[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]
[H.A.S.C. No. 111-26]
MEDICAL INFRASTRUCTURE: ARE
HEALTH AFFAIRS/TRICARE
MANAGEMENT ACTIVITY PRIORITIES
ALIGNED WITH SERVICE REQUIREMENTS?
__________
JOINT HEARING
BEFORE THE
MILITARY PERSONNEL SUBCOMMITTEE
MEETING JOINTLY WITH
READINESS SUBCOMMITTEE
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
MARCH 18, 2009
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13
U.S. GOVERNMENT PRINTING OFFICE
50-823 WASHINGTON : 2010
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MILITARY PERSONNEL SUBCOMMITTEE
SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas JOE WILSON, South Carolina
LORETTA SANCHEZ, California WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
David Kildee, Professional Staff Member
Jeanette James, Professional Staff Member
Rosellen Kim, Staff Assistant
------
READINESS SUBCOMMITTEE
SOLOMON P. ORTIZ, Texas, Chairman
GENE TAYLOR, Mississippi J. RANDY FORBES, Virginia
NEIL ABERCROMBIE, Hawaii ROB BISHOP, Utah
SILVESTRE REYES, Texas MIKE ROGERS, Alabama
JIM MARSHALL, Georgia TRENT FRANKS, Arizona
MADELEINE Z. BORDALLO, Guam BILL SHUSTER, Pennsylvania
HANK JOHNSON, Georgia K. MICHAEL CONAWAY, Texas
CAROL SHEA-PORTER, New Hampshire DOUG LAMBORN, Colorado
JOE COURTNEY, Connecticut ROB WITTMAN, Virginia
DAVID LOEBSACK, Iowa MARY FALLIN, Oklahoma
GABRIELLE GIFFORDS, Arizona JOHN C. FLEMING, Louisiana
GLENN NYE, Virginia FRANK A. LoBIONDO, New Jersey
LARRY KISSELL, North Carolina MICHAEL TURNER, Ohio
MARTIN HEINRICH, New Mexico
FRANK M. KRATOVIL, Jr., Maryland
BOBBY BRIGHT, Alabama
David Sienicki, Professional Staff Member
Thomas Hawley, Professional Staff Member
Megan Putnam, Staff Assistant
C O N T E N T S
----------
CHRONOLOGICAL LIST OF HEARINGS
2009
Page
Hearing:
Wednesday, March 18, 2009, Medical Infrastructure: Are Health
Affairs/TRICARE Management Activity Priorities Aligned with
Service Requirements?.......................................... 1
Appendix:
Wednesday, March 18, 2009........................................ 23
----------
WEDNESDAY, MARCH 18, 2009
MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/TRICARE MANAGEMENT ACTIVITY
PRIORITIES ALIGNED WITH SERVICE REQUIREMENTS?
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California,
Chairwoman, Military Personnel Subcommittee.................... 2
Ortiz, Hon. Solomon P., a Representative from Texas, Chairman,
Readiness Subcommittee......................................... 1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking
Member, Military Personnel Subcommittee........................ 3
WITNESSES
Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for
Health Affairs................................................. 4
Potochney, Peter, Director, Basing, Office of the Deputy Under
Secretary of Defense, Installations and Environment............ 7
Robinson, Vice Adm. Adam, USN, Surgeon General, U.S. Navy........ 10
Roudebush, Lt. Gen. James G., USAF, Surgeon General, U.S. Air
Force.......................................................... 9
Schoomaker, Lt. Gen. Eric, USA, Commanding General, U.S. Army
Medical Command, Surgeon General, U.S. Army.................... 12
APPENDIX
Prepared Statements:
Casscells, Hon. S. Ward...................................... 32
Davis, Hon. Susan A.......................................... 28
Forbes, Hon. J. Randy, a Representative from Virginia,
Ranking Member, Readiness Subcommittee..................... 30
Ortiz, Hon. Solomon P........................................ 27
Potochney, Peter............................................. 47
Robinson, Vice Adm. Adam..................................... 63
Roudebush, Lt. Gen. James G.................................. 58
Schoomaker, Lt. Gen. Eric.................................... 68
Wilson, Hon. Joe............................................. 31
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Mr. Kline.................................................... 77
Questions Submitted by Members Post Hearing:
Ms. Bordallo................................................. 88
Mr. Kissell.................................................. 87
Mr. Wilson................................................... 81
MEDICAL INFRASTRUCTURE: ARE HEALTH AFFAIRS/TRICARE MANAGEMENT ACTIVITY
PRIORITIES ALIGNED WITH SERVICE REQUIREMENTS?
----------
House of Representatives, Committee on Armed
Services, Military Personnel Subcommittee,
Meeting Jointly with Readiness Subcommittee,
Washington, DC, Wednesday, March 18, 2009.
The subcommittees met, pursuant to call, at 2:06 p.m., in
room 2118, Rayburn House Office Building, Hon. Solomon P. Ortiz
(chairman of the Readiness Subcommittee) presiding.
OPENING STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE
FROM TEXAS, CHAIRMAN, READINESS SUBCOMMITTEE
Mr. Ortiz. The subcommittee will come to order.
Today, the Readiness Subcommittee and the Military
Personnel Subcommittee will meet in a joint session to receive
a briefing on how the Department is managing their medical
military construction program.
As our Nation responds to different threats, we adapt and
change our strategy and the force structure of our military,
and one of the most recent decisions to change our force
structure has been to expand the Army and Marine Corps and add
74,000 soldiers and 27,000 Marines.
The services have been steadily applying facility funds to
accommodate this growth, but some areas are significantly
lacking, including medical facilities to support the growing
force.
It is imperative that the men and women that join our Armed
Forces are provided the best medical care possible.
To this end, I am glad that we provided almost $1.3 billion
to support medical facilities deficiencies in the stimulus
bill.
I hope that the witnesses will take the opportunity to
address the Department's investment priorities on how they are
managing to address medical facilities needs for all of our
growing installations.
On a related point, our subcommittees had the opportunity
to visit Bethesda yesterday and we were amazed at the
resilience of the wounded warriors, their high spirits, their
bravery, their dedication to our country.
And to receive men and women at Bethesda within 48 hours of
a casualty from anywhere in the world is an amazing feat, and I
was very, very impressed to know that.
This capability that exists today will be particularly
challenged when the Walter Reed complex is realigned to
Bethesda and Fort Belvoir.
