BRAC decision with regard to Walter Reed. My own view is

that that, I think, would be a mistake. But I wanted to hear you

all’s perspective since it impacts on both your facilities.

General Pollock.

General POLLOCK. Sir, I think that it is very important that we

continue with the BRAC. But we must be fully funded in order to

do that. Fully funded in order to do that is about $400 million. And

that would allow us to truly develop the world-class facilities that

are essential at both the Bethesda campus and down at Fort

Belvoir.

33

And it will also be important that we have relief from some of

the requirements and legislation that have prevented us from investing in facilities once it is identified as a BRAC location. So we

will need the funding to ensure that we sustain Walter Reed at a

high level throughout that entire transition period.

Dr. SNYDER. Admiral Arthur, do you have any comment?

Admiral ARTHUR. Yes, Dr. Snyder. I agree with what General

Pollock said.

We have an opportunity to create a tremendous national asset

with the Walter Reed National Military Medical Center juxtaposed

to the National Institutes of Health, the National Cancer Institutes

with the USUHS, Uniformed Services University of Health

Sciences, on the property as a great medical school and to build the

facility that the National Capitol area needs in that location as

well as to plus-up the Fort Belvoir facility. And this is our opportunity to create a much better facility than either of the two could

be as stand-alones.

Dr. SNYDER. And my final question is the bill that passed out of

the full Armed Services Committee last week and will be on the

floor this week that will be called the Wounded Warriors Bill. Have

any of you had a chance to look at it and have any thoughts or

criticisms about it. Would you share that with us today?

We will start with you, General Pollock.

General POLLOCK. One of the concerns that I do have and I have

shared with the line Army is it is important that we not discriminate against the different warriors. Not all of them are combat injuries. And the ones who are not combat injuries deserve the same

level of care as the others. So I just would like to remind you that

it is a warrior medical assistance process because we certainly

don’t want to only take care of our wounded soldiers.

I think that I would like to provide some of the feedback from

the staff in writing as your response. And we can do that for you

quickly, sir.

[The information referred to can be found in the Appendix beginning on page 209.]

Dr. SNYDER. Is there anything specific in the legislation, other

than the terminology, the title of the bill, a provision that you

think specifically discriminates between those who are combat

wounded and those who maybe have picked up an illness or something overseas?

General POLLOCK. Well, the concern that we have is so many

people now—and now the Congress included—is using the phrase

‘‘wounded warrior.’’

Dr. SNYDER. As is the military. Your point is——

General POLLOCK. And that is why I said I started with the

Army leadership.

Dr. SNYDER. Well, your point is a very good one.

General POLLOCK. Just trying to make that point, sir, so that we

don’t cause yet other second and third effects.

Dr. SNYDER. I get your point.

Admiral Arthur.

Admiral ARTHUR. Only small things that we have looked at so

far. One of them is case management. We have a very robust program for case management that isn’t only centered on the nurse

34

case managers, but on social work, on administrative staff who are

non-medical who support the families and deal with the pay and

records issues.

So some of the issues surrounding the case manager and the requirement to be an active-duty service member who does that we

might want to have reviewed because I think we have got a robust

system that is contracted civilian. It is active-duty.

And I think the purpose of the bill is to ensure that every service

member who needs one has appropriate case management, which

should include the medical and administrative needs and the family needs involved in their care.

Dr. SNYDER. General Roudebush.

General ROUDEBUSH. Yes, sir. We, too, use a case manager approach also in our reserves. We have at the command level case

managers who are managing reservists in their communities, if you

will, getting their care. So we think the case manager approach is

a very good one. And we look forward to working with you to identify both the ratio and the location for medical and administrative

family support in terms of case managers.

And also the training activities are identified in the language are

good, particularly with the disability evaluation system being sure

that our folks that are dealing with that are properly trained. And

we will look forward to that.

And if I could add one comment on the BRAC.

Dr. SNYDER. Yes.

General ROUDEBUSH. The focus has been on Walter Reed and Bethesda, and very appropriately so. But Malcolm Grow Medical Center at Andrews is a key player in the National Capitol area, both

in terms of the implications and the execution of the BRAC as well

as meeting the needs for Andrews Air Force Base and the key missions that they support. So I just want to be sure that as we pay

appropriate attention that that is not lost as we move through.

Dr. SNYDER. Thank you. Yes. I thank you for that comment, General Roudebush.

Mr. McHugh.

Mr. MCHUGH. Well, actually, Mr. Chairman, you took my intended question on BRAC. And I am glad you did because I think

we heard valuable input. And the funding is an absolutely critical

component of this, including, by the way, over $470 million if you

factor in the cost increases that have been effected by inflation and

time, as happens in our economy, of course. So we have got an important role to play there.

Let me just state—and if any of the members want to comment—

that we have had a kind of challenging history, if you will, between

the services and this Congress with respect to military to civilian

conversions, particularly as they relate to required—beginning in

2006—required certifications. And we have had some ups and

downs and starts and stops and fits.

And suffice to say that right now we are by law have a freeze

on military to civilian conversions prior to an expected submission

of report that was due in January. I believe it was January 17th.

And we are still waiting on that.

35

Was it you, Admiral, that spoke about you are working on that

certification? Can you fill me on a little bit more about what is happening there?

Admiral ARTHUR. We are working on that. It is very difficult to

certify cost, quality, and access prospectively because quality and

cost can be a retrospective look at the lagging indicators, if you

will.

Mr. MCHUGH. Well, you owe us a retrospective look as well because we required recertification.

Admiral ARTHUR. Yes.

Mr. MCHUGH. Correct.

Admiral ARTHUR. I would say that in clarification these conversions cannot be made until the certification is done. However, the

military billets that derive into that process are cut on October 1st.

So our military billets are gone by recertification.

Mr. MCHUGH. You mean Personnel Army Manning Document

(PMAD)?

Admiral ARTHUR. Pardon me?

Mr. MCHUGH. You mean the PMAD? I would say yes, there is

a definitional difference between how the services and how you had

been instructed that versus how we do. I agree with that. And I

don’t think that is a call you made, but it is a call I am very unhappy with.

Admiral ARTHUR. Yes, sir.

Mr. MCHUGH. Because common sense should tell those who

made that interpretation for you that Congress intended that to be

outright freeze. And if you are losing the billets, you are losing the

people. I mean, that is a conversion.

Admiral ARTHUR. No, sir. The billets are gone October 1st.

Mr. MCHUGH. Yes.

Admiral ARTHUR. And even if we were to convert, we don’t get

the conversion money until third or fourth quarter.

Mr. MCHUGH. I understand. But that wasn’t your decision.

Admiral ARTHUR. No.

Mr. MCHUGH. It was somewhere else.

Admiral ARTHUR. Correct.

Mr. MCHUGH. The conversions or the certifications are something we are waiting for. So we are going to get them, right?

Admiral ARTHUR. It is at the secretary of the Navy level at the

moment.

Mr. MCHUGH. Okay.

How about the Army? Do you know, General?

General POLLOCK. I know it is with the under secretary, sir.

Mr. MCHUGH. All right. So they are out of your shop?

Is that the same for you as well, General?

General ROUDEBUSH. Yes, sir.

Admiral ARTHUR. Yes, sir.

Dr. SNYDER. Okay. Thank you.

Mr. MCHUGH. Thank you, Mr. Chairman.

Dr. SNYDER. Ms. Davis.

Mrs. DAVIS OF CALIFORNIA. Thank you, Mr. Chairman. And I

know we have more panels, so I will try and be brief.

I wanted to just address the issues around the Guard and Reserve and the fact that we have so many men and women returnVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
36

ing to communities that may be somewhat remote and with difficulty of receiving the kind of follow-up care that they might need.

How do you see that that is being addressed? And do these conversions effect that at all?

General ROUDEBUSH. Ma’am, I can speak for the Air Force. For

our reservists, our Guard and Reserve, we keep them on status.

They are put on Manpower Personnel Account (MPA) days, which

keeps their full benefits and entitlements coming while we work

through with them in their communities the health care issues that

are identified.

So we use case managers at the Major Command (MAJCOM)

level that deal with these folks on a daily or weekly basis to make

sure that they are getting the care that they need and that their

circumstances are properly adjudicated and come to a good conclusion. So for us——

Mrs. DAVIS OF CALIFORNIA. Was there a tendency at the beginning to not have them return to their home communities? And I

know their families were——

General ROUDEBUSH. No, for us in the Air Force that is the way

we have worked it by policy. And that also puts them back in their

support realm where their commanders can attend to them as well

so that we have that support structure in place. But that is the Air

Force policy to do that and has been.

Admiral ARTHUR. Navy and Marine Corps do very much the

same. We send them back to their home units. And we have case

managers in the Navy and Marine Corps who follow each and

every member.

Mrs. DAVIS OF CALIFORNIA. Do you feel that the support is there,

they can get the care that they need?

Admiral ARTHUR. I think it is because we have the case managers who keep track of each patient and know when their appointments are. If they need to be kept on active duty because of continuing medical issues or surgery that is needed, we do that. So we

only let them go back to their home stations when they are stable

and healing and we are following their progress prior to a medical

board.

Mrs. DAVIS OF CALIFORNIA. Okay. I guess part of the concern

would be in defining whether they are going to stay in the service

or not and what that transition period for the VA is.

Admiral ARTHUR. Yes.

Mrs. DAVIS OF CALIFORNIA. And I appreciate that issue. And just

quickly, I think you spoke to the need to anticipate the needs of

the service members and so that we are embedding some of the behavioral health providers in units. I know that in San Diego—and

I think that we are going to hear from Mr. McIntyre shortly.

But what they are doing with the special forces there is to embed

a nurse with the unit because they felt that actually they weren’t

getting some of the care, that that had been a problem. Do you see

that? Or do we have special forces units, for example, that, in fact,

have missed out in some ways on some of the care that they should

be receiving?

Admiral ARTHUR. The special forces units, the Seals in the Navy

have made a decision that their health care providers are going to

be from the Seal units. They will train their own health care proVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
37

viders. So they don’t use Navy corpsmen far forward. They use

Seals that they have specifically trained to be paramedics.

I applaud Mr. McIntyre’s efforts to get that nurse embedded with

the units. I think it is very innovative. And I think it speaks to the

integration of our TRICARE contractors with our military treatment facilities and the dedication of, especially Mr. McIntyre and

his focus on supporting the warfighter and their families. He saw

an opportunity and supported it as well to support the comprehensive combat casualty care center that has just been opened at Balboa, which is a collaboration between Balboa, Camp Pendleton

Naval Hospital, the Veterans Administration, and TriWest as the

TRICARE provider.

Mrs. DAVIS OF CALIFORNIA. So hopefully we will see more of that

kind of activity?

Admiral ARTHUR. Absolutely. Put the patients closer to home so

that they can be properly supported.

Mrs. DAVIS OF CALIFORNIA. Okay. Thank you very much.

Thank you to all of you.

Thank you, Mr. Chairman.

Mr. MCHUGH. Mr. Chairman.

Dr. SNYDER. Thank you, Ms. Davis.

Mr. McHugh.

Mr. MCHUGH. If I may, just for the good of the order, a little

housekeeping here. The staff has identified on the New York Times

Web site an addendum, a correction to one of the cases that existed

in the article that you have very rightly, and I think appropriately,

included in the record. I think just for procedural sake—and I don’t

think it in any way changes the overall challenge presented by the

article.

But this correction as appearing on the Web site ought to also,

without objection, be included.

Dr. SNYDER. Without objection, we will include that in the record

also.

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

page 206.]

Mr. MCHUGH. Thank you.

Dr. SNYDER. So that you all can respond to the article plus the

addendum in total.

Anything further, Mr. McHugh.

Mr. MCHUGH. No, thank you.

Dr. SNYDER. Okay.

Ms. Davis, anything further?

Mr. MCHUGH. God bless you.

Dr. SNYDER. We want to thank you all for being here.

General Roudebush, I appreciate you letting me use you as a

pawn today in my discussion about the tremendous service that all

our men and women in uniform and their families give in terms

of well beyond what most of us perceive as the American work

week.

And, General Pollock, I neglected to mention that I spent a couple of unexpected nights at Tripper Army Medical Center some

years ago and probably received the best advice I have ever received in my life from a cardiologist there. And I appreciate your

38

service and also you stepping forward at a challenging time in the

position that you are in. We appreciate you being here today.

And, Admiral Arthur, our gratitude to you for your 33 years of

service to the Navy and to the country. And I look forward to seeing you again, perhaps not testifying before this committee, but we

appreciate your efforts and everything you have done for the Navy.

Admiral ARTHUR. Thank you.

Dr. SNYDER. And, Mr. McHugh, why don’t we say we will pick

up here in precisely five minutes and give everyone a chance, including our next table of witnesses, a chance to bust for the restroom if they need to. But this will be in military five minutes, not

congressional five minutes. So we really will be back here.

[Recess.]

Dr. SNYDER. Let’s resume our hearing.

And, gentlemen, we appreciate your patience and appreciate your

attending the first session. These issues are obviously very important, not just to this subcommittee, but to the American people.

And we appreciate you being here.

Our second panel is Mr. David McIntyre, Jr., who is the President and chief executive officer (CEO) of TriWest Health Alliance;

Mr. David Baker, the President and CEO of Humana Military

Health Care Services; and Mr. Steve Tough, the President of

Health Net Federal Services.

And we will begin with Mr. McIntyre and go down in that order.

And as I instructed the first panel, we will have David put the

light on, but that is just to give you an idea of the time. If there

are some things after the five minutes that you need to tell us,

don’t let the red light stop you from sharing those with us.

So, Mr. McIntyre, we will begin with you.

STATEMENT OF DAVID J. MCINTYRE, JR., PRESIDENT AND

CEO, TRIWEST HEALTHCARE ALLIANCE

Mr. MCINTYRE. Good morning, Mr. Snyder, Ranking Minority

Member McHugh, and Congresswoman Davis. Thanks for the invitation to appear before you today.