We were briefed that the majority of care will be moved
from the Walter Reed campus in August of 2011. With the
construction of almost $2 billion in the National Capital
Region (NCR), in addition to commissioning the facilities and
installing complex equipment, there is no question that this
will be a very difficult task.
A seamless transition from Walter Reed to Bethesda and Fort
Belvoir is essential to provide the quality of care for our
wounded warriors.
[The prepared statement of Mr. Ortiz can be found in the
Appendix on page 27.]
The chair now recognizes the distinguished chairwoman from
California, Mrs. Davis, for any remarks that she would like to
make.
Mrs. Davis.
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE
Mrs. Davis. Thank you. Thank you, Chairman Ortiz, Mr.
Forbes and Mr. Wilson, for this joint hearing of the Readiness
and Military Personnel Subcommittees.
The Military Personnel Subcommittee is tasked with
oversight of the defense health program and the Readiness
Subcommittee with the oversight of military construction.
While our staffs have already spent lots of quality time
together on this topic, it is good that we are meeting jointly
to receive testimony and explore the issue of medical military
construction.
As Chairman Ortiz mentioned, it is vital that we program
and build the infrastructure required to support the expansion
of the Army and the Marine Corps. It is our responsibility to
ensure that our service members and their families,
specifically, their families, too, have the facilities they
need from the outset and not be forced to wait years before
these facilities are even programmed, let alone built.
We must also ensure that the recommendations of the Base
Realignment and Closure Commission are implemented.
Yet another reason to have this hearing is the fact that
medical military construction is handled differently by the
Department of Defense and all other military construction
(MILCONs). That is not to say that it is bad different or good
different, just different.
Consequently, it is both appropriate and responsible
oversight for our two subcommittees to examine this process so
that we may understand exactly how the Department analyzes,
prioritizes, budgets and then builds medical facilities.
We must also keep in mind the long-term enduring costs of
maintaining these facilities once they are completed.
Today, we will hear from all of the relevant parties within
the Department of Defense (DOD). Dr. Ward Casscells, the
Assistant Secretary of Defense for Health Affairs, will
describe how Health Affairs/TRICARE Management Activity (TMA)
prioritizes projects.
Mr. Peter Potochney, director of basing for the office of
the deputy under secretary of defense for installations and
environment, will speak to Base Realignment and Closure (BRAC)
issues.
Finally and importantly, we will hear from the service
surgeons general, Lieutenant General Roudebush from the Air
Force and Vice Admiral Robinson from the Navy, and Lieutenant
General Schoomaker from the Army, of how well the current
process supports their requirements.
Welcome to all of you and thank you very much for being
with us.
Throughout our conversations today, it should go without
saying that all of us, both members of the legislative and
executive branches, are committed to providing the very best
care possible to service members, their families and our
retirees.
Chairman Ortiz rightly mentioned the impressive feats that
our military health system has made routine.
On Monday, many of us had a chance to meet and speak with a
wounded warrior at Bethesda. Given how recently he was wounded
and the type and extent of his injuries, it was awe inspiring
to see how far he has come so quickly.
All of his caregivers agreed that just a few years ago, any
recovery, let alone one as dramatic as his, would have been all
but impossible. That the standard of care has risen to such a
high is a testament to the commitment displayed on a daily
basis by everyone who is associated with the military health
system.
We must all do our part to make sure this trend continues.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 28.]
Thank you, Mr. Ortiz. We look forward to the hearing.
Mr. Ortiz. The chair now recognizes the distinguished
gentleman from South Carolina, Mr. Wilson.
STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH
CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE
Mr. Wilson. Thank you, Chairman Ortiz.
And it is an honor for me to be here today with Chairwoman
Davis. I appreciate joining our good friends on the Readiness
Subcommittee, led by Chairman Solomon Ortiz and Ranking Member
Randy Forbes, for our hearing on military medical construction.
I welcome the distinguished members of our witness panel.
At this time, Congressman Forbes is actually in a markup of
the Judiciary Committee, and I would like to move for unanimous
consent to submit his opening statement for the record.
Mr. Ortiz. Without objection, so ordered.
[The prepared statement of Mr. Forbes can be found in the
Appendix on page 30.]
Mr. Wilson. I believe that there is nothing more important
than providing the outstanding members of our military, their
families and our retirees with world-class health care
delivered in world-class medical facilities.
There is no question, in my mind, that they deserve nothing
less.
As the grateful father of four sons in the military today,
our family has experienced the quality service, with two
grandsons born at Bethesda National Naval Medical Center, and a
granddaughter born at Portsmouth Naval Hospital.
With that being said, I understand that there are a number
of military treatment facilities that are 30 or more years old.
In the district I represent in South Carolina, Moncrief Army
Community Hospital at Fort Jackson was built in 1972 and the
Navy hospital at Beaufort was built in 1947.
I know that the outstanding medical personnel in each of
these facilities provide excellent care to our troops and their
families.
On personal tours of each facility, I have been very
impressed by the dedicated and competent professional personnel
I have met.
I also know that as a medical facility gets older, it is
more challenging to keep up with the advances in medicine.
As I prepared for the hearing today, I was reminded that
the planning process for military medical construction is very
different than that for other types of construction within the
Department of Defense.
I am interested to hear from our panel why medical
construction is unique within the Department. To that end,
today, I hope to hear from our witnesses how the Department and
the military services plan to spend medical construction
dollars to either replace or modernize our military hospitals.
The members of our Armed Forces deserve the best.
With that, I would like to thank our witnesses for
participating in the hearing today. I look forward to your
testimony.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 31.]
Mr. Ortiz. Today, we are very honored to have with us five
distinguished witnesses representing the Department of Defense.
We have the honorable Ward Casscells, the Assistant
Secretary of Defense for Health Affairs; Mr. Pete Potochney,
Office of the Under Secretary of Defense for Installations and
Environment; Lieutenant General Eric Schoomaker, the Surgeon
General of the Army; Vice Admiral Adam Robinson, Surgeon
General of the Navy; and, Lieutenant General James Roudebush,
Surgeon General of the Air Force.
Without any objection, all of your testimony will be put in
the record.
Mr. Casscells, whenever you are ready, you can begin your
testimony, sir.
STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS
Secretary Casscells. Thank you, Chairman Ortiz, Chairwoman
Davis, Ranking Member Wilson.