It is an honor to be here to talk about how our organization, in

collaboration with TRICARE regional office West, and our west region military treatment facility partners are doing whatever it

takes to make good on the promise of TRICARE for those that reside in the 21-state region, more than 2.8 million beneficiaries.

Together we are taking a concerted proactive approach toward

ensuring that these most deserving individuals have access to quality care and dedicated customer service, that which they have

earned.

I request that my written statement be accepted for the record.

It details much of the work that we have accomplished with regard

to communication and education of both beneficiaries and providers, our robust behavioral health initiatives, our comprehensive formalized program to partner effectively with the direct care system,

a program we call Joint Strategic and Operational Planning Process (JSOPP), which is affording facilities in our region to do a

make, buy business case and much more.

Our overall environment in the west region is one of success. It

has come from collaboration and as a result of the partnership that

39

we together have built and maintained in our on-going effort to leverage the strengths of our colleagues for the benefit of our joint

military family customers. It is on these successes that I would like

to concentrate my oral remarks today.

Our provider network, which exists to serve as a resource and in

some cases, a safety net for the military treatment facilities, has

grown, and we continue to enhance its ability to serve our beneficiaries. Our 18 owner organizations also serve in the local west

region communities as our network subcontractors. I am pleased to

announce that our network is growing 1 to 2 percent a month, and

we are now to 117,000 providers across the 21 states. And it is an

example of the power of progress inherent in this collaborative focused partnership.

Seeking to make sure that the network reaches into the communities where there is a substantial presence of Guard and Reserve

we have called on the 21 governors of our region to join with us

in thanking the doctors that are part of our network today and encouraging the others to reach out and support their fellow citizens

in the state, much like, Mr. Chairman, the concept that you put in

the AMA News a year or so ago.

To date, 15 governors from our states have stepped up and done

exactly that. Working together we have been able to grow the network, particularly in the outlying communities, to make sure that

the Guard and Reserve have a robust network on which to rely.

In the OB area, an issue of focus for this committee a couple of

years ago, we placed substantial effort along with TMA to try and

get them to change the rates so that in no state did we have OB

rates that were below Medicaid as it related to TRICARE. Seven

of those states of the nine were in our region.

I am pleased to say that the folks at TMA did a great job with

the involvement of this committee in addressing that issue. And we

have now grown that network by 71 percent in our region as a result of the policy change.

And we thank you on behalf of all of the families in our region

for your work, especially your leadership personally, Mr. Chairman, in this area.

In spite of all these successes, we are seeing challenges, as mentioned by Congresswoman Davis, with behavioral health. A 5.8 percent cut in reimbursement rates is absolutely unsustainable in

terms of making sure that the providers rise to the occasion in our

region and come alongside those that have increasing demand in

this area. I think, like OB, we have a problem because of the anomaly of Medicare and particularly given the growth of demand that

we are seeing in this area.

For the Guard and Reserves, we continue our aggressive outreach. As many units within our region were activated and mobilized overseas and to our borders, we joined forces with Tricare Regional Office (TRI)-West to vigorously pursue numerous opportunities for educating and growing the beneficiary base. We have also

done a couple of innovative things with the Guard and Reserve. We

put DVDs out to all the families.

We are in the process of releasing the second version that is

aimed predominantly at children and their parents. We have embedded the combat stress team concept in the California Guard as

40

a test. As Congresswoman Davis was talking about, that is being

met to much success. And we also have an integrated project in

Hawaii that links medical surge and behavioral health together.

As was mentioned previously, we now are focusing on those that

are at the sharpest point of the spear. And that is the special operations teams. I have had the ability to visit with the head of the

Navy Seals and to talk about the challenges that they face and

their families face in making sure that they don’t drop through the

cracks. These are folks, as we all know, who bear a disproportionate burden because they are often called at night and leave the

next day.

Their families don’t know where they are going. They don’t know

when they are coming back. They don’t know how long they are

going to be gone.

The Seals tell me that they are suffering nearly a 40 percent casualty rate. And they are on average on their ninth deployment. It

is very important that all of us continue to look for those gaps in

the areas that we together can plug and make the system sharper

for all. And I am excited about the work that we are doing together

in our region in that area.

Last, in response to the Walter Reed situation, we freed up $1

million a couple of weeks ago, reached out across our region to ask

how we might be of assistance to our military partners. One of the

things that I am most excited about is something that we are starting with the Navy and the Marine Corps in the West. And that is

what I would call an integrated care management prototype.

We are actually taking the concept that we are in the process of

working with the Seals and embedding that together with the Navy

and the Marine Corps in our region up and down the West Coast.

We have a seat at the care management table. That allows us not

to drive where a patient goes because that is not our decision. It

allows, though, for us to look as a team end to end on what the

needs of that patient are and where it is possible that we might

be able to place them in the private-sector network if there is not

capability and capacity available in the VA system.

And so, we are very excited about that. It is just starting under

way this last week or two. And we are looking forward to doing our

part.

At TriWest, we believe that the successful delivery of services is

a cooperative approach, a joint effort among all the stakeholders in

our region: our company, our owners, our TRI-West leaders, our civilian and military medical partners and you. By working together

with our beneficiaries’ best interests in mind, we can make this

program more effective.

I would last like to offer one thought on the budget as I close.

And that is we do have challenges. And I think that it is fair to

say that none of us, not you, not the services, not ourselves anticipated the kind of demand that we are looking at. While I know it

was politically complicated last cycle, I believe that it is time to reopen the question of whether there should be mandatory home mail

delivery of pharmaceuticals.

That is not a change in the benefit. It is a change in the delivery

of a product for maintenance drugs. It has been done for the VA

41

for some time. And you can pick up somewhere between $600 million and $1 billion by doing that.

Thank you very much.

[The prepared statement of Mr. McIntyre can be found in the Appendix on page 118.]

Dr. SNYDER. Mr. Baker.

STATEMENT OF DAVID J. BAKER, PRESIDENT AND CEO,

HUMANA MILITARY HEALTHCARE SERVICES, INC.

Mr. BAKER. Thank you, Mr. Chairman. Dr. Snyder, Mr. McHugh,

Ms. Davis, thank you very much on behalf of the dedicated men

and women of Humana Military Healthcare Services for the opportunity to update you today on the state of the TRICARE program

from our perspective. I have provided a written statement for your

consideration.

Dr. SNYDER. I should have said earlier, Mr. Baker, all the written statements from both the previous panel and this panel will be

made a part of the record.

Mr. BAKER. Perfect. Thank you very much, Mr. Chairman.

Dr. SNYDER. Without objection.

Mr. BAKER. For background, our company was awarded its first

TRICARE contract in 1995. And we began serving military beneficiaries in 1996. Since 2004, we have been administering our current TRICARE contract for 2.8 million TRICARE eligible beneficiaries in DOD’s south region of the United States.

And though it does not seem possible, on Sunday, April 1st, we

will begin the fourth option year of our five-year contract. And as

we begin the new option year, it is my feeling that the operational

status of TRICARE is excellent, thanks in large part to the tangible support of this subcommittee, the oversight of the Department of Defense, and the superior service being rendered by your

contractor partners, especially those represented on this panel to

my right and left.

I believe active-duty military personnel, retirees and their family

members have exceptional access to a rich array of high-quality

health care services that are being delivered as cost-effectively as

possible. Service levels are outstanding. Processes are stable. And

all available evidence indicates high satisfaction among TRICARE

members.

Mr. Chairman, my written statement highlights the status of the

program across several domains, including cost control, clinical

quality, access to health services, and service to the deserving

members of the military community, both active and retired. And

I have provided examples of processes and programs that we have

successfully implemented in the south region under the current

contract structure. I am happy to report that after some initial disruption during startup these processes and programs are working

very well.

And I chose this array for my statement cost, quality, access, and

service, because it reflects the objectives of the TRICARE program

as originally set forth by both the Congress and the Department of

Defense a decade-and-a-half ago. To be sure, there are challenges

for the program, particularly today. But the important point is that

42

today’s TRICARE program has been able to meet the challenges of

a changing world environment.

Against that backdrop I am aware that this subcommittee and

others on Capitol Hill are carefully examining the delivery of

health care to our service members and veterans alike and that the

TRICARE program undoubtedly will be subject to careful scrutiny.

I applaud those efforts.

But as you go about your critical work, please bear in mind that

today’s TRICARE program is working very well. We at Humana

Military Healthcare Services look forward to working with you and

with our Department of Defense partners to continue fulfilling the

promise of TRICARE for many years to come.

Again, Mr. Chairman, please allow me to thank the subcommittee for the opportunity to be here today. And I look forward to your

questions.

[The prepared statement of Mr. Baker can be found in the Appendix on page 137.]

Dr. SNYDER. Mr. Tough—and I am pronouncing that correct?

Mr. TOUGH. That is correct, sir.

Dr. SNYDER. Mr. Tough.

STATEMENT OF STEVEN D. TOUGH, PRESIDENT, HEALTH NET

FEDERAL SERVICES

Mr. TOUGH. Thank you. Good morning, Chairman Snyder, Congressman McHugh, and Congresswoman Davis. And I appreciate,

as was stated by my colleagues, to be here this morning to share

with you perspectives in experience with the TRICARE program

and in particular, the Health Net experience.

Let me begin by giving you some background about the Health

Net Federal Services and the dedicated 1,700 employees who are

focused and clearly targeted on delivering high-quality benefits and

services to the beneficiaries of TRICARE.

Health Net has a long history in working in partnership with the

Department of Defense. As Foundation Health Federal Services, we

were the first company to develop comprehensive managed care

programs for military families. Under the first Civilian Health and

Medical Program of the Uniformed Services (CHAMPUS) reform

initiative contract, a precursor program to TRICARE, we provided

health care services to DOD beneficiaries located in California and

Hawaii.

During the first generation of TRICARE contracts, Health Net

administered 3 contracts covering 5 regions, 11 states, and 2.5 million TRICARE beneficiaries. Under the current TRICARE contracts, we administer health care services in the TRICARE North

region, which includes 2.9 million beneficiaries in 23 states primarily in the Northeast. In addition to our North region contract,

our sister company, MHN, provides behavioral health counseling

services to military members and families through a number of

contracts with the Department of Defense.

These services include military family counseling, rapid response

counseling to deploying units, victim advocacy services, and reintegration counseling. We also perform a number of health carerelated services for the Department of Veterans Affairs. And

43

through these various programs, we have helped the VA save over

$150 million since 1999.

The primary underpinning of the success of the TRICARE program is our partnership with the military health system. Our 19

years of working with the Department of Defense gives us a clear

appreciation for the need to understand and be aligned with our

government customer and continuously work to improve, tailor,

and integrate our services to be most responsive to the evolving

needs of the health system and the beneficiaries we serve.

We do this by working in close collaboration with the Department, the military services, maintaining strong relationships and

open and proactive communications with the beneficiary associations and by tapping into the advice and counsel of a group of

former military, senior military leaders throughout the TRICARE

advisory board. Based on our interaction with these groups as well

as our strong performance levels, our perspective of the current

state of the TRICARE program is that the program is working exceptionally well. And let me expand on some of the key points.

Health Net and the TRICARE regional office North have fostered

a strong collaborative relationship. This relationship ensures open,

honest, transparent communications as well as a clear understanding on our part of the goals and expectations of our customer. It

also helps ensure that we prioritize our initiatives appropriately,

focus on those that help DOD achieve and even exceed the

TRICARE contract objectives.

For example, we have been working actively in concert with numerous initiatives to improve on health care costs and quality for

the TRICARE beneficiaries. One such initiative is a collaborative

effort undertaken recently to increase TRICARE mail order pharmacy usage. I am sure you are aware that DOD achieved significant savings on prescription drugs purchased through the mail

order pharmacy program. And that is because the DOD has access

to the Federal supply schedule for pharmaceuticals under the mail

order program but not to the retail pharmacy outlets.

To help DOD encourage the use of mail order program, Health

Net implemented a multi-faceted approach at no cost to the government. This approach had several components: educational efforts

targeted to beneficiaries in our disease management, case management, and transitional care programs, an educational program that

targeted our high-volume providers with low TRICARE mail order

pharmacy penetration and offering e-prescribing tools to a select

group of network providers.

These efforts have resulted in a demonstrative increase in the

overall pharmacy usage within the north region up 25 percent over

the past year. We talked about earlier about the performance excellence. This generation of TRICARE contracts contains a number of

performance standards that exceed those used in the commercial

health care marketplace. Even though these standards are higher,

we are either meeting or exceeding those standards. And I will just

give you a highlight of a few.

Beneficiaries calling our toll-free customer service line on average are connected to a customer service representative in four seconds. Health Net now obtains nearly 78 percent of network claims

electronically. This is significantly higher than the average comVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00047 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
44

mercial mass care experience of 55 to 72 percent. Health Net tries

to minimize provider hassle factor paying providers promptly, on

average paying within 6 days for claims submitted electronically,

13 days for paper claims and within 2 days for Web-submitted

claims. And referrals and authorizations are processed within 2

days.

The efforts to reduce the provider hassles seem to be paying off.

Our network is robust. We have nearly 100,000 contractor

TRICARE providers servicing the TRICARE North beneficiaries.

This number is up by 35,000 or 53 percent since the start of the

service delivery in September of 2004.

Regarding the beneficiary satisfaction levels, this program is also

performing well in this area. Beneficiary satisfaction with the

TRICARE program remains very high, higher than with commercial or other governmental agency programs, according to a recent

survey by the Wilson Health Survey Group.

Of all the plans and programs included in the Wilson survey,

TRICARE was the top rated health insurer in member satisfaction

for the fourth year in a row. The results are consistent with surveys of TRICARE users performed by the TRICARE regional office

North, which have also found high beneficiary satisfaction levels.