I am delighted to be here with my colleagues and I cannot
tell you how much we appreciate your interest in our facilities
and your recent visit to Walter Reed.
Joining me here today, from left to right, I think you have
already mentioned, General Schoomaker, General Roudebush, Mr.
Pete Potochney, who is representing Wayne Arny, the director of
installations and environment, and Vice Admiral Robinson.
Secretary Gates has said over and over again that our
service members and their families deserve the best medical
facilities possible. We certainly agree with him and we
appreciate very much the fact that the Congress has taken that
to heart.
Let me be frank. We do not have big corporations and others
for whom this is a top priority calling you. This is the group
that advocates for military medical facilities and we are very
grateful that you have taken it to heart.
We are in a bit of an awkward position today, because the
President's budget won't come to you until April. In fact, we
don't have the details ourselves.
We know what we have requested, and this is being arm-
wrestled with the Office of Management and Budget (OMB) and the
comptroller and so forth now.
So we don't know. We won't be able to answer some of your
questions the way we would like to.
Likewise, the details of the stimulus proposal and our
military medical construction proposals, as part of that bill,
are not yet approved. I can tell you that we have requested a
balanced construction program favoring the urgent, the
strategic and the joint.
We also are a little bit handicapped today in the sense
that we don't have the report from the independent review of
the hospital design. This group is due to report now to the
defense health board and we should have that report, also, in a
matter of weeks.
Together, these have put us in a position of delay, as your
staffs know well. The report that was due in January was only
delivered to you, I understand, on your way out to Walter Reed,
and I apologize for that. We had hoped you would have several
days to digest that. And we will have a full report of all of
this in early summer.
Mr. Chairman, you alluded to the fact that we have a
different funding mechanism, as did Mr. Wilson. We do, indeed,
and as opposed to regular military construction, which is done
by a top line allocation to the services, the medical
construction is done differently, as recommended by or as
required by Congress, and as we, the surgeons and I and
installations and environment leaders, as we have jointly
designed.
The way this works has been different from other military
construction since the defense health program was created by
Congress several decades ago.
And what it means is that instead of having service
surgeons general having to ask the line leaders for their
budget, Congress set this up so that there would be a defense
health program so that the budgets could be put together
jointly and we wouldn't be trading hospitals versus weapons
systems.
I think the wisdom of Congress' decision here is apparent,
because we are now once again building hospitals, and I think
that is good.
There was a time when we were letting the hospital
maintenance be deferred year by year by year. I think the
members of these committees are well aware that our
accreditation has been--we have passed, our hospitals pass
their inspections, but not with commendation, typically.
Usually, we are cited for deferred maintenance and we take
the pledge to get to it. But you cannot defer these things
indefinitely. Otherwise, you may compromise medical care
eventually.
We are not doing that at this time, but we cannot defer the
upgrades of these hospitals forever.
As you mentioned, sir, some of these hospitals were built
before any of us were even in medical school. So that is 35
years ago. So they can't be neglected indefinitely.
The mechanism that we use now to determine these
allocations, the priorities, are set by something called the
capital investment decision model, or CIDM.
This is something that we and our predecessors actually
developed. It has been a painstaking business model that has
been developed, and we took our cues from the business
community and, particularly, from the Veterans Administration
(VA), which, as you know, has revitalized their facilities over
the past couple of decades and they have some really first
class hospitals now.
One of the things that has come out of that is commercially
available software that facilitates this decision-making. So
this is what we have used. We have worked on it together, and I
hope that what we will be able to do today, if not answer every
single question about a given facility, is at least persuade
you that we are working on it in a transparent and in an
earnest and joint fashion.
It remains to be seen whether this new process, CIDM, will
actually be the right one or whether it is just another layer
of DOD bureaucracy laid over top of service bureaucracies. None
of us wants that.
What we want, of course, is to have an even playing field
and to have people speak and meet together, share their best
ideas, cross-fertilize, and reach a consensus on what the
military hospital should look like, and I believe we have.
We want hospitals that will be welcoming, that will be
empowering for the patients, that will be comforting. They will
be a little bit different than the civilian hospitals. We
compare ourselves constantly to what is happening at the Mayo
Clinic or the Cleveland Clinic or Kaiser Permanente.
Our needs are a little bit different, because we have such
a preponderance of psychological issues to deal with.
But many of the features are ones that we have been able to
take from the VA and from the commercial competitors, and I say
competitors in a respectful way, but we are the only Health
Maintenance Organization (HMO) that deploys. I am sure you have
heard that expression. And it is critical that the military
treatment facilities (MTFs) be maintained strong and, in fact,
be strengthened.
The future of the military health system requires this. We
cannot outsource everything. There are things we can do in that
vein and I want to commend what the Air Force has done, with
great wisdom and great innovation, working with the private
universities and private hospitals, where that is the best
thing to do.
In other areas, we are working closely with the VA. So we
have joint facilities.
Still, we have to have a core called the MTFs, the military
hospitals or military treatment facilities, where people train
together and so that they can deploy together. This is critical
for the efforts we are engaged in overseas, whether it is the
wars in Iraq and Afghanistan, caring for our wounded, whether
it is the best preventive, getting them in the best shape to
deploy, and whether it is teaching the Iraqis and the Afghans
to take care of their own people medically.
All these are things that we train to do together and the
health of the MTFs is critical.
So thank you for supporting them. It is very heartening for
us to have this opportunity to talk to you about the military
treatment facilities.
I think next is General Schoomaker, and I think then we
will have some questions at the end.
But thank you, again, on behalf of my colleagues and the
Department of Defense for this opportunity.
[The prepared statement of Secretary Casscells can be found
in the Appendix on page 32.]
Mr. Ortiz. Mr. Potochney, go ahead, sir.
STATEMENT OF PETER POTOCHNEY, DIRECTOR, BASING, OFFICE OF THE
DEPUTY UNDER SECRETARY OF DEFENSE, INSTALLATIONS AND
ENVIRONMENT
Mr. Potochney. Good afternoon, Chairman Ortiz, Chairwoman
Davis, Congressman Wilson and distinguished members of the
subcommittees.
I am honored to appear today before you. I am taking the
place of my boss. That is Wayne Arny, the deputy under
secretary of defense for installations and environment, who is
today attending his son's change of command at Naval Air
Station (NAS) Lemoore. He is the outgoing Strike Fighter
Weapons School Commanding Officer (CO).
Absent a significant personal commitment like that----
Mr. Ortiz. Sir, if you could get a little closer to your
mic, sir. Thank you.
Mr. Potochney. Absent a personal commitment like that, he
would be here.
I will keep my remarks brief, and I would like to relate
what we do in the installations community, in the construction
world, compared to what we do with the other witnesses today,
in the health affairs world, as well as BRAC.
So let me begin.
The installations and environment community, my world, has
oversight responsibility for the Department's installation
portfolio. We are the advocates for ensuring our facilities
compete effectively for the investment necessary to sustain,
restore and modernize them to ensure their continued operation
in support of their mission occupants.
As such, we support our colleagues in the medical community
in their application of the resources supporting the Defense
Department's health program facilities.
The Department places great emphasis on sustaining all of
our facilities. Sustainment is the term we use to describe what
is necessary to keep facilities in good working order and the
preventative maintenance necessary to avoid the increased costs
and mission impacts that result from premature deterioration.
To this end, we use something called the facilities
sustainment model, and it is a robust tool we have developed to
parametrically estimate the funding required for this purpose,
and it allows us to gauge our investment against the
requirement, and that was a substantial and significant
development for us over the last couple of years, because now
we had a tool to better compete for the limited resources we
have in the Department, particularly because sustainment has
been traditionally underfunded in the Department.
In the 2009 President's budget, we were at 90 percent of
the overall requirement and health facilities were at 93
percent of the overall requirement. That is better than it used
to be, but it is certainly not where it should be, and we are
continuing to work to get it up, frankly, to 100 percent.
Sustainment is only one piece of the equation. Facilities
must also be modernized through the investment we make in their
recapitalization.
Modernization is driven by new standards, new technology
and changing missions and, as such, it is not easily modeled.
However, the fact that the average age of our hospitals is
less than other facilities indicates we recognize the relative
importance of their modernization.
But here, too, there is certainly more to do and the
witnesses at this table will provide details of the work we are
doing in order to respond to medical care advances.
Restoration is the final part of the equation. While, in
the past, the Department had focused on recapitalizing
facilities on a yearly rate, essentially, a ratio of the
funding we were placing in the budget compared to the
replacement value of all of our facilities and then our 67-year
goal was something I think you heard about in the past, we have
recognized the limitations of this metric, particularly with
regard to medical facilities and are working on more
comprehensive measures.
To that end, we are using Q ratings now, much more so than
in the past, and that is Q1 through Q4, Q1 being the best, Q4
the lowest, and they are essentially the percentage of work
orders to repair a building compared to the building's
replacement cost.
Medical facilities have a higher Q rating than the rest of
the Department, but they are not a good indicator of our
medical facilities' health, because--no pun intended--because
medical facilities have a high priority, as I just said, and
they are subject to accreditation requirements, and the
accreditation requirements drive us to more robust engineering
assessments of the individual condition of the facilities in
coming up with our estimates.
So we are continuing to refine our approach and right now
that is the best means we have available to gauge what it is we
are doing as far as investing in recap, sustainment and
restoration.
There is one special area that I need to note, and that is
BRAC. Particularly, here in the National Capital Region (NCR)
and in San Antonio, those are the two major BRAC areas.
BRAC is a significant recapitalization engine for the
Department. BRAC is pouring a lot of money into our facilities
across the board, but particularly in the medical community.
Through BRAC, the Department is realigning, rationalizing
military health care, particularly in the NCR in San Antonio,
as I said. In the NCR, we have avoided recapitalizing the aged
Walter Reed facility so that we can instead focus our resources
more effectively by realigning functions into the new Walter
Reed National Military Medical Center.
We are also building a new facility at Fort Belvoir that
will address the significant demographic shift in patient
population that has occurred in this area.
In San Antonio, we are consolidating inpatient services
into a recapitalized Brooke Army Medical Center and converting
the aging Wilford Hall to an ambulatory care center.
These two initiatives have produced investments in medical
care in the NCR and San Antonio of $2 billion and $900 million,
respectively. These two areas, coupled with lesser BRAC
initiatives, represent a substantial recapitalization effort.
In closing, I want to thank the subcommittees for this
opportunity. The Department's medical construction program has
made great progress, but certainly more work remains, as you
will hear from the other witnesses.
We also recognize and appreciate the great support you have
demonstrated for all of our efforts.
Thank you.
[The prepared statement of Mr. Potochney can be found in
the Appendix on page 47.]
Mr. Ortiz. Thank you, sir.
General Roudebush, go ahead, sir.
STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH, USAF, SURGEON
GENERAL, U.S. AIR FORCE
General Roudebush. Thank you, sir. Chairman Ortiz,
Chairwoman Davis, Ranking Member Wilson, it truly is a pleasure
to be here today to review our MILCON activities with you, to
hear your thoughts and to provide ours.
We believe this is a very, very useful and necessary
opportunity. Thank you.
First, let me express our gratitude for the overwhelming
support that Congress and you, in particular, have provided to
address the critical needs of our medical facilities. Your
efforts will greatly assist us in building and sustaining the
state-of-the-art medical facilities that we require now and for
the future.
This is especially important in the Air Force, as much of
our medical infrastructure was built in the 15 years following
the establishment of the Air Force in 1947.
The shortage of MILCON funds in the past several years has
forced us to pursue ever increasing Operations and Maintenance
(O&M) repairs on buildings well past their useful life.
While we have been successful in implementing stopgap
measures in this manner, we cannot sustain an adequate baseline
of maintenance and repair.
To properly characterize and prioritize our Air Force
MILCON requirements, our Air Force health facilities division
aggressively engages with each medical facility leadership to
identify those modernization requirements that are most
pressing.
Our prioritization of these requirements is then aligned to
an Air Force-wide perspective.
For requirements that drive a MILCON solution, we now
prepare a capital investment proposal and submit to the TRICARE
management activity to be scored in the military health service
capital investment decision model, the CIDM process, which you
have heard a bit about this afternoon.
This CIDM process was successfully applied in 2008 to
determine the Department of Defense fiscal year 2010-2011
military MILCON priorities, and I can report to you that the
Air Force's most pressing medical projects were appropriately
prioritized within this process.
As a result, we are beginning to turn the corner on our
MILCON shortfalls. As we work to recapitalize our
infrastructure in both the MILCON and O&M arenas, it is
important to note that green design initiatives and energy
conservation continue to be high priorities in the Air Force
medical service.