For the past 5 quarters all beneficiary satisfaction levels have

averaged between 87 and 88 percent. Additional proof that the program is working well is the survey results of MTF commanders.

For the past 5 quarters, overall MTF commander satisfaction has

averaged 86 percent. However, I am pleased to report the most recent performing quarter Health Net received a 94 percent satisfaction rating from the north region MTF commanders.

Earlier I mentioned our 19 years of experience with DOD has

taught us the value of understanding our customer and aligning

with the objectives of the military health system. Again, we do this

by tailoring our services to meet the unique needs of the Military

Health System (MHS). Perhaps the best example and the one of

most interest to this committee, based on the recent events, is the

way we stand ready to help and support the health care needs of

our active-duty service members.

While, as you know, the active-duty service members receive

most of their care from the direct care system, we do provide a

number of important support services. As you know, we support

the facilities in the national capital area, which include Walter

Reed Army Medical Center and the National Naval Medical Center

in Bethesda. And we provide an extensive network of civilian

health care providers to augment the services at the MTF.

We also operate a TRICARE service center on-site at each military treatment facility to provide customer service, including enrollment, claims, and referral assistance. The TRICARE service

center at Walter Reed averages over 600 beneficiary visits per

month.

We provide a full range of medical management support to the

wounded warriors and other MHS beneficiaries referred out to care

within the civilian network. These include benefit review, customer

support and service, transitional care, case management, and discharge planning. Specifically at Walter Reed, Health Net has been

45

participating in various committees and tiger teams developing solutions for implementation where appropriate.

Our medical management and field operations team are assisting

with the training of the wounded warrior transition brigade case

managers. And our behavioral health company, MHN, has readied

three licensed clinical social workers to provide additional social

service support at Walter Reed.

MHN has also identified additional experienced consultants who

can be made available on short notice. These social work consultants are experienced in providing non-medical supportive consultation services to active-duty members and their families. If requested, Health Net is prepared to provide additional support to

support the Walter Reed Army Medical Center and our Nation’s

wounded warriors.

Another way we provide support to both active-duty members

and their family members is through reintegration counseling. We

provided this service in response to the reintegration and redeployment needs at installations where large numbers of returning

troops called for greater support for health care access and coordination. This support also extends to the Guard and Reserve members.

MHN for the military family counseling services contract provides short-term, face-to-face problem resolution for military personnel and their families with over 150 counselors on sites at military installations across the United States and overseas. MHN provides rapid response counseling to the National Guard and Reserve

members and their family members to help them best cope with

the stresses of deployment or reintegration to the civilian life after

deployment.

There are two other examples of our tailored approach that best

meet the needs of the Department and the TRICARE beneficiaries

and include our involvement with the Fort Drum regional health

planning organization and our efforts to advance disease management and consumer empowerment. My written remarks go into

both of these initiatives in much more detail.

On the disease management and consumer empowerment front

we have been talking with the Department of Defense about establishing a program to pilot the use of commercial decision power

program as an enhanced disease management, consumer empowerment service that helps members better manage their own health

care, navigate the complex health care system, and have a more

proactive and productive discussion and interaction with their physicians.

In closing, I would like to thank you for inviting me to testify before this committee today. The TRICARE program is stable and

performing exceptionally well. And we are very proud to be a

proactive and coordinated partner with the MHS system.

Thank you.

[The prepared statement of Mr. Tough can be found in the Appendix on page 156.]

Dr. SNYDER. Thank you, gentlemen.

And we will put ourselves on the five-minute clock again. I think

all three of you were here. I saw Mr. McIntyre and Mr. Baker in

the audience.

46

You were here also, Mr. Tough, during the preceding testimony.

Is that correct?

Mr. TOUGH. Correct.

Dr. SNYDER. I wanted to give you all a chance to make any comments that you might want to with regard to anything the surgeon

generals said, particularly with regard to their—what we referred

to as wedge efficiencies and so on.

Beginning with you, Mr. McIntyre, anything that you heard this

morning that you would like to comment on?

Mr. MCINTYRE. I think that you all put your finger on the topic

of relevance for the direct care system. The challenge is how do you

make the system more efficient in its use of resources. But from

the services’ perspective, at least our perspective has been they suffer for the ability to hire people on a contracted basis, oftentimes

taking as much as 18 months to find people, if they can find them

at all. And staying attuned to that issue and pushing through the

detail, I think, is going to be very constructive and very useful for

the system itself.

Dr. SNYDER. Mr. Baker.

Mr. BAKER. I would echo Mr. McIntyre’s comments and the comments of the previous panel members.

As you know, Mr. Chairman, I go back a long way in the military

health system. It has always been my belief that it is better to deliver care to military family members, to military members, and indeed to retirees, better to do so when possible in the military system. Our TRICARE contracts are established in a way that

incentivizes us to try to make that happen.

I urge the military departments to look carefully at the notion

of conversion to civilians and indeed the reduction in military medical personnel. I don’t think that serves the system well.

As one of the panel members indicated a moment ago, care is

going to be delivered. The question is will it be delivered within the

military system or within the purchased care system. I believe this

Nation is better served if it is delivered within the purchased care

system.

Dr. SNYDER. Mr. Tough.

Mr. TOUGH. Yes, thank you. I would agree with both David and

Dave.

You know, it is important to keep in mind that there is a dual

mission of the military health system. It is military readiness, military medical readiness, and peacetime health care delivery. And so,

it is important that we have that MTF as that centerpiece for care.

And certainly, one of the primary objectives of this contract is to

optimize the military treatment facility. And it is difficult to do

that with a declining base of active-duty military medical personnel.

Dr. SNYDER. I wanted to ask about the reimbursement online. I

think all of you would be in agreement that over the last several

years the reimbursement to providers has gotten more efficient.

Would you all just briefly describe how you have done that?

How do you handle those small practices that are still struggling

a bit with the electronic age? Is it a paper claim? Or do you have

a program where you actually install a computer yourself for access?

47

Again, if you would just make this brief, if we could. Just go

down the line, starting with you, Mr. McIntyre.

Mr. MCINTYRE. It is a challenge for small practices. My father actually retired as a surgeon a couple of years ago, not because of

loss of dexterity, but because he didn’t want to go through the cost

of converting and suffered for the fear of what Health Insurance

Portability and Accountability Act (HIPAA) was going to bring.

And, you know, it really has to be worked practice by practice by

practice.

And what we did is we have started with the highest volume

practices and are working our way down that list, not because the

smaller volume aren’t important. But the larger bang for the buck

from a taxpayer perspective is to move those things along more

readily where there is higher volume. And we are finding success

with that.

I was involved a couple of years ago in an effort to wire offices.

The challenge is when only three percent of the services that a

practice provides are to this population. Why would you retrofit

your entire operation by involving software that you are only going

to use three percent of the time?

And so, it is a little bit of a challenge. I am not sure we are ever

going to get to the last mile, which is the smallest doctor’s operation with the smallest volume. But we have seen a dramatic

change in the amount of electronic submission since we have started this contract a couple of years ago.

Dr. SNYDER. Mr. Baker.

Mr. BAKER. I would echo Mr. McIntyre’s comments. We, too, have

had a strategy. In fact, a TRICARE contract has incentivized us to

try to move from paper to electronic submission. In our region now

for all providers, or all care rendered, rather, we are hitting over

73 percent of the claims are being submitted electronically.

But just as Mr. McIntyre has done, it has often been by the ones.

It has started with those providers who had the highest volume of

TRICARE claims. They were the ones most interested. And we

have tried to make it as easy as we possibly can. We continue to

work that every day.

There are simply some providers, though, who are never going to

come onboard. Because averages are a bit misleading. In our region, we have over 42 percent of the licensed providers are in our

networks. And part of the deal there is that you agree to submit

your claims electronically. But they are responsible for 3.7 percent

of the population of the region. So that disparity in some areas,

some practices have high volumes. Others have very, very low volumes.

We just have to demonstrate to them the benefits of the electronic filing, the statistics that Mr. McIntyre referenced and indeed

Mr. Tough referenced about speed and accuracy and payment and

so forth and the cash flow advantages seem to resonate. But it is

a game of inches.

Dr. SNYDER. Mr. Tough, anything to add?

Mr. TOUGH. Yes, just similar comments. Again, we try to pick

them off in order of the highest volume. I think David McIntyre’s

comment about small percentage of TRICARE beneficiaries in an

office practice will not necessarily drive up an individual physiVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00051 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
48

cian’s interest to specific activities that might work more inclined

to electronic communication, electronic transfer of claims.

The Web-based efforts we have undertaken—we have about eight

percent of our claims on Web-based transactions. If we can get providers to consider that, that is a fairly simply way to transact

claims with us. It also is the fastest turnaround, two days to pay.

Dr. SNYDER. My time is up, Mr. Tough. But so I understand you,

when you say Web-based, you mean that the physician’s office

would not necessarily have to have any new software or anything.

He just would go to your Web site with a code and be able to enter

it in even if they have a paper-based records system in their own

office. Is that a fair way of describing it?

Mr. TOUGH. Yes. There is an express claim process that we have

built with our subcontractor at Palmetto Government Benefits Administrators (PGBA). And it allows for that kind of ease in transaction.

Dr. SNYDER. Mr. Jones.

Mr. JONES. Mr. Chairman, thank you. And I couldn’t help but

think—I have been here 13 years, 7 terms. And I have Camp

Lejeune, Cherry Point and Seymour Johnson Air Force Base. And

I want to say to you and your companies and corporations that you

have made tremendous progress in a very difficult system. And you

have talked about it today in certain answers to the chairman

with, you know, electronics.

And I realize that no system is perfect. But I would have to say

that you have made such progress. And who benefits? The user.

And that is our military and our retirees. And you certainly have

done a tremendous job.

I want to go to one statement that Mr. Baker said that I think

General Pollock, who just left—you know, we all realize that this

nation is in serious financial shape. I mean, I don’t care which side

of the aisle you are on. Anybody that would look at the debt—when

I came in 1995, it was $4.9 trillion, $4.6 trillion in debt.

It is well over $8.3 trillion. And if you talk to David Walker, who

has spoken to this committee, subcommittee and committee, you

know, he will tell you that the true debt is probably somewhere

around $50 trillion.

Not only do we have to provide the quality of medical care to our

military, but we also have to make sure that they are getting the

best value for the dollar. Which, that is your responsibility. And

again, I compliment you on that.

Mr. Baker, you made the statement that, you know, at some

point in time—at least I interpreted it this way, and I could be mistaken. At some point in time when you have to make the decision

of whether the military is going to have to make some very difficult

decisions as to the quality of care on base—and we heard General

Pollock talking about, you know, pediatrics and Obstetrics and

Gynecology (OBGYN)—those services now are pretty much out in

the public more so than it used to be.

And then she also mentioned that it is going to be an education

process, that from the standpoint of the services that you used to

have on base. Let me explain that. Used to have on base we now

don’t have on base. So therefore, the education to the quality of

49

life—I am not sure you can answer this question, but I am going

to ask it anyway.

What do you see 10 years down the road? And this is your personal opinion. It is not your professional opinion. Or it could be.

What do you see 10 years down the road for your industry in providing the service and what the military can provide knowing that

we have got some very, very difficult decisions to make, whether

we have the war on terrorism or it has all been over? We have got

some really difficult times based on the economy of this country

and what the government has to spend.

Mr. BAKER. Sir, I am humbled that you would ask my opinion

on such a question. And I would be the first to say that my crystal

ball is not only cloudy, it is probably scratched up a bit. So it is

really hard for me to make that kind of prediction. I think the outcome is going to be predicated on the kinds of decisions that were

discussed with the earlier panel. And that is the future of the direct care system.

I mentioned to the chairman that I have been around for quite

some time. I had a full Air Force career as a health care administrator and actually grew up in a military family. So I have seen

the military health system all my life. And I can tell you that one

of the things I have seen during my life is an on-going contraction

of the size of the military facilities on installations, the scope of

services provided.

General Roudebush made mention of the Air Force and some of

the changes that have occurred with the small community hospitals

over the years. I saw a statistic not long ago that really drove

things home. And forgive me if I don’t have the numbers exactly

right. But somewhere a little over 100 hospitals among the three

services being operated. I remember a day when the Air Force operated 120 facilities.

So if we follow the same glide path, it strikes me that we are

going to continue to contract. The people who can change that are

resident in the Congress and they are resident in the Pentagon.

And I urge them to look very, very carefully at what we are trading

off.

Mr. JONES. The other two gentlemen?

Mr. MCINTYRE. If I might, Congressman Jones. I think as Mr.

Baker said, you put your finger on an important issue. And I, too,

have somewhat of a warped crystal ball. I started my career on

Capitol Hill doing health policy on the Senate side for a decade before I came to do operations. And I grew up in a health care family,

my father having served in the Army at Fort Bliss for a while

while I was a child.

I look at this from the standpoint of what is it that we can afford

and how is it that we properly make the right make, buy decisions.

In my own company, I buy spikes or surges in a contracted way.

I staff to the average. And I came to that conclusion—and I have

now been running this company that I built for a decade. And I

came to that conclusion when I started looking at the spikes and

the changes in my budget from cycle to cycle. And I started to come

to the conclusion that I need to figure out what are those averages

and how do I make that work.

50

And the first responsibility, as we all know, that the military

health system has is to be ready to support the warfighter as they

go into combat. The second responsibility is to make sure that they

have got caseload that will give them the capacity to keep those

skills sharp and to serve basic needs of the family. And then the

third is to either build or purchase the rest of that care.

And I think that one of the challenges we have together in this

environment is what is the right make, buy analysis. How do we

do that right? And how when we look at this over the complexity

of the Federal debt—and that was a topic when I was working for

Senator Gorton in Washington state in the mid-1980’s when we

lost the Senate on the Republican side over the debt issues and our

reaction to the debt issues or the members’ reaction.