We are already incorporating nationally recognized
benchmark processes to design and construct buildings with
sustainable design elements, such as increased natural day
lighting, recycled or recyclable materials, and optimized
energy performance.
We have established a rigorous system to capture and
compare energy consumption data from all of our major
facilities using the Energy Star measurement tool, and this
system is already up and running at the majority of our medical
facilities.
And finally, we recognize that caring for our airmen,
soldiers, sailors, Marines, and their families in safe and well
maintained medical facilities is both our duty and a national
priority.
I assure you that the Air Force is meeting these
expectations. All 74 Air Force medical facilities undergo
regular and thorough inspections, both scheduled and
unannounced, by two national accreditation organizations, the
joint commission and the Accreditation Association for
Ambulatory Health.
All Air Force medical facilities have passed inspection and
are fully accredited.
Again, we thank you and look forward to your continued
strong support in this critically important task, and I look
forward to your questions.
Thank you.
[The prepared statement of General Roudebush can be found
in the Appendix on page 58.]
Mr. Ortiz. Thank you, sir.
Admiral Robinson.
STATEMENT OF VICE ADM. ADAM ROBINSON, USN, SURGEON GENERAL,
U.S. NAVY
Admiral Robinson. Good afternoon, Chairman Ortiz,
Chairwoman Davis, Ranking Member Wilson, distinguished members
of the committee.
Thank you very much for the opportunity to testify before
you today on the prioritization of military construction of
medical facilities.
Your unwavering support of our service member, especially
those who have been wounded, is deeply appreciated.
Navy medicine continues making significant strides in
enhancing both living quarters and medical treatment facilities
for our sailors and Marines. The military health systems
capital investment decision model was implemented in May 2008
and was used in the programming and budgeting of military
construction projects slated for construction beginning with
fiscal year 2010.
This new system serves all the services by carefully
evaluating proposed medical MILCON projects through a rigorous
capital investment prioritization method across the entire
enterprise.
In addition, the new methodology allows more costly
projects to receive the funding they need by harnessing the
global, enterprise-wide perspective to effectively prioritize
scarce resources.
Another positive aspect of the CIDM prioritization process
is the inclusive representation of those who care for our war
fighters as members of the military health systems capital
investment review board (CIRB).
Clinicians, health system managers, resource managers and
health care facility experts from the services and from TMA are
all voting members of the capital investment review board. They
represent their services or TMA and play pivotal roles in
creating an enterprise-wide assessment of projects needed.
As Navy Surgeon General, I, as well as my Army and Air
Force colleagues, can engage the capital investment decision
model process to clearly articulate our views and priorities to
all the members of the CIRB for consideration and deliberation.
The CIDM and the CIRB delivered the integrated military
health system priority list of projects for the programming
period from 2010 through 2015. The services surgeon generals
and the TRICARE Management Activity came to a joint agreement
on the top priority construction project, and it is the Naval
Hospital Guam replacement.
This antiquated facility was built in 1954 and has survived
55 years in tropical climates.
The new prioritization system allows us to maximize our
limited project planning money by focusing on projects that are
considered by all to be a major priority and the best and most
efficient use of limited resources.
Distinguished members of the Readiness and Military
Personnel Subcommittees, thank you again for the opportunity to
testify before you today on the positive results Navy medicine
has experienced from the new medical MILCON prioritization
process.
I believe that the military health systems' CIDM and
associated CIRB, as implemented to date, offers the military
health system enterprise the best overall means to properly
prioritize military medical projects.
In addition, this new process ensures projects of the
highest relative merit are consistently programmed, budgeted
and executed first in a coherent fashion, while still ensuring
the focus of the entire MILCON evaluation process remains where
it should always be, namely, the health care needs of our
sailors, our Marines, and their families, as our number one
priority.
Thank you very much.
[The prepared statement of Admiral Robinson can be found in
the Appendix on page 63.]
Mr. Ortiz. General Schoomaker.
STATEMENT OF LT. GEN. ERIC SCHOOMAKER, USA, COMMANDING GENERAL,
U.S. ARMY MEDICAL COMMAND, SURGEON GENERAL, U.S. ARMY
General Schoomaker. Chairman Ortiz, Chairwoman Davis,
Representative Forbes and Representative Wilson, distinguished
members of the Readiness and Military Personnel Subcommittees,
thank you for inviting me and my colleagues here to discuss
this really important subject today of our medical
infrastructure.
Before I go on, I would just like to take a moment to
introduce my battle buddy, my Command Sergeant Major Althea
Dixon. Although we are talking about buildings, brick and
mortar today, I think we can all agree that the centerpiece of
our formation are our people.
And the Army has declared this year the year of the
noncommissioned officer, the NCO, and probably nobody better
symbolizes the NCOs of our Army than my senior medic here to my
left, who has kept me honest and on track for a number of years
now.
The condition of our military medical facilities speaks
volumes to our staff and our beneficiaries about how much the
Nation values their service and their well-being. In fact, I
used these exact words when I turned the soil with my
colleagues at the new hospital at Fort Belvoir.
The most tangible evidence of the Nation's investment in
the health and well-being of our people are the facilities that
we build for them.
As I testified before the two Defense Appropriations
Subcommittees last year, medical facility infrastructure was
and remains today one of my top concerns.
On behalf of the 130,000 team members that comprise the
Army medical department throughout the world and our 3.5
million beneficiaries whom we serve within Army medicine, I
really want to thank you all here and the Congress as a whole
for listening to our concerns about military medical
infrastructure and taking some significant action to improve
our facilities.
With your help, I think we have made some real progress in
the last year.
Funding provided for military hospitals in the fiscal year
2008 supplemental bill and what we hope to have in the American
Recovery and Reinvestment Act of 2009 will positively impact
the quality of life of thousands of service members, family
members, retirees, as we build new world-class facilities in
places like Fort Benning, Georgia, Fort Riley, Kansas, and San
Antonio, Texas.
And I think we can all sit here and talk to you about the
abysmal state of some of our facilities, but I don't want to
get in a contest with my colleagues here. We all are working
very, very hard to raise the quality of our facilities and,
while doing that, using our Sustainment, Restoration and
Modernization (SRM) dollars to maintain the safety and the
reliability of even these aging facilities.
Modern new facilities not only stimulate the local economy,
they energize the hospital staff who work in these new spaces
and they comfort the military beneficiaries who seek care in
them. They become healing environments for our patients and
they inspire confidence in their families.
As a child who was raised in and around Army hospitals and
clinics myself, a husband and a parent of an Army family who
has received care in these same and some newer medical
treatment facilities, and as an Army physician who has served
and commanded a variety of hospitals, I can tell you I have
witnessed firsthand the impact that improvements of our
infrastructure made.
I was one of the first chiefs of medicine at the new
hospital that we opened in 1992 in Madigan Army Medical Center
at Fort Lewis, Washington and I helped lead the transition from
that.
The impact of that new facility was really nothing short of
startling.
The old hospital, although it was beloved for this
sprawling one-story cantonment facility, it covered many, many
acres and miles and miles of corridors, it was really a
challenge for all of those who attended to the sick and for our
patients, as well.
And the new hospital, when we built it, was sited such that
it either looked out over Mount Rainier or the Olympic
Peninsula, and it had an instantaneous effect on patients.
It created a sense of patient and family-centered care and
patient-friendly waiting areas and clinic spaces, the impact of
all that light and fresh air, and even the selection of
photographs, of artistic photographs that we had really was
instantaneous on patients.
I saw it in my patients' faces, I heard it in the voices of
their families, and I witnessed it in the renewed energy of our
staff.
We really had little difficulty, following opening that
building, attracting trainees into my department and we used it
as a major recruiting tool for Army medicine, and continue to
this day.
The three services and the TRICARE Management Agency have
worked hard to develop an objective process for prioritizing
medical MILCON requirements through this capital investment
decision model. I won't go into it at length. You have heard
about it from my colleagues.
But its criteria focus on supporting all of our needs
simultaneously and, also, targets the heart of health care,
looking at the need for functional modernization and customer
and patient-centered care, our productivity and how we use our
space.
In 2008, we in the Army participated in the development of
the first version of this prioritization model and I believe it
really is a step in the right direction. But it requires
continuous development and refinement.
The Army is challenged, as all my colleagues have
described, with aging facility infrastructure, with growing
workload, and caring for a large portion of our DOD
beneficiaries. We maintain about 40 percent of the total
inventory of medical buildings, 1,800 in total, of which 386
are direct health care facilities with a replacement value of
about $9 billion.
Our critical priorities right now for hospital replacement
are at Fort Hood, Texas and Fort Bliss, Texas, Landstuhl,
Germany, Fort Irwin, California, and Fort Knox, Kentucky.
We have identified requirements for another 12 hospital
expansions, 25 health and dental clinic replacements or
expansions, and 16 force projection projects. These are
research facilities and blood centers and preventive medicine
clinics and training facilities.
As Landstuhl Regional Medical Center, which many of you, if
not all of you have gone through and probably been impressed by
its critical role in evacuation of casualties back home,
approaches its 56-year anniversary, we see this as a critical
need for replacement.
Landstuhl is an enduring part of our evacuation and
treatment plan for wounded, ill and injured soldiers throughout
the world and I would ask you to consider it as a significant
infrastructure need.
We also continue construction on a state-of-the-art
replacement facility for the United States Army Medical
Research Institute for Infectious Diseases, the hot zone up in
Fort Detrick, Maryland. This is part of a national interagency
bio defense campus that has partnered with the National
Institute for Allergy and Infectious Diseases, the Centers for
Disease Control and Preventive Medicine, the Department of
Homeland Security, and the United States Department of
Agriculture.
It is a realization of a post-9/11 vision that brings
vastly different and new government agencies together for a
common cause. Providing appropriate facilities for this and
other areas of medical research are just as important as our
hospitals and contribute greatly to the readiness of our
soldiers and the defense of our country.
I respectfully request that we continue the support of the
DOD medical construction requirements that deliver treatment
and research facilities that are the pride of this Department.
In closing, I want to thank you on the Readiness
Subcommittee for your interest in this issue and the Military
Personnel Subcommittee for your vigorous and enduring support
of the defense health program and of Army medicine.
I greatly value the insights of the Armed Services
Committee and look forward to working with you and your staffs
over the next year.
Thank you for holding this hearing and thank you for your
continued support of the Army medical department for our
warriors and our families.
[The prepared statement of General Schoomaker can be found
in the Appendix on page 68.]
Mr. Ortiz. General, thank you so much. And we want to thank
all the witnesses and all the staff for the fine work that you
have done and will continue to do for delivering the best that
you can medically for our soldiers.
Mr. Potochney, let me ask you a question. On Monday, we had
the opportunity to visit Bethesda and see the magnificent care
that is being provided to the wounded warriors, and, frankly, I
was very, very impressed. So were the members who were with us
on this tour.
We were also briefed on the magnitude of the BRAC effort
associated with the realignment of Walter Reed. We were told
that the moves associated with this realignment would occur in
August 2011, one month before the statutory deadline.
Maintaining the quality of care that exists today is
extremely important. Now, how important, in your estimation, is
meeting the September 2011 deadline and what steps will be put
in?
I have been here several years in the Congress. I am just
wondering, how did we get to the 2011 date? Was it you in the
medical field? Was it DOD? How did we get to that date, 2011?
Was it the BRAC commission?
Maybe that is the first question that we would like to
know.
Mr. Potochney. I will take the first shot at it, if I
could, sir. The Department is implementing the BRAC commission
recommendation on the schedule that it established.
A year and a half ago or so, the Department also decided to
enhance and accelerate, but mostly enhance, some of the
construction and the facilities at Bethesda, which has
stretched out some of the construction.
So the Department itself, and we can't blame it on the
commission, has decided upon a construction schedule, a
facilitization schedule that brings us bumping up against the
end of the statutory six-year period, which is September 2011.
That is the answer to your first question, sir, I believe.
Yes, we did it.
Mr. Ortiz. The thing is this, I know you are going to
receive the hospital when the construction is finished, but
then you are going to have to buy a lot of equipment and a lot
of equipment would be there, there would be testing on the
equipment.
Is it realistic to say that by September 2011, not only
will the hospital be finished, but that you will also have all
the equipment to start functioning as a first class hospital?
Mr. Potochney. Yes, sir. I wouldn't argue that it is an
aggressive schedule and it is a challenge. Admiral Madison, who
you all met on Monday, is confident, and we have spoken at
length about this, that while it is aggressive and it is a
challenge, he can do it and he wants to do it that way.