I think the challenge is to look at the system on the totality of

the budget, not just firewall component parts and get all the pieces

at the table to include the VA, to talk about the care from end to

end. How do we leverage where the DOD spent money, for example, to pay the three of our organizations to build massive provider

networks to support the DOD’s direct care system when they have

to surge?

Why would the VA be buying with a different checkbook? Why

wouldn’t we size it together? Why wouldn’t we buy one way? Why

would we not only spend one check of the taxpayers’ rather than

two? And I think the examples of that go on and on.

And I think my hope is that the heat of Walter Reed and the fire

and the focus has all of us backing up together and asking the

kinds of hard questions that you all this morning have been asking

of all of us, those of us that contract, those of us that support in

that area, the VA, the DOD, and Congress coming together to talk

about what is the right way for us to do this for the next century,

not for the one we have been through.

Mr. TOUGH. If I can take a moment and add, agree with my colleagues. Again, I have 19 years of experience with this same contract. And I reflected back as Dave Baker and David McIntyre were

talking and said I can recall when the CHAMPUS reform initiative

contract was started in California and Hawaii. Letterman Naval

Hospital, Oakland, McClellan—those facilities aren’t there anymore.

So I think the key is really what is the basic floor of what is

needed for military readiness and to prepare the warfighters for

the military medical system for warfighting and combat. And I

think that is a question that needs to be solidified because, again,

we see a retraction of the system.

I would also agree with Dave McIntyre’s comment about joint

spending. God save me for using this term, but there is a need for,

you know, a common checkbook. We even see it a little bit in today’s contractors. There is the military health system activity, and

then there is the civilian health care spending.

And I think if we look more jointly as to that as being one common checkbook and how we would best manage those assets in

make, buy decisions, then we can decide exactly what we want to

purchase in the military health system and exactly what we want

to purchase in the external system and then configure those purchases in different kinds of ways. Dave has taken it a step further

51

in embracing the VA, which is yet but another dimension of government spending.

Mr. JONES. Thank you very much.

Thank you, Mr. Chairman, for that time.

Dr. SNYDER. I have to share this anecdote with you. But it was

some years ago prior to—I don’t know, seven years ago or something. And I, in my early fifties, came down with appendicitis when

I was here and was referred to Bethesda Naval Hospital.

And it was about 2:00 p.m. in the afternoon. And I am laying on

a stretcher looking at a bunch of people looking down on me. And

the surgeon who was going to do the surgery said, ‘‘We have a

slight delay on an operating room availability.’’ He said, ‘‘Let’s

spend that time talking about military medicine.’’ Now, that is lobbying. [Laughter.]

And I appreciate the discussion that is going on. I think it is an

important one. I think back to a friend of mine who maybe still is,

but was in the Army Reserve and had a solo private practice as a

family doctor and was mobilized during the first Gulf War and was

struggling, scrambling trying to find someone to cover his practice

and I don’t think he did.

And I think his life—I mean, he loved the military and loved the

participation. But it was a big, big hit on his family and his business, which was a solo medical practice because we can talk about

it is great to have these reserve medical people and we can surge

them when we need them, forgetting what is left behind. So that

was——

Mr. MCINTYRE. A lot of providers lost their practices during that

period.

Dr. SNYDER. Right.

Mr. MCINTYRE. I was on the Senate staff at the time. And it is

one of the reasons why the deployment cycles for doctors have

changed in the reserves.

Dr. SNYDER. Yes.

Mr. MCINTYRE. Was to reflect that burden.

Dr. SNYDER. I wanted to ask specifically, again, a brief question

for the three of you.

I think, Mr. McIntyre, you talked the most about the improvement that has been made specifically in obstetricians, which I appreciate. As you are looking ahead now rather than back, what do

you see as the needs that you are facing with regard to either numbers of providers or geographic areas with regard to providers or

specialty needs with regard to providers? Is there any gaps that

you see out there or issues that are facing you in the provider

issue? Shall we start with Mr. Tough just to——

Mr. MCINTYRE. Sure, go right ahead, yes.

Mr. TOUGH. Actually, certainly, in low-supply areas we are always going to have some difficulty in gaining access to providers

because providers in low-supply areas have choices that they may

wish to make. But in terms of gaps, we haven’t seen as many gaps

as early on in the program. And I think a lot of that has to do with

the fact that a lot of the other improvements that have occurred

in the relationships. The streamlining of the relationships has

helped.

52

We always have a concern regarding compensation. So that is

going to be—it is an on-going issue. And quite frankly, we live with

some concern that Medicare can change a reimbursement on us,

and then we are off running trying to figure out how to resolve relationships with providers.

I see the one that is coming downstream, the one that concerns

us the most has been talked about here earlier is in the mental

health arena. We have about 800 mental health providers, different

kinds of categories from physicians to psychologists to licensed clinical social workers. But I think to strike to the point, the current

circumstances of the war on terrorism has created some added

stress.

We are in an environment we haven’t seen in an awfully long period of time. And I don’t think some of the mental health issues

or the family issues are going to surface for a while, whether those

are child issues or spousal issues or other kinds of mental stresses

and strains that exist. And I think that is the one area that we

have the most concern.

We have some pocket areas, as you know. We talked a little bit

about the Fort Drum area. We have got a special effort that has

being undertaken with the Fort Drum regional health planning organization. And we are very dedicated and focused on that community in particular. We have done some gap analysis work with the

community.

It is one of the few communities, quite candidly, that I have seen

a totally engaged and embraced effort by the medical community,

the military system, and ourselves to try to find the best way of

meeting the needs of that military system up there as well as the

community at large. But we are, in fact, working on mental health

case workers to bring into that community specifically to respond

to the, we know, the on-going up and down pressures of deployment, redeployment.

Dr. SNYDER. Mr. Baker.

Well, let me ask a follow-up. You say you are bringing in mental

health. Who do they then work for?

Mr. TOUGH. They will actually be working—they are actually

contracting providers. We bring them in under contract and set

them up in clinical practice in the community to respond to the

need.

Dr. SNYDER. So it is essentially a full-time military family caseload?

Mr. TOUGH. Yes.

Dr. SNYDER. Yes.

Mr. Baker.

Mr. BAKER. Yes, sir. I would echo Dave’s comments. I think over

the years that we have done better in terms of networks and in

terms of those non-network providers who are participating. There

are pocket shortages in our region just as there are in the others.

But overall I think our coverage is pretty good.

The mental health issue that we have talked about today concerns me a great deal because I am not sure that we yet know

what the demand is going to be. We know it is increasing. We

know that we are not particularly rich in terms of mental health

53

providers as a Nation. And so, I worry about that, I would say, a

great deal.

The other piece, though, that I would also pass along is relevant

to the earlier discussion and the question that Congressman Jones

raised a moment ago about the on-going downsizing. That can have

a significant impact on the availability of care in a community. If

you think about it, the medical community in a civilian setting

flexes to the demand. And it flexes to the demand based on the

amount of care that is required for the civilian members of the

community, but also the amount of care that has been coming out

from the base.

Significant reductions in the capacity and capability of the military facilities can often put a stress on the availability of medical

care in a civilian community, whether it is a TRICARE beneficiary

or not a TRICARE beneficiary. And I worry about the impact of

what we are seeing long-term here, particularly where we have our

bases located today.

Dr. SNYDER. Mr. McIntyre.

Mr. MCINTYRE. I would like to associate myself, Mr. Chairman,

with my colleagues’ comments because I think they are right on.

We are all working at this as hard as we can. There was a year

a couple of cycles ago when we were all talking about dramatic concern around reimbursement rates. I stated at the time that I didn’t

think it was just rates. I thought it was about how we pay. It was

about making the system more effective for providers.

And at the end of the day, it is about——

Dr. SNYDER. We used to talk about it was low, slow and complicated.

Mr. MCINTYRE. That is exactly right.

Dr. SNYDER. And I think you all are taking care of slow and complicated, but we have still got low to deal with.

Mr. MCINTYRE. Yes, sir. That is right. And, you know, the challenge is it is the Federal budget. And I remember when I came to

Capitol Hill in the middle of the 1980’s, my father was an ophthalmologist. They were the first ones to go under the knife on Medicare provider cuts. And, man, I didn’t want to go home. In fact, he

wouldn’t pay for my tickets home when I was working as a young

staffer because he wanted to disown me.

I think we have made it complicated. Yet what we are doing is

we are demonstrating that it can work. And when you ease the

complication and you pay people quickly, it is money that they are

not having to subsidize out of their own pocket for already tight

rates. And I think all three of us and our staffs are told regularly

you are the fastest payer in the marketplace. That is a great thing.

They deserve that. And they deserve every piece of what we can

do.

We, too, have embedded mental health folks at our own dime

into certain areas because that is important. There is one item that

has not been covered that I think is one of the very complicated

things that members of the military family are facing. Particularly,

it has been spearheaded by the Marine Corps in terms of the focus.

You all have addressed this in the way of asking for some reports.

But that is the issue of autism.

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And I had the privilege of spending a day at Camp Pendleton a

few weeks ago with General Conway’s wife where we listened to

beneficiaries and their families talk about the challenges in autism.

And the thing I was struck by—and this is where our greatest challenge, I think, as an enterprise with your assistance, is going to be.

There is only one certified provider to care for autistic kids in all

of New Mexico. And it stretches from Florida with 3,800 providers

to California with 1,700 to Hawaii with 22 to New Mexico with one.

How do we address that?

And how is it that we take care of the challenge that is being

faced by these families when they rotate every couple of years

based on their time in the military and the role that they have and

they drop to the bottom of the state’s eligibility priority list and

they can never earn their way all the way back up that list before

they rotate again?

And I think there are some opportunities there to do some very

focused and specific work and something that I would hope would

be on your priority list as you are working through this legislative

cycle.

Dr. SNYDER. I think that report—Jeanette or David, you can correct me—I think the autism report is scheduled to come back to us

in April, is my recollection. I think that is right. And we will see

what that shows. It is an interest of mine. And there are so many

dynamics to it, as, you know, we are aware more and more how frequent the diagnosis is, about one in 94 boys now.

The intensive therapy seems to help substantially, but it is not

without cost. And then you think of our military families who are

dealing with a child, a special needs kid or kids—this can be more

than one child in a family. And then one of them is literally pulled

out of the household for a year or 16 or 18 months in a mobilization, which can happen both with the reserve component or active

component. And what the change in the family dynamic is. So it

is an important topic to this committee.

Mr. Wilson for five minutes.

Mr. WILSON. Thank you, Mr. Chairman.

Actually, I apologize. I was at another committee meeting. And

as the ranking member, I wanted to stay through the conclusion.

But I want to thank you for your service and providing services to

our veterans and current military.

And particularly, Mr. Baker, I am very pleased that PGBA–LLC

is in the district that I represent along with Blue Cross-Blue

Shield.

And they are, Mr. Chairman, extraordinary public minded companies that if anybody needs a sponsor for the 5K run, somehow

they get called upon and participate. And so, they promote health

in different ways.

And again, I am just happy to be here. Thank you for your service. And truly a way—I know you are doing a good job. And I think

this may apply to all of us is the number of complaints we get,

which are so few. And indeed, my late predecessor, the late Congressman Floyd Spence, was such a promoter and person supporting the development of TRICARE to really serve our military. And

thank you for bringing that to fulfillment.

I yield the balance of my time.

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Dr. SNYDER. Mr. Jones.

Mr. JONES. Mr. Chairman, thank you. And as you were talking

about mental health, I was looking at the paralyzed veterans. They

had supported the supplemental bill that was up last week. And

in their letter to Members of Congress, it was all about the funding

issue. And I am reading here very quickly of that total of the $1.7

billion total. Of that total, $100 million would go for contract mental health care for men and women returning from the war.

And, Mr. Baker, you and the other two gentlemen, I am sure,

would—I took from your comments—and maybe it is the other two

as well—that we know with the PTSD, the brain injuries that this

is something that is going to be hard to project. You can, through

your experts, determine that, yes, there are going to be a larger

number of men and women that are going to have these mental

health needs. But we don’t know exactly how many and how long.

You made the comment—and I wish you would all three pick up

on this—that as this need grows and expands over the next two or

three years—because if a man or woman—I will never forget a kid.

All of us go visit the hospitals. But I will never forget a kid from

New Mexico named Eric. Eric was in a wheelchair. His mother was

there from New Mexico. His little sister, about seven or eight, was

there with him. And the doctor—it was another Member of Congress. And I think it was Gene Taylor. I stand to be corrected.

But anyway, when we left the room, Eric could not speak. And

his mom kept saying, well, you know, these nice congressmen came

to visit you. And all he could do was move his finger that was on

his chest. And I will never forget the doctor when we walked out

said that Eric is going to need care. He was 26 years old. Eric will

probably need care for the next 45 or 50 years. And I realize that

is not quite the same as mental care, but it is a brain injury. So

it is related.

Where do you see—this is the question. Your comments, well, we

have got a problem because we need the medical experts, whether

they be psychiatrists or psychologists or doctors. Do you see that

pool is in a situation where we need to as a government, both state

and Federal Government, we need to encourage more young people

to look at that as a profession? Because where are we going to get

the providers if we don’t educate and get out in the field?

Mr. BAKER. Well, again, I appreciate the opportunity to offer an

opinion on that.

Mr. JONES. Sure. Right, certainly.

Mr. BAKER. But it is not very informed. And I need to be the first

to indicate that. But the truth of the matter is that I think we

probably do need to try to encourage people to go into those sorts

of professions. I believe the demand is going to increase. I think

that is one of the outgrowths of this conflict. And I am not sure

that we have the capacity to deal with that increased demand,

whether it is within the military health system or outside.

Mr. TOUGH. I would have to agree with Dave’s comments. I don’t

think we really have a full sense of what the magnitude of the patient load is likely to become.

I know that as a result of the efforts that are being undertaken

to manage the active-duty service members who may suffer from

traumatic brain injury we are in the process of doing a national

56

survey and search for every hospital that has the capacity to do

treatment for TBI and try to develop an inventory of those services

and a relationship with those contract facilities or those facilities

individually as well as providers who are well-schooled and trained

in TBI cases so that we can use them as advisers on cases that

may be of a difficult nature.