He will have equipment delivered before then and the
hospital will be run through its paces. But the actual
transition of patients over into the new facility will happen
in a compressed period of time within the statutory deadline.
Why is it a compressed period of time? Admiral Madison
feels strongly, based on his own opinion and the research that
he has done, that doing it in a compressed period of time is
the best for the patients.
In other words, if you will permit me, it is do it in a
concentrated effort, get it over with quick, so you are back up
and running as fast as you can, and that is his position.
Mr. Ortiz. So you feel comfortable that by the date of
September 2011, you will be running smoothly and ready to go.
Mr. Potochney. Yes, sir. But I can't say that we are not
wary and exercising a fair amount of vigilance to make sure
that it remains on track.
Mr. Ortiz. We want to be sure that this does not degrade
the quality of care. This is why earlier I said what we would
like to do--and I don't want you to feel pressure from me or
from some of the members here--we want you to do it right.
Mr. Potochney. Yes, sir. So do we.
Mr. Ortiz. And this is more important than anything of
meeting a deadline. But it will not degrade the quality of care
that you are going to----
Mr. Potochney. Yes, sir. We have signed up to that and
right now we are on a schedule that we can meet.
If something changes, I am sure you will be seeing that as
quickly as we are.
Mr. Ortiz. And just like I stated earlier, we walked into
the hospital and we were so impressed. For once, I saw
something that I said, ``My God, they have it right,'' the way
you are giving treatment to the warriors.
I don't want to take too much time, because we have got a
lot of members here who have a lot of questions.
But I would like to turn it over now for questions to my
good friend, the chairperson of the Military Personnel
Subcommittee, Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
Again, thank you, all of you, for being here and for your
service to our country.
General Schoomaker, I wanted to ask you about any
limitations that the Army may have providing care as a
consequence of an undersized or antiquated military treatment
facility.
The issue really is that if we have an MTF commander who
feels a need to send a beneficiary downtown, for example,
because they can be treated in the facility for whatever reason
that might be, perhaps it is because they would get treatment
sooner if they did that, if they went to another facility.
Does the MTF then not get credit for that workload and can
that come back at some future time to suggest that the workload
isn't as great as they might be representing? How might it
affect future budgets down the line?
How does the decision-making around that impact future
budgets or even the workload generally?
General Schoomaker. Well, ma'am, I think that is an
excellent question. I would say in the past, we would have been
much more focused on what I call how many widgets of health
care we build and deliver in sort of a simple productivity
model.
But I think that led to some bad clinical and business
practices, not the least of which was an impetus to hospitalize
people when perhaps management in an ambulatory setting was
much more important.
What we in Army medicine are doing, and I am pleased to say
that we, across the Military Health System (MHS) are doing
increasingly, is shifting to a model that really looks at the
total outcome of care and asks the question, ``What is best for
a patient and what does the patient need for that particular
condition and/or what can we do to prevent the beneficiary from
being a patient at all by doing preventive measures.''
And so we are shifting a lot of our resources and our
revenue generation, if you will, toward prevention and toward
outcomes.
I, frankly, spend more time with my commanders, regional
commanders and, through them, my medical treatment facility
commanders, focusing on, ``Are you practicing good evidence-
based medicine? Are you practicing good preventive medicine,''
and not whether they are shifting work downtown or keeping it
within the hospital.
Mrs. Davis. Is there a lot of care that is being shifted?
How would you characterize the kind of care that needs to be
diverted from a major facility?
General Schoomaker. Well, we still perform the vast
majority of the care, both inpatient and ambulatory care,
within the direct care system. We are sending more cases of
patients that are enrolled in our facilities downtown, as we
are taking care of more wounded, ill and injured soldiers, as
we are more intensively placed in there, as we deploy our own
caregivers to theater of operation and don't prompt replacement
because of hiring lags and the like.
But those are the dynamics that generally--and then there
are highly specialized care that may be given, say, in South
Carolina at Columbia. We won't necessarily have highly
specialized cancer care or something and so we lean upon or we
depend upon our colleagues in the VA and Columbia or in the
private sector to deliver that care.
That is really kind of the rubber band between the direct
care system, as we call it in our uniformed services, and our
TRICARE managed care support contractors.
Mrs. Davis. I know in certain areas it is going to be more
than others, but is there a way of saying that a third of the
care, a quarter of the care?
General Schoomaker. No, ma'am. I would say my ballpark
would be across Army medicine, I would estimate that probably
no more than about 20 percent of the care that we enrolled in
our hospitals is going downtown and that shift to downtown for
specialty care or when families are displaced by soldiers that
are growing in the community, that is occurring in a minority
of the cases.
Does that answer your question, ma'am?
Mrs. Davis. I think so. I think part of the concern is I
think initially is that there is--is there a reluctance to even
send a beneficiary for care someplace else?
General Schoomaker. Yes, ma'am. I think there is very much
a reluctance, in part, because when we use the network of care,
if I have enrolled--we use very, very strict enrollment models
to ensure that our hospitals do not over-enroll to their
capacity to deliver primary care, which is the principal driver
for getting sub-specialty care.
There is a reluctance to send our enrollees into the
network, for a number of reasons. Number one, it disrupts
continuity of care. Number two, we don't have the information
systems that give us ready access to what is done downtown and
it may take us a month or longer sometimes to get information
back about the patient that has gone downtown.
So is there a reluctance? There is, but I have given direct
and specific orders to all of my subordinate commanders that
they will not compromise access standards under the TRICARE
published access standards in order to hang onto a patient that
should go downtown.
Mrs. Davis. All right. Thank you. I appreciate that.
Kind of quickly, I think it has been mentioned, Dr.
Casscells mentioned the fact that there are about 59 hospitals
in the military health system.
And how many of those, Dr. Schoomaker, are Army of those
59?
General Schoomaker. I have a total of how many 36--35, 35
hospitals in the Army.
Mrs. Davis. When you look at the system that is being used
now in terms of the prioritization, and we, obviously, have
representation here in Congress, no matter how many issues we
have, we have one vote on a particular issue.
Does that in any way compromise the outcome whether or not
you could move and each have a single vote as opposed to a
collective vote on those issues or even a proportional vote?
General Schoomaker. Well, I have suggested that I get the
entire vote, but that didn't go over very well with my
colleagues.