The beauty of a national program such as TRICARE is that we

have three contractors we can coordinate and communicate with regarding care across the country. And we recognize that there is

also an infrastructure of VA that also has similar types of support

mechanisms. There are four traumatic brain injury centers in the

VA.

So it is trying to look at the pool of the universe of what we can

access. But being quite candid, I don’t think we yet know what the

requirements are going to be for whatever is extended into the future.

Mr. MCINTYRE. The challenge in this area is obvious. The challenge is to figure out how much demand are you going to have. And

then do you build it or do you buy it or do you use a combination

thereof? In this environment in this city, the decision was made to

build it. That probably is the right decision.

In San Diego, as was referenced previously, the military and us

made the decision that while we wanted people to come closer to

home, the volume that was going to end up there probably did not

justify the full construction of everything to be resident on the Balboa campus.

And so, we searched the market in San Diego, which is very

medically robust, and brought two institutions to the market, to

the table that have specific expertise in brain injury, now, not blast

brain injury like what we are seeing in Iraq and Afghanistan, particularly in Iraq, but brain injury nonetheless that they could work

from.

I am struck—and I spend time like you all at these facilities from

time to time every couple of months just to keep me grounded in

why it is important to stay focused and what the needs are. I had

the chance about six weeks ago to spend time with the highest

ranking patient at Walter Reed. He is a reservist one-star general

from Florida. And he was the military attache ́ to the U.S. ambassador to Afghanistan.

And he was second in line behind a Humvee that blew over. And

he hit his head against the crossbar. This is a very, very smart

guy. I know his law partner in Florida personally. He is a medal

of honor recipient. And he was walking me through his journey of

the last 18 months in dealing with this.

And here is a judge, and, you know, very articulate, but struggling. And so, it is going to show up in a lot of different ways. And

I think the analogy of sports injuries is a good one. And you all are

putting focus in this area, which is to be applauded. All of us as

a society are going to learn about this going forward.

And the challenge is to be impatient about it, but also very focused and to be marshalling the resources that are available and

matching those with things that need to be constructed but to be

very careful to not build capacity where it may not be warranted

long-term or we are going to create an on-going expense that can’t

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be sustained to the degree that we are able to get out of this kind

of conflict in the near future.

Thank you.

Mr. JONES. Thank you, Mr. Chairman.

Dr. SNYDER. And we will continue to learn about this for 60 or

70 years as this generation of veterans ages and deals with these

impacts.

I think we are winding down here, gentlemen. But I had a few

more questions I wanted to ask.

When you all first picked up the newspaper when The Washington Post began running their stories on Walter Reed and then saw

the events that occurred over the next several weeks up until now,

what did you all and do you all see today as your responsibility in

dealing with this whole complicated issue of—I mean, obviously

you don’t have responsibility for mold at Walter Reed—but that

whole issue of the medical holdover care?

What did you all see as your responsibility or do you see as your

responsibility?

Mr. MCINTYRE. I believe that we have the responsibility to do

two things. One is as the partners of those that wear the uniform

and who lead organizations like Walter Reed—and they are all over

our regions of all different service types. And there are challenges

in many of them. How do we come to the table to bring our assets

and expertise to assisting them where there are gaps that we can

plug together? That is first.

Second, I believe strongly that the real challenge that came from

Walter Reed—and it was not the mold and the cockroaches and all

of that. It is the bureaucracy. And it is having patients and their

families fall into the trap of the bureaucracy. And how is it that

we streamline the focus to make sure that we are having the system serve the patient, not the system be a slave—or the patient be

a slave to the system?

And clearly, the focus that you all are putting in this area to look

at the medical boarding process and the like is very useful. The

plussing up, the care coordination is useful. I believe that we have

a responsibility to share in the work on care coordination. It is why

we are working on the pilot with the prototype with the Navy and

the Marine Corps right now in the West.

And it does come down to a resourcing question but also a make,

buy portion of that resourcing question. But it is solvable. And it

is going to take the kind of heat, in my opinion, having served on

the Senate side as a staffer for a while. It is going to take this kind

of heat to melt the bureaucracy in our programs in a direction that

is more responsive to the patients and their families.

Dr. SNYDER. Mr. Baker.

Mr. BAKER. Sir, I think we all do have a responsibility here. And

in terms of the steps that we took after the Walter Reed story

started to break, one of the first things we did was to reach out

to the commanders of the military facilities in our region, again, to

try to determine was there something that we could do to assist.

We felt like that was a key component.

The other thing, frankly, that we looked at was facility by facility

where did we have the opportunity to flex. That is, where did we

have networks that perhaps were too large as justified by the deVerDate 22-MAR-2001 12:00 Dec 01, 2008 Jkt 038314 PO 00000 Frm 00061 Fmt 6633 Sfmt 6633 C:\DOCS\110-45\086020.000 HAS2 PsN: HAS2
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mand, but also that those other facilities where perhaps our network was not as robust as it might have been and what could we

do to renew our efforts on the theory that if the commanders were

going to have pressure to process the troops through faster, that

could displace some care for non-active-duty folks down into the

network. So we felt like we had to do that.

The third thing we looked at was, again, to make an offer under

the terms of our contract. Are there services that you need that we

could bring into your particular military facility? Under a program

in this contract that we collectively, I think, all refer to as optimization—is there something we could do there? Is there a nurse or

a technician or something that you need that we could help you acquire? So I think across those domains those were the kinds of activities that we engaged in.

Dr. SNYDER. Mr. Tough, anything to add?

Mr. TOUGH. Yes, I think this is uniformly the same approach we

all took, was that we are partners with the military health systems, counterparts. And when the need arose, we immediately tried

to jump in and assist them and how we could best support them.

Clearly, the majority of the care is in the direct care system. But

when that care is in need of being outsourced to the civilian sector,

we need to make sure it is a seamless transition and to make sure

that we have solid case management support between that case

that has been transferred from within a military treatment facility

to the civilian sector.

Dr. SNYDER. If I might ask you all—and, in fact, we will go down

the line. Because it was General Pollock, I think, that she and I

had a brief exchange about she was—I don’t know if the word was

critical, but concerned about that she couldn’t follow quality control

so much with services that were contracted in the private sector.

Do you remember that comment?

Mr. TOUGH. Correct.

Dr. SNYDER. I think this is what you are getting at here. Would

you comment on what she said, please, about that?

Mr. TOUGH. Well, exactly. What she was trying to get at is that

when we do get into that transfer of care into the civilian sector,

we are going to have to have a mechanism to get that information

back into a centralized point of control.

And I think that is now being more actively worked as a result

of the Walter Reed experience, I think, more clearly today than

probably ever before because a centralized point of control is now

evolving within the Walter Reed and certainly other military treatment facilities. So it is that information flow back and forth.

We recognize, too, that sometimes in the nature of the care we

are asked to get engaged in some of that might be very short-term

in nature. It could be as simple as an out-patient visit or a shortterm burst. But it could be longer term in nature. It could be a case

managed activity that is in a civilian facility for a longer period of

time. So it is important that we have that ability to communicate

those case records back into the system.

The difficulty we are challenged with and faced with right now

is that is not electronic. It is going to be paper. So one of the things

we are going to have to work and overcome—but again, we are also

involved in other kinds of activities similar to what Dave Baker

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just mentioned. We have been asked to do some case manager

training as they begin to ramp up their case managers within the

system.

We have also stepped forward and indicated we would be willing

to help recruit those case managers. We would even deploy some

of our staff. We have several of our personnel that work for us that

actually came out of the Walter Reed facility. And we told them we

would be happy to just deploy them back into the system because

they are well-familiar with the Walter Reed’s needs, put them back

on the ground, and they could use them in any ways they wished.

I think the challenge, quite frankly, that remains is when you

get into the civilian sector—and this may be true for the activeduty side as well—is the beneficiary is going to move down a continuum of coverage. They are going to move from TRICARE. They

might move to VA. And they might even move to Medicare.

And so, we have to make sure that that process is as seamless

as possible because there are going to be differences in the way

that care is managed. There might be pass points that need to be

thoroughly flushed out. And there might be differences in scope of

coverage. So we have to make sure that that becomes a fairly clear

and clean process.

Our takeaway of all of this is that we really have to understand

that when there is an active-duty service member that ends up in

our hands or at any point that they need somebody’s hand to hold.

That is the primary issue. And we actually should treat this as

both a concierge service, that we really have to care—take the ultimate in care management to that active-duty service member.

Mr. MCINTYRE. That is the very reason why in our region we

have done what we have done with the Marines and the Navy, is

to get all three legs of the stool under the chair. And that is the

VA, the DOD, and downtown. And it is this seamless handoff issue

that is critical.

It is important to look at the needs of the patient through that

entire cycle and do it together. And it is important to make sure

that if we are going to place someone downtown like a reservist

that was at 29 Palms whose family was in Colorado who could be

placed in Colorado for a while to convalesce and then potentially

come back into the reserves that the only way to manage that well

is to make sure that all three of those domains are focused on that

individual as they morph in and out of the different systems getting what they need. And this notion of surge capacity is very, very

important.

This is where we are going to struggle, in my opinion, because

it is not——

Dr. SNYDER. With the surge capacity?

Mr. MCINTYRE. Well, potentially the surge capacity because it is

not natural for people to say well, maybe I should buy it versus

build it. That is the first thing. That happens in our own organizations. It happens everyplace.

The second thing, I think, where we are going to struggle systemically is this notion of really making sure that all the parties

are at the table at the same time because there is this natural inclination that I own this, I want to make sure that it is delivered

the right way. The challenge is, if you go back to medical hold of

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a couple of years ago growing out of Georgia, you can’t hire case

managers or move them off a ward and have them take care of TBI

and know what to do the next day.

They flat out can’t get there. It is a very, very specialized niche.

And that is where it is important to draw from the assets that are

available as we continue to share information and train each other

in how to optimally manage these patients.

Dr. SNYDER. Which is why, as we are closing down here, Mr.

McIntyre, I disagree a little bit. I don’t use the term. I don’t say

that I think the problem at Walter Reed is a bureaucracy problem.

That implies that somehow the laws are perfect and the people

that are there—it just kind of gets lost in the maze.

I think if we don’t have adequate numbers of people with adequate training with well-understood expectations of what the laws

are, I don’t think it is fair to call that a bureaucracy problem. I

mean, it is a maze. But I think that may not recognize the real

cause of the problem. We as an institution may be the cause of the

problem if we have disability laws that are really hard to navigate

through.

I have one final question. I think it is probably just a yes or no

to you, Mr. Tough. In your written statement, you say that 95 percent of the calls to your hotline are answered within 30 seconds.

Is that a real person that answers them?

Mr. TOUGH. Yes.

Dr. SNYDER. Thank you very much.

Mr. Wilson, do you have further questions?

Mr. WILSON. No, Mr. Chairman.

Dr. SNYDER. Mr. Jones, do you have any further questions?

Mr. JONES. Mr. Chairman, I just want to thank this panel and

the first panel. This has been very, very helpful and educational to

me.

Mr. Chairman, I want to thank you as well.

This is an issue that you have all articulated extremely well. It

is with us. It is in front of us.

And, Mr. McIntyre, I will use your term. Hopefully we will encourage the common checkbook, one check, I hope.

Dr. SNYDER. Mr. McIntyre, Mr. Baker and Mr. Tough, we appreciate you being here.

The committee is adjourned.

[Whereupon, at 12:21 p.m., the subcommittee was adjourned.]

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QUESTIONS AND ANSWERS SUBMITTED FOR THE

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QUESTIONS SUBMITTED BY DR. SNYDER

Dr. SNYDER. General Pollock and Admiral Arthur and General Roudebush, the article that Ms. Davis called to my attention last week is from the New York Times

Magazine March 18, 2007, ‘‘The Women’s War’’ by Sara Corbett.

I have no expectation that you all read everything that is in the press out there

about men and women at war and their families. But if you would respond for the

record to this.

General POLLOCK. Sara Corbett’s Article ‘‘The Women’s War’’ published in The

New York Times Sunday Magazine 18 March 2007 is a thoughtful, balanced, and

detailed examination of unique problems facing some service women today. The Iraq

war has seen unprecedented numbers of female Soldiers serving with many Combat

Service and Service Support units. As the article highlights, both the military and

Department of Veterans Affairs are devoting increasing attention to the unique

problems of female service members. More attention needs to be given to studying

the effects of combat on our female warriors. The development of effective treatment

programs tailored to women should be a priority for our military Behavioral Health

community.

The Army takes the issues of Sexual Harassment and Sexual Abuse very seriously

and has set up an extensive program to encourage victims of harassment or sexual

assault to seek help. The Army’s Sexual Assault Prevention and Response Program

(SAPR) provides confidential victim advocates who diligently work with victims to

provide them with treatment resources and support. Annual training on the SAPR

is required for all military personnel. A detailed explanation of the Army program

can be found at: http://www.sexualassault.army.mil/.

In regard to the noted increase in reporting since the initiation of the SAPR program, we feel this is a positive development. It has long been understood that when

one pays attention to a problem by encouraging reporting and offering protection to

those who report, the rates of reporting will rise. This increase therefore likely reflects victims who previously did not report, rather than an actual increase in assaults. While no one believes we are reaching 100% of the victims of sexual assault,

early intervention and the support of victim advocates are helping many women recover.

On the issue of PTSD, there has long been demonstrated a significant gender difference in willingness to seek help between males and females, with female personnel more open to doing so. Our data from the Mental Health Advisory Team studies

do not show any gender difference, but more research needs to be done.

The Department of Defense is currently engaged in unprecedented efforts to find

and help service members adversely affected by their deployment experiences. The

Post-Deployment Health Assessment given immediately upon re-deployment and the

Post-Deployment Health Reassessment, given 90–180 days after re-deployment

bring soldiers into direct contact with Behavioral Health personnel and give them

the opportunity to obtain immediate assistance. Additionally the physical examination process has been revised to a Periodic Health Assessment, which also looks for

evidence of depression, anxiety or substance abuse. Although more can and needs

to be done in this area, the Army is aware of the challenges faced by both male

and female Soldiers and is doing everything possible to ensure their needs are met.

Dr. SNYDER. General Pollock and Admiral Arthur and General Roudebush, the article that Ms. Davis called to my attention last week is from the New York Times

Magazine March 18, 2007, ‘‘The Women’s War’’ by Sara Corbett.

I have no expectation that you all read everything that is in the press out there

about men and women at war and their families. But if you would respond for the

record to this.

Admiral ARTHUR. In reference to the article titled ‘‘The Women’s War’’, the following comments are provided on Navy Medicine’s efforts for providing medical care for

the physical and psychological sequelae of women serving in the Navy and Marine

Corps as a result of combat experience.

Navy Medicine seeks to proactively address the broad range of combat and operational stress injuries, to include PTSD, in a number of ways. In November 2006,

Navy Medicine established a directorate at the Bureau of Medicine and Surgery led

210

by an experienced combat stress psychiatrist specifically dedicated to addressing

mental health stigma, combat stress training needs, non-stigmatizing care of returning deployers, and support services for Navy caregivers. Other efforts include prevention, outreach, and early intervention to warfighters using Navy mental health

providers trained in clinical best-practices related to combat and operational stress

control. One specific example is Operational Stress Control and Readiness teams

providing early intervention, outreach, and prevention at the unit levels in close

proximity to operational missions in order to reduce stigma that can be encountered

in conventional mental health care settings.

Navy Medicine plans to utilize existing data sets to study combat stress and gender. Naval Health Research Center’s Millennium Cohort Study is addressing a variety of combat-related behaviors in both men and women. Additionally, the first

phase of the Navy’s in-theater Behavioral Health Needs Assessment (BHNAS) is

complete, and analysis of gender differences associated with deployment stress is

currently underway.

Service Members returning from deployment are screened using the Post Deployment Health Assessment (PDHA–DD Form 2796). A review of 261,008 PDHA forms

completed from January 2003 to present demonstrate that 2.2% of male Marines

and Sailors were referred for mental health services, compared to 2.6% of returning

female Marines and Sailors (Defense Medical Surveillance System, 19 June 2007).

Researchers from Walter Reed Army Institute of Research (Hoge et. al., 2007)

have reviewed recent studies of military personnel with service in Iraq and Afghanistan, and reported that ‘‘military duty in Iraq confers a similar risk of [Post Traumatic Stress Disorder] and depression by gender.’’ The authors suggest that risk for

developing significant combat stress disorders is a factor of intensity and frequency

of combat exposure, rather than gender (Hoge CW, Clark JC, Castro CA. Commentary: Women in combat and the risk of post-traumatic stress disorder and depression. International Journal of Epidemiology 2007).

The issue of compassion fatigue among Navy Medicine personnel is also of significant interest. Navy Medicine has established a Care for the Caregiver mandate in

order to address this concern. Assessment of operational and occupational stress of

medical personnel, to include focus groups, will begin in summer 2007.

Dr. SNYDER. General Pollock and Admiral Arthur and General Roudebush, the article that Ms. Davis called to my attention last week is from the New York Times

Magazine March 18, 2007, ‘‘The Women’s War’’ by Sara Corbett.

I have no expectation that you all read everything that is in the press out there

about men and women at war and their families. But if you would respond for the

record to this.

General ROUDEBUSH. The Air Force is concerned about all Airmen with traumarelated mental health problems, regardless of gender. We have procedures to guide

base helping agencies as they assist Airmen who are transitioning back to their

home station from deployment. These procedures include education on the recognition of PTSD signs and symptoms and where to go for help. Upon redeployment and

then 3 to 6 months later, we ask Airmen to complete a survey describing their current health status. This survey includes questions about PTSD; when Airmen screen

positive, they are referred to their primary care provider for further evaluation and,

if indicated, onto a mental health specialist. Ms. Corbett makes note of Dr. Edna

Foa’s Prolonged Exposure Therapy for the treatment of PTSD. I am pleased to tell

you that the Air Force brought Dr. Foa to a number of our bases to train mental

health professionals in her evidence-based treatment. To date, she has trained 100

mental health professionals. We are working with her currently to have her provide

training to an additional 300 professionals. We are also working with Dr. Patricia

Resick, another one of our nation’s top PTSD clinician/researchers. Dr. Resick will

be providing training in her Cognitive Processing Therapy, the other main evidencebased treatment for PTSD.

Dr. SNYDER. My final question is the bill that passed out of the full Armed Services Committee last week and will be on the floor this week that will be called the

Wounded Warriors Bill. Have any of you had a chance to look at it and have any

thoughts or criticisms about it. Would you share that with us today?

General POLLOCK. I’d like to thank the Congress for its commitment to care for

our warriors in transition, as demonstrated by the wounded warrior legislation recently passed by the House. The attention of Congress at the strategic level and as

an oversight body will help ensure that the Department addresses concerns regarding outpatient care and the Physical Disability Evaluation System with the right

level of attention, enthusiasm, and resources. My major comment regarding your

legislation relates to timing and specificity. The Army is moving forward very quickly to correct deficiencies and improve processes. There are currently a number of

efforts and investigations underway within the Army, the DoD, and the executive

211

branch that will provide us with findings and recommendations to move forward.

Legislating solutions now, before the commissions and reviews are completed, would

be premature. We are in the process of developing a supporting infrastructure for

our wounded warriors and would prefer to determine how all the pieces fit together

before pursuing specific ratios. Furthermore, I am not comfortable with the thought

that one solution suits the entire military health system. Depending on supporting

structure, case complexity, and a variety of other factors, staffing ratios must remain flexible. We understand your interest in appropriate access and availability to

case managers, physical evaluation board liaison officers (PEBLOs), and advocates.

I would suggest establishing a reporting requirement so the Department can regularly update Congress on existing ratios and practices.

I would also like to comment concerning the provision for congressional notification. I believe that Members of Congress should be notified when a Soldier-constituent is evacuated from a combat theater to a hospital in the United States. The majority of evacuations out of theater, however, do not result in hospitalizations in the

U.S. Many are returned to duty within a matter of days. I do not believe it is the

intent of Congress to track these Soldiers. In addition, congressional notifications

should be limited to those members of Congress who represent the district or state

that includes the Soldier’s home of record.

Dr. SNYDER. MG Pollock stated that she has asked the Department of the Army

to re-look the efficiency edge figures for FY 2008–09. What is the status of this reevaluation?

General POLLOCK. A decision was made on 19 June 2007 by the Under secretary

of Defense, Personnel and Readiness, to establish a study group to re-evaluate the

efficiency wedges. We look forward to participating in this re-evaluation.

Dr. SNYDER. MG Pollock agreed to provide written answers on the current status

(process and numbers) of the Army’s military to civilian conversions.

General POLLOCK. The initial analysis to select military billets for conversion considered availability of skill sets in the local market, projected costs, and historical

fill rates. Billets linked to operational readiness were not targeted. The Army has

certified to Congress that 1,504 of the 1,669 military-to-civilian conversions programmed for FY06 and FY07 will not increase cost or reduce access to care or quality of care. Of the 165 positions not certified for conversion, 52 were determined to

be hard to fill. The Army is currently re-evaluating its strategy on medical militaryto-civilian conversions and does not want to stop conversions when it makes sense

due to operational demands, cost or level of care. During execution of programmed

medical conversions, some hiring actions took longer than expected due to shifts in

the health care market. Inability to backfill converted military billets in a timely

manner with equally qualified civilian health care workers could impact mission capability. Therefore, we are reassessing our plans and program for medical militaryto-civilian conversions. Military-to-civilian conversions play a key role in increasing

Army operational capabilities. Backfilling medical positions in the Institutional

Army with civilians and realigning military positions to the operational Army helps

reduce stress on the force.

ARMY MEDICAL DEPARTMENT (AMEDD)

MILITARY TO CIVILIAN CONVERSIONS

(CUMULATIVE)

FY06 FY07 FY08

AMEDD Officers 127 191 224

AMEDD Warrant Officers 4 8 15

AMEDD Enlisted 498 978 1210

AMEDD TOTAL 629 1177 1449

Non-AMEDD Officers 3 3 12

Non-AMEDD Warrant Officers 6 6 7

Non-AMEDD Enlisted 430 483 774

Non-AMEDD TOTAL 439 492 793

Total Programmed Conversions 1068 1669 2242

Total Certified Conversions 1068 1504

QUESTIONS SUBMITTED BY MR. MCHUGH

Mr. MCHUGH. Since the widely publicized problems at Walter Reed Army Medical

Center, there has been much discussion on the MEB/PEB system. For several years

212

this committee has heard complaints about the timeliness and accuracy of both systems. I understand that only the MEB system is under the control of the Service

medical departments. Please tell us what steps you have taken to ensure that the

documents that are considered by the Medical Evaluation Board are complete and

accurate. What mechanisms are in place for ensuring that a service member has

gained the maximum medical benefit from the treatment provided before they are

referred to the MEB?

General POLLOCK. Due to past complaints about the Physical Disability Evaluation System (PDES), several steps have been taken to ensure quality control and

consistency of process, while still taking into account the requirements to respond

to the individual Soldier’s needs as well as the needs of the Army. The newly implemented ‘‘triad’’ of patient care: the primary care physician, the nurse case manager

and the squad leader, are all to be involved in the determination of when maximum

medical benefit is achieved. As a check/confirmation of this, as Soldiers enter the

MEB process, they are each given a comprehensive physical exam. The purpose of

this exam is to ensure that each and every condition the Soldier is adequately addressed prior to submitting his/her MEB to the PEB. One of the outcomes of this

comprehensive physical may be additional consults to other specialties. Ideally, once

initiated, an MEB should be processed efficiently and with care and compassion for

the Soldier. However, every Soldier’s case is unique and there are instances where

the MEB process is actually stopped to provide additional treatment and/or surgery

if deemed medically necessary.

As discussed above, additional dedicated medical resources (such as dedicated

MEB physicians) have been and are in the process of being hired/assigned throughout the Army Medical Department to process MEBs and assist Soldiers in their

healing and recovery. These dedicated personnel have received training on the evaluation and processing of Soldiers undergoing the physical disability evaluation process. We have enforced a corporate understanding of the process through standardization of MEB Physical Evaluation Board Liaison Officer (PEBLO) and physician

training requirements.

In May 2007 a Worldwide PEBLO Conference was held, where physicians and

counselors participated in dedicated training tracks, problem-solving breakout sessions and certification testing. There is a dedicated website repository, available for

counselors and physicians to utilize as a resource for additional information. An

Army Medical Action Plan (AMAP) was developed by Army agencies/activities involved in the PDES process to implement and execute new business practices as it

pertains to clinical and administrative quality improvements.

To summarize, the PDES is designed with a number of checks and balances in

place to ensure adequate due process. The senior clinical physician in the hospital

is the local deciding authority for appeals to the MEB and any questions regarding

maximum medical benefit. Soldiers also have the ability to appeal their MEB findings. Based on their appeal, the MEB can stand as written, be sent back to health

care provider for further information, or be forwarded to the PEB with attachments

or additional notes. Finally, the regional PEBs have the discretion to reject the MEB

if they feel it is not complete and the Soldier has not reached optimal medical benefit.

Mr. MCHUGH. Since the widely publicized problems at Walter Reed Army Medical

Center, there has been much discussion on the MEB/PEB system. For several years

this committee has heard complaints about the timeliness and accuracy of both systems. I understand that only the MEB system is under the control of the Service

medical departments. Please tell us what steps you have taken to ensure that the

documents that are considered by the Medical Evaluation Board are complete and

accurate. What mechanisms are in place for ensuring that a service member has

gained the maximum medical benefit from the treatment provided before they are

referred to the MEB?

Admiral ARTHUR.

Steps to Ensure Complete and Accurate Documentation

Accurate and timely submission of the Medical Evaluation Board Record (MEBR)

to the Physical Evaluation Board (PEB) is a critical component of caring for the ill

and injured sailors and Marines who have volunteered to serve their country. Steps

to ensure that the documentation that is presented to the PEB is complete and accurate include the provision of thorough policy guidance, training, documentation review and program oversight.

Policy Guidance: Detailed guidance about documentation required in a medical

board package is outlined in ManMed Chapter 18–12 through 18–16, including templates for a complete medical evaluation board report and non-medical assessment.

This guidance was last updated in January of 2005, includes PEB policy guidance

213

contained in SECNAVINST 1850.4E, and has subsequently been reviewed to ensure

that it continues to provide proper instruction on the scope and content of information required by the PEB.

Training: Navy Medicine has recently combined the Annual Patient Administration Conference with the Annual Physical Evaluation Board Liaison Officer Conference to ensure maximum participation and interaction between DON PEB Staff,

BUMED staff, Patient Administration Officers and PEBLOs. This interactive conference serves as an opportunity to ensure proper training of administrative staff

and counselors as well as to identify problems, and solutions, with all stake holders

at one location. Patient Administration Officers receive additional training at the

Quarterly Patient Administration Courses. Clinicians involved in the dictation of

MEBRs or who serve on the Medical Evaluation Board receive training prior to assuming this responsibility and periodically throughout their career. The DON PEB

provides training to clinicians and administrative staff upon request as well as during site visits to Military Treatment Facilities.

Documentation Review: The Convening Authority (the hospital’s Commanding Officer) along with the involved service member has ultimate responsibility to ensure

the accuracy and quality of the MEBR prior to sending it to the PEB. A minimum

of two physicians trained in the MEB process will review the MEBR for accuracy

and completeness. The Patient Administration staff reviews all documentation of

the MEBR for completeness prior to presenting it to the Convening Authority for

signature. The MEBR package presented to the service member for review must be

complete, including all medical documentation, non-medical assessments and line of

duty determinations that are to be submitted to the PEB. The service member has

5 days to review the MEBR and either sign it for submission as a complete package

or provide a rebuttal. If they submit a rebuttal they can submit additional documentation that they feel should be included for the PEB’s review.

Program Oversight: MedBOLT (Medical Board Online Tracking) is the database

used by Navy Medicine to track efficacy in executing the MEB process. All parts

of the MEB process can be tracked in this system to assist in ensuring completeness

and timeliness of submission. The system also allows communication of historical

MEB data across MTFs allowing for a complete and accurate picture of the individual’s history. MedBOLT has technical safeguards in place that alert the user to ensure all necessary forms and supporting documentation are complete prior to submission to the PEB. The Patient Administration Officer is responsible for running

periodic reports to ensure timely progress through the MEB process. Additionally,

Navy Medicine Inspector General (MEDIG) performs reviews the MEB process during their periodic MTF inspections.

Mechanisms to Ensure Maximum Medical Benefit Prior to referral to MEB

The timing of referral to the PEB must be individualized for each service member

to ensure maximum benefit to the patient. For instance, there are circumstances in

which referral of the service member to the PEB early into medical treatment may

be in the best interests of the member, as it could maximize the delivery of disability benefits and compensation. Examples of cases in which the member may desire

early referral are very severely injured members whose disabling condition makes

them ratable by the VA at 100%. Those members would be eligible for financial benefits not otherwise available while they are still in an active duty status. DoN ran

a pilot program in conjunction with the VA last year, with a small sampling of eligible members to determine the best processes and develop procedures to streamline

benefits delivery. There are other circumstances when it is in the best interest of

the service member to defer referral to the PEB until the patient has reached maximum medical benefit and the condition is stable. Policy outlined in ManMed Chapter 18 allows for this provision. When a service member has a medical condition

that limits their ability to fully perform their job and the condition is expected to

persist for over 90 days, they are to be placed in a Limited Duty Status (LIMDU).

While each period of LIMDU is for no more than 6 months, subsequent periods of

LIMDU are authorized if the medical condition is not stable or maximum medical

benefit has not been reached to make a determination of fitness for continued service/disability. The policy outlines procedures for requesting Service Headquarters

approval of subsequent LIMDU to ensure that members do not linger in this status.

However, if the clinician caring for the patient outlines reasons for continuation of

LIMDU, including need for ongoing care prior to referral to the PEB, Service Headquarters can grant extended LIMDU until the condition is stable or maximum medical benefit has been achieved. Moreover, the PEB applies a separate assessment of

completeness and clinical appropriateness upon receipt of an MEBR and does not

hesitate to seek further documentation with respect to a variety of issues including

diagnostic and treatment status as indicated from the referring MTF.

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Mr. MCHUGH. Since the widely publicized problems at Walter Reed Army Medical

Center, there has been much discussion on the MEB/PEB system. For several years

this committee has heard complaints about the timeliness and accuracy of both systems. I understand that only the MEB system is under the control of the Service

medical departments. Please tell us what steps you have taken to ensure that the

documents that are considered by the Medical Evaluation Board are complete and

accurate. What mechanisms are in place for ensuring that a service member has

gained the maximum medical benefit from the treatment provided before they are

referred to the MEB?

General ROUDEBUSH. In the AF, a service member’s physician will start an MEB

when the physician feels the member has obtained optimum benefit from treatment

(in compliance with DODI 1332.38, paragraph E2.1.22). Once the physician feels

there is enough information to determine the member’s ability to return to duty, the

physician submits a narrative medical summary to the MEB clerk. The AF requires

three physicians to review each MEB package. If there is a psychiatric diagnosis

(e.g. PTSD), a psychiatrist must be one of the three MEB physicians. If the physicians feel a member has not yet obtained optimum benefit, they can recommend additional treatment for the member. Additional medical specialty evaluations may be

requested if the physicians are unsure about the member’s fitness for duty. Once

a MEB recommendation has been made, the senior MTF physician (SGH) reviews

the case to provide senior clinical oversight. Additionally, the PEB Liaison Officer

(PEBLO), while not typically a medical clinician, may also provide advice to the

physicians based on the PEBLO’s past experience with similar MEB cases. Every

attempt is made to tailor the process to meet the individual patient’s needs.

Mr. MCHUGH. Recent emphasis on traumatic brain injury suffered by service

members in Iraq and Afghanistan has raised the awareness of Congress and the

American public to this often deceptive medical condition. What mechanisms does

each of you have in place to identify TBI in redeploying service members, including

those who are not obviously wounded or injured? How are military health providers

distinguishing TBI from other mental health conditions, such as PTSD? What additional resources do you need to identify and treat TBI?

General POLLOCK. We recently modified the Periodic Health Assessment (PHA)

screening questions to include TBI specific questions. The PHA screen will be fully

functional in July. If a Soldier answers ‘‘yes’’ to a potential traumatic brain injury

event like a fall, a motor vehicle accident, or being near an explosion, then an additional more detailed questionnaire will open and be reviewed by a clinician. This

tool will be used to ‘‘catch up’’ the entire Army by screening for TBI at the time

of an annual health assessment. In addition, we will be using the recently revised

Post Deployment Health Assessment (PDHA) (DD Form 2796) and Post Deployment

Health Reassessment (PDHRA) DD Form 2900) as specified by Health Affairs.

These revised forms include several TBI screening questions that have been recommended by the Defense Veterans Brain Injury Center (DVBIC) and other subject

matter experts. Concurrently, we are compulsively performing TBI screening for Soldiers in theater following blast exposure even when no other wounds or injuries

have occurred. We published an ALARACT, ‘‘Documenting Blast Exposure/Injury in

Theater Medical Records’’ (15 June 2007) requiring documentation of exposure in

the electronic health record (AHLTA–T), mandating specific International Classification of Disease (ICD–9) codes, and requiring the use of the Military Acute Concussion Evaluation (MACE) template.

This Blast ALARACT builds on the increased awareness and improved identification of Soldiers with potential TBI from the ALARACT published 27 July 2006,

‘‘Concussion in Soldiers on the Battlefield’’. The Concussion ALARACT delineated

the signs and symptoms of concussion and provided guidelines for Commanders and

staff to determine when to refer Soldiers for medical evaluation. In addition, we

have recently initiated pre-deployment baseline neurocognitive testing of several deploying units, including the 101 st Airborne Division and the 1st Armor Division. We

are using the Automated Neuropsychological Assessment Metrics (ANAM) TBI Battery as the instrument of choice at this point in time as the ANAM has military

norms based on over 9000 Soldiers from Fort Bragg for comparison in the assessment of the Soldier’s neurocognitive performance. We have established a process to

test large groups of soldiers; transmit and store the baseline test results and subsequent test results on a central server; allow providers in theater and in fixed facilities to access the baseline data remotely and generate a results report; and conduct

post-deployment testing. The ANAM output report is designed to meet the needs of

primary care providers and will be included in the Soldier’s electronic medical

record. We are following the DVBIC Clinical Practice Guidelines for theater, specifically using the Military Acute Concussion Evaluation (MACE) immediately after an

exposure or injury and using the ANAM if the Soldier is still symptomatic 24 hours

215

after the injury. Providers at all levels can administer the ANAM to get an objective

assessment of cognitive functioning and performance to use in the overall evaluation

of a Soldier’s condition and to track the Soldier’s recovery. In conjunction with the

pre-deployment testing, we are providing TBI assessment and management training

for providers as well as offering Neurology and Neuropsychology teleconsultation for

providers seeking advice and assistance through the DVBIC. The demand for ANAM

pre-deployment, post-injury, and post-deployment testing from both the medical unit

and line Commanders is growing dramatically. All Service members medically evacuated through LRMC are also screened for TBI using the MACE if their condition

permits. Since medically evacuated Soldiers may not receive a Post Deployment

Health Assessment (PDHA) prior to departing the combat theater or they may not

be in a condition to be screened for TBI at LRMC, I have directed Medical Treatment Facility (MTF) Commanders to ensure that all OIF/OEF medically-evacuated

Soldiers receive or have received the following three evaluations: (1) the PDHA; (2)

TBI screening and follow-up with a clinician if necessary, and (3) the Post Deployment Health Reassessment (PDHRA).

Traumatic brain injury is a neurologic injury with possible physical, cognitive, behavioral, and emotional symptoms. Like all injuries, TBI is most appropriately and

accurately diagnosed as soon as possible after the injury. TBI is not a mental health

condition. The range of TBI includes mild, moderate, severe, and penetrating. Well

after the injury event, if the TBI was of mild severity and if the symptoms are primarily behavioral and emotional, the co-existence of or distinction from PTSD can

be difficult to discern. Certainly some Soldiers have both residual symptoms from

a TBI and new or emerging PTSD symptoms. If proper injury documentation is not

available, a compassionately obtained description of the traumatic events in theater

usually allows a well-trained clinician to make a distinction between TBI and PTSD

or other mental health conditions. We are committed to the earliest identification

and documentation of TBI. We provide education for our providers prior to deployment and while in theater. We are implementing a mandatory standardized webbased TBI training program for all health care professionals to include clinical support personnel.

Mr. MCHUGH. Recent emphasis on traumatic brain injury suffered by service

members in Iraq and Afghanistan has raised the awareness of Congress and the

American public to this often deceptive medical condition. What mechanisms does

each of you have in place to identify TBI in redeploying service members, including

those who are not obviously wounded or injured? How are military health providers

distinguishing TBI from other mental health conditions, such as PTSD? What additional resources do you need to identify and treat TBI?

Admiral ARTHUR. As military spokesperson for consolidation of Traumatic Brain

Injury (TBI) initiatives in the DOD and DVA, I am gravely concerned about our

ability to diagnose and treat TBI, particularly the mild to moderate forms of TBI

that may not be immediately apparent on initial examination. TBI in personnel who

are exposed to a blast but do not suffer other demonstrable physical injuries is particularly difficult to detect. Redeploying servicemembers who have suffered such injuries may later manifest symptoms that do not seem to have a readily identifiable

cause, with potential negative effect on their military careers. As many as 20% of

injured servicemembers may have TBI as an additional diagnosis.

Navy Medicine uses a validated clinical assessment tool, the Military Acute Concussion Evaluation (MACE), in field settings to detect neuropsychological sequelae

to blast exposure. MACE is used in assessing all concussion type injuries, including

blast. Our standardized Emergency Treatment Record, that is a part of the Joint

Trauma Registry, also has a series of screening questions about blast exposure and

concussion symptoms. In October 2006, we deployed field devices at Navy Medicine

Echelon II trauma facilities for neurotologic auditory-vestibular evaluation. We are

actively pursuing full roll-out of a field tested computerized assessment, the Automated Neuropsychological Assessment, which can be administered via a hand-held

device. In spite of these advances, much needs to be done to ensure that screening

is comprehensive and accurate.

TBI often exists in the context of polytrauma, including psychological trauma, and

its symptoms may overlap with those of behavioral disorders or diagnoses, such as

Post Traumatic Stress Disorder (PTSD). Although PTSD is a less common problem

than other psychological disorders such as depression or anxiety, it is a significant

concern in our population. We screen all redeploying servicemembers for symptoms

of combat stress on our Post Deployment Health Assessment/Reassessment devices.

Those whose responses suggest some distress are referred for full evaluation. All returning combatants treated in our military treatment facilities receive a psychological evaluation to detect for comorbid symptoms of emotional disorders in conjunction with other injuries.

216

We urgently require research to better understand the etiology of TBI resulting

from blast, as evidence suggests the resulting symptoms differ from those resulting

from TBI from other injuries. We must examine universal pre-screening to assess

for baseline levels of cognitive function. Clinically usable, hand-held computerized

devices will also require significant test and development. On the treatment side,

we have identified needs across all echelons of care, from enhanced recognition at

the point of injury through definitive rehabilitative care. We have significant gaps

in care when critically short critical specialty providers are required and we lack

the capability to provide for a continuum of care for servicemembers and their families in all locations.

Mr. MCHUGH. Recent emphasis on traumatic brain injury suffered by service

members in Iraq and Afghanistan has raised the awareness of Congress and the

American public to this often deceptive medical condition. What mechanisms does

each of you have in place to identify TBI in redeploying service members, including

those who are not obviously wounded or injured? How are military health providers

distinguishing TBI from other mental health conditions, such as PTSD? What additional resources do you need to identify and treat TBI?

General ROUDEBUSH. Screening patients for TBI can be challenging, especially

when not accompanied by obvious physical injury. Airmen with moderate, severe,

or penetrating brain injury are readily identified, entered into the Defense Veterans

Brain Injury Center (DVBIC) registry, and treated according to established protocols. All service members aeromedically evacuated from theater are screened for TBI

using a questionnaire developed at Landstuhl Regional Medical Center (LRMC). In

addition, all airmen returning from deployment complete both a Post-Deployment

Health Assessment (PDHA) within 30 days and a Post-Deployment Health Re-Assessment (PDHRA) at 3–6 months. Specific TBI screening elements are being added

to each.

It is important when treating patients with mild TBI or PTSD to begin therapy

early and it is possible to see patients with elements of both conditions. To distinguish between mild TBI and PTSD, our providers use clinical symptoms, physical

examination, imaging studies (x-rays, CT scans, MRIs) and neuro-psychologic testing.

Mr. MCHUGH. In your written statements you mention the health care professionals who are deployed in support of our troops in the field. Between the Army

and the Navy close to 16,000 medical personnel are deployed around the world on

any given day. At the same time military medical personnel are working in military

treatment facilities caring for our troops, their families and our retired beneficiaries.

DOD and the military Services have testified on many occasions regarding the need

for rotation policies for deploying troops. I am wondering about the rotation policy

for medical personnel. Please describe the deployment policies each of you have for

military medical personnel in support of OIF and OEF. How many medical personnel have been deployed once, twice, three times or more? Given the challenges in

recruiting and retaining medical personnel, how long will you be able to sustain

your current deployment policies?

General POLLOCK. We have various deployment policies under which Army Medical Department (AMEDD) personnel deploy.

MEDCOM MEDICAL AUGMENTATION Replacement Policy—all Medical Corps

(MC) Dental Corps (DC) and Army Nurse Corps (AN) 66Fs (Nurse Anesthetists) in

an Individual Augmentee (IA) or Medical Augmentee status will deploy for 180 days

(90 days if the filler is an MC Program Director).

180-day AMEDD PROFIS Replacement Policy (APRP)—MC and DC (select AOCs)

and 66Fs in a PROFIS or IA status at Echelons Above Division (EAD) units deploy

for 180-days.

90-day Program Director Policy—Medical Corps Graduate Medical Education Program Directors in a Professional Officer Filler System (PROFIS)/IA status at EAD

units will deploy for 90-days.

DA Policy—All other AMEDD, PROFIS/IA, TCS or assigned permanent party will

deploy 15 months/until mission complete.

90-day Boots on the Ground—Reserve component MC, DC and Nurse Anesthetists

(not in leadership positions) in an assigned status will deploy/mobilize for 90 days

(boots on the ground, 120 days door-to-door).

DA Policy—All other AMEDD in an assigned status will deploy/mobilize for 365

days.

Mr. MCHUGH. In your written statements you mention the health care professionals who are deployed in support of our troops in the field. Between the Army

and the Navy close to 16,000 medical personnel are deployed around the world on

any given day. At the same time military medical personnel are working in military

treatment facilities caring for our troops, their families and our retired beneficiaries.

217

DOD and the military Services have testified on many occasions regarding the need

for rotation policies for deploying troops. I am wondering about the rotation policy

for medical personnel. Please describe the deployment policies each of you have for

military medical personnel in support of OIF and OEF. How many medical personnel have been deployed once, twice, three times or more? Given the challenges in

recruiting and retaining medical personnel, how long will you be able to sustain

your current deployment policies?

Admiral ARTHUR. There are three parts to Navy Medicine’s deployment policy for

medical personnel deployed away from Navy medical facilities in support of OIF/

OEF. First, they should be onboard at least six months prior to deploying; second,

they should return from deployment within 6 months of their PRD; and third, there

should be 365 days dwell time after returning from a deployment. We strive to ensure that all qualified personnel have deployed once before we order someone to deploy twice.

Based on the FY06 OSD (Health Affairs) Tri-Service study, 14,677 (13,020 Active

and 1,657 Reserve) Navy medical personnel were deployed to OEF/OIF. Of the

13,020 Active deployers, 9,451 (73%) were deployed once and 3,569 (27%) were deployed more than once. Of the 1,657 Reserve deployers, 1,430 (86%) were deployed

once and 227 (14%) were deployed more than once. We plan to request this study

be updated with FY07 data.

Based on current operational tempo, we expect to average 2,500 medical deployments per year to CENTCOM. About half, or 1,250, will be sourced from our medical facilities. We continue to closely monitor some high demand communities such

as, surgery, mental health, preventive medicine and independent providers (nurse

practitioners, independent duty corpsman and physician assistants).

Mr. MCHUGH. In your written statements you mention the health care professionals who are deployed in support of our troops in the field. Between the Army

and the Navy close to 16,000 medical personnel are deployed around the world on

any given day. At the same time military medical personnel are working in military

treatment facilities caring for our troops, their families and our retired beneficiaries.

DOD and the military Services have testified on many occasions regarding the need

for rotation policies for deploying troops. I am wondering about the rotation policy

for medical personnel. Please describe the deployment policies each of you have for

military medical personnel in support of OIF and OEF. How many medical personnel have been deployed once, twice, three times or more? Given the challenges in

recruiting and retaining medical personnel, how long will you be able to sustain

your current deployment policies?

General ROUDEBUSH. Air Force medics deploy following the Air Expeditionary

Forces (AEF) construct. The AEF involves deployment of personnel for 4 months,

followed by 16 months at home station (there are exceptions, particularly with

those deploying in support of Army missions that have longer deployment

cycles). Non-traditional taskings extending up to a year or longer have to be

worked outside of the AEF construct.

Since 2003, 25.5 percent of our medics have deployed. Of those deployers, 8 percent have deployed twice and one percent have deployed three times. Some service

members have deployed as many as 8 times but most do so voluntarily. We continue

to monitor our personnel being deployed, its impact on our members and their families, and our recruiting and retention. At this time, we believe we can sustain our

AEF rotation policy for the foreseeable future.

Currently we have 1,464 Air Force medics deployed around the world. DHP medical assets are also assigned to garrison and are heavily involved in providing direct

beneficiary care every day. When one looks at Service-specific deployed DHP (only)

medical assets, Air Force, Army and Navy are almost equal in their contributions

to supporting GWOT operations (see chart below).

Military Medical Service Deployment History

Billets with Program Element Codes = Defense Health Program

Service

Estimated Full Time Equivalents

FY 2002 FY 2003 FY 2004 FY 2005 FY 2006

Army 369 1,419 1,139 1,147 1,375

Navy 39 1,952 882 908 1,205

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Military Medical Service Deployment History—Continued

Billets with Program Element Codes = Defense Health Program

Service

Estimated Full Time Equivalents

FY 2002 FY 2003 FY 2004 FY 2005 FY 2006

Air Force 1,078 1,275 1,105 1,141 1,134

ASource OSD/HA

QUESTIONS SUBMITTED BY MRS. BOYDA

Mrs. BOYDA. We hear that funding for TBI research has been cut back. Can you

address that? Do you know anything about that? Is that true? And is there something that Congress can do?

General POLLOCK. Army core research programs on Traumatic Brain Injury (TBI)

did not suffer a cut in funding in Fiscal Year 2007. Congress expressed some concern that the Defense and Veterans Brain Injury Center (DVBIC), a major contributor to military TBI initiatives both clinical and research, would lose funds as the

result of an organizational realignment. The Defense Appropriations Act for FY06

directed the transfer of the full amount of DVBIC funds from the Uniformed Services University of Health Sciences (USUHS) to the US Army Medical Research and

Materiel Command (MRMC). This transfer of funds coincided with DVBIC’s move

from USUHS to MRMC. Additionally, in FY06 MRMC provided the DVBIC approximately $12M of Defense Health Program funding, including congressional adds. In

FY07, MRMC provided $19.8M of DHP funding. Research on traumatic brain injury

and the effects of blast injuries is a high priority for MRMC and the Army. We will

continue to dedicate resources to this critical research.

QUESTIONS SUBMITTED BY MRS. DAVIS OF CALIFORNIA

Mrs. DAVIS. I wanted to ask you about the article in the New York Times Magazine the other day by Sara Corbett. I don’t know if you happened to see that about

women in combat and women in theater and the impacts of PTSD on women, particularly as primary care givers, but also some of the instances that were cited in

the article, abuse to women in theater and how that is being dealt with and how

the services are providing the kind of care and support that the women need and

being certain that they get that while in theater and then they certainly get that

when they return home.

Could you speak to that?

General POLLOCK. Sara Corbett’s Article ‘‘The Women’s War’’ published in The

New York Times Sunday Magazine 18 March 2007 is a thoughtful, balanced, and

detailed examination of unique problems facing some service women today. The Iraq

war has seen unprecedented numbers of female Soldiers serving with many Combat

Service and Service Support units. As the article highlights, both the military and

Department of Veterans Affairs are devoting increasing attention to the unique

problems of female service members. More attention needs to be given to studying

the effects of combat on our female warriors. The development of effective treatment

programs tailored to women should be a priority for our military Behavioral Health

community.

The Army takes the issues of Sexual Harassment and Sexual Abuse very seriously

and has set up an extensive program to encourage victims of harassment or sexual

assault to seek help. The Army’s Sexual Assault Prevention and Response Program

(SAPR) provides confidential victim advocates who diligently work with victims to

provide them with treatment resources and support. Annual training on the SAPR

is required for all military personnel. A detailed explanation of the Army program

can be found at: http://www.sexualassault.army.mil/.

In regard to the noted increase in reporting since the initiation of the SAPR program, we feel this is a positive development. It has long been understood that when

one pays attention to a problem by encouraging reporting and offering protection to

those who report, the rates of reporting will rise. This increase therefore likely reflects victims who previously did not report, rather than an actual increase in assaults. While no one believes we are reaching 100% of the victims of sexual assault,

early intervention and the support of victim advocates are helping many women recover.

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On the issue of PTSD, there has long been demonstrated a significant gender difference in willingness to seek help between males and females, with female personnel more open to doing so. Our data from the Mental Health Advisory Team studies

do not show any gender difference, but more research needs to be done.

The Department of Defense is currently engaged in unprecedented efforts to find

and help service members adversely affected by their deployment experiences. The

Post-Deployment Health Assessment given immediately upon re-deployment and the

Post-Deployment Health Re-Assessment, given 90–180 days after re-deployment

bring soldiers into direct contact with Behavioral Health personnel and give them

the opportunity to obtain immediate assistance. Additionally the physical examination process has been revised to a Periodic Health Assessment, which also looks for

evidence of depression, anxiety or substance abuse. Although more can and needs

to be done in this area, the Army is aware of the challenges faced by both male

and female Soldiers and is doing everything possible to ensure their needs are met.

Mrs. DAVIS. I wanted to ask you about the article in the New York Times Magazine the other day by Sara Corbett. I don’t know if you happened to see that about

women in combat and women in theater and the impacts of PTSD on women, particularly as primary care givers, but also some of the instances that were cited in

the article, abuse to women in theater and how that is being dealt with and how

the services are providing the kind of care and support that the women need and

being certain that they get that while in theater and then they certainly get that

when they return home.

Could you speak to that?

Admiral ARTHUR. In reference to the article titled ‘‘The Women’s War’’, the following comments are provided on Navy Medicine’s efforts for providing medical care for

the physical and psychological sequelae of women serving in the Navy and Marine

Corps as a result of combat experience.

Navy Medicine seeks to proactively address the broad range of combat and operational stress injuries, to include PTSD, in a number of ways. In November 2006,

Navy Medicine established a directorate at the Bureau of Medicine and Surgery led

by an experienced combat stress psychiatrist specifically dedicated to addressing

mental health stigma, combat stress training needs, non-stigmatizing care of returning deployers, and support services for Navy caregivers. Other efforts include prevention, outreach, and early intervention to warfighters using Navy mental health

providers trained in clinical best-practices related to combat and operational stress

control. One specific example is Operational Stress Control and Readiness teams

providing early intervention, outreach, and prevention at the unit levels in close

proximity to operational missions in order to reduce stigma that can be encountered

in conventional mental health care settings.

Navy Medicine plans to utilize existing data sets to study combat stress and gender. Naval Health Research Center’s Millennium Cohort Study is addressing a variety of combat-related behaviors in both men and women. Additionally, the first

phase of the Navy’s in-theater Behavioral Health Needs Assessment (BHNAS) is

complete, and analysis of gender differences associated with deployment stress is

currently underway.

Service Members returning from deployment are screened using the Post Deployment Health Assessment (PDHA–DD Form 2796). A review of 261,008 PDHA forms

completed from January 2003 to present demonstrate that 2.2% of male Marines

and Sailors were referred for mental health services, compared to 2.6% of returning

female Marines and Sailors (Defense Medical Surveillance System, 19 June 2007).

Researchers from Walter Reed Army Institute of Research (Hoge et. al., 2007)

have reviewed recent studies of military personnel with service in Iraq and Afghanistan, and reported that ‘‘military duty in Iraq confers a similar risk of [Post Traumatic Stress Disorder] and depression by gender.’’ The authors suggest that risk for

developing significant combat stress disorders is a factor of intensity and frequency

of combat exposure, rather than gender (Hoge CW, Clark JC, Castro CA. Commentary: Women in combat and the risk of post-traumatic stress disorder and depression. International Journal of Epidemiology 2007).

The issue of compassion fatigue among Navy Medicine personnel is also of significant interest. Navy Medicine has established a Care for the Caregiver mandate in

order to address this concern. Assessment of operational and occupational stress of

medical personnel, to include focus groups, will begin in summer 2007.

Mrs. DAVIS. I wanted to ask you about the article in the New York Times Magazine the other day by Sara Corbett. I don’t know if you happened to see that about

women in combat and women in theater and the impacts of PTSD on women, particularly as primary care givers, but also some of the instances that were cited in

the article, abuse to women in theater and how that is being dealt with and how

the services are providing the kind of care and support that the women need and

220

being certain that they get that while in theater and then they certainly get that

when they return home.

Could you speak to that?

General ROUDEBUSH. The Air Force is concerned about all Airmen with traumarelated mental health problems, regardless of gender. We have procedures to guide

base helping agencies as they assist Airmen who are transitioning back to their

home station from deployment. These procedures include education on the recognition of PTSD signs and symptoms and where to go for help. Upon redeployment and

then 3 to 6 months later, we ask Airmen to complete a survey describing their current health status. This survey includes questions about PTSD; when Airmen screen

positive, they are referred to their primary care provider for further evaluation and,

if indicated, onto a mental health specialist. Ms. Corbett makes note of Dr. Edna

Foa’s Prolonged Exposure Therapy for the treatment of PTSD. I am pleased to tell

you that the Air Force brought Dr. Foa to a number of our bases to train mental

health professionals in her evidence-based treatment. To date, she has trained 100

mental health professionals. We are working with her currently to have her provide

training to an additional 300 professionals. We are also working with Dr. Patricia

Resick, another one of our Nation’s top PTSD clinician/researchers. Dr. Resick will

be providing training in her Cognitive Processing Therapy, the other main evidencebased treatment for PTSD.

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