Ma'am, I think this is one of the really tough things about
running the CIDM process is trying to decide the strategic
value of various installations and various facilities and
ensuring that, as a Department, that we don't leave someone
behind simply because they don't have a constituency.
You heard my comments about Landstuhl. I think you heard
Admiral Robinson's comments about Guam. It is very hard to get
a constituency for some of our Outside the Continental United
States (OCONUS) facilities, even though they may have strategic
value to the force.
So I look at the CIDM process, I characterize it the way we
look at personnel sometimes, we are not happy until everybody
is equally unhappy.
Mrs. Davis. Thank you. Thank you, Mr. Chairman.
Mr. Ortiz. Mr. Wilson.
Mr. Wilson. Thank you, Chairman Ortiz.
I want to join you and my colleagues for the opportunity
that we had to meet with Admiral Madison and his staff. It was
really exciting to me, just as it was for you, to see the
dedicated staff.
They were so interested in the wounded warriors, each one.
They were so proud of the progress that they were making. It
just made you feel so good to see the extraordinary planning
and thoughtfulness put into the individual care given to each
one of these young people who make such a difference for our
country.
Additionally, for each of the surgeon generals, I think you
should be--I want to thank you for making military medicine
some of the most advanced in the world.
It is looked to around the world as leading the efforts in
terms of prosthetics, in terms of trauma care, in terms of
preventive virtual medicine, on and on. I wish the American
people knew of how extraordinary military medicine is and the
challenge that you have.
And for each of the surgeon generals, and you have touched
on this, but all of you have hospitals and military facilities
that would be considered old by any standard.
How do you each of you prioritize the facilities that you
submit to the military health system MILCON prioritization
process and what are your top priorities for medical MILCON for
the next five years?
Admiral, I had the opportunity to fly over, I didn't
actually visit, the Naval hospital last month at Guam, but I am
very happy, as the Marines are being relocated there, to hear
that that is proceeding.
Admiral Robinson. Yes, sir. Thank you very much for the
opportunity.
Guam is proceeding. I think that Guam represents the
overseas OCONUS facility that doesn't necessarily have the
constituency, does not necessarily have the TRICARE network
downtown that can take care.
Not suggesting a network doesn't exist, but it doesn't have
the robust network that a CONUS facility may have.
So the point is that the educational, development,
instructional programs, the exceptional family member programs,
the programs that are related to specialty care with the
network, all of those programs may be at either lesser
condition or may not exist OCONUS, which then makes those
facilities a top priority, from a Navy medicine perspective,
because then I would have to make sure that the men and women
and families there are cared for appropriately in that
particular geographic location.
I also think, related to the question of network care and
going downtown, network care and access standards are always
going to drive how we do business, and they should.
At the same time, the reasons that patients often don't
want to go downtown or we send them downtown is that they don't
want to go down, they would rather stay with us.
With that said, we will never degrade care or get into a
quality issue with the patient related to an access standard.
I would suggest that if we could relook at network and how
we run military networks within a geographic area and give more
responsibility to local commanders with the network, that there
could be a more seamless and effective method of how we would
actually run our patients and the network, both from the direct
and the purchase care side, so that we could have a better and
a much easier system of care, and I think the continuity and
the quality would follow.
General Roudebush. Mr. Wilson, I appreciate your question,
because it helps me put things in context for the committee.
As I mentioned, a significant amount of our medical
facilities were built within 15 years after the Air Force was
established.
The Air Force is positioned across the United States,
generally in small communities, and many of our medical
facilities were, in fact, small hospitals.
But we very appropriately followed the U.S. medical model
and we closed those small hospitals in favor of ambulatory
clinics, because they didn't have the critical mass, they were
costly, and, frankly, they were not safe.
They didn't have the caseload and complexity to maintain
the currency that the staff would require.
So we followed that model and we have a significant number
of ambulatory facilities, which really are in old inpatient
chasses which have been modified over the years.
So those do, in fact, create a concern.
Now, I will tell you that we have 15 hospitals and we have
leveraged our O&M dollars, as well as our MILCON, to maintain
those platforms, although several of those come up on the
priority list that you asked about, and two primary ones would
be the Wilford Hall Medical Center, which, under BRAC, becomes
a large ambulatory surgical center, as does the Andrews
Hospital become an ambulatory surgical center.
So from an aging infrastructure standpoint, they need to be
replaced, and from an alignment with BRAC, to assure that they
are viable parts of that BRAC outcome, they need to be
replaced.
So that is, in fact, driving our prioritization as we work
through this process, along with other facilities in the 2010-
2011 window, but that is where we find ourselves with aging
facilities, but also the need to align appropriately with other
activities, with our sister services and BRAC.
General Schoomaker. Sir, we use a model of prioritization
that is based upon three principal factors, what the current
condition of the hospital or the facility is and how much it is
going to cost to repair that.
Obviously, the more that is going wrong within a facility
that we can't get back to a safe and high standard, then the
more impetus to replace it.
We look at the population that is supported by that
facility and what its capacity is to take care of that
population, to include the population that is moving.
I think you all are aware that the Army right now is going
through four simultaneous kind of word salads--Global Defense
Posture Realignment, Grow the Force or Grow the Army, Army
modularity, and Base Realignment and Closure--GDPR, GTA, AMF
and BRAC are moving about 250,000 people right now, the largest
movement of soldiers and their families across communities in a
generation.
And so we are also looking at projected populations served
by those facilities.
The last thing I will make a comment about, as General
Roudebush says, although we tend to be sort of hospital-centric
in our thinking, we are comprehensive in building facilities
that attend to the health requirements and dental requirements
and preventive medicine requirements and veterinary public
health requirements of that community, and I don't think we
want to lose track of that.
Mr. Wilson. Thank you very much.
In the interest of time, I will submit further questions,
because we have votes.
Mr. Ortiz. We will now allow Mr. Reyes to ask a question,
because it will take 45 minutes before we come back and you are
very important individuals. We don't want to keep you here.
So we will proceed with Mr. Reyes. Do you have a question?
Mr. Reyes. Yes, Mr. Chairman, thank you.
Secretary Casscells, the Navy surgeon general stated in his
opening statement that the replacement of the Naval hospital at
Guam is the top military construction priority identified by
the capital investment model.
Can you share that report with our committee and, also, can
you tell us how new missions, like expansion or Grow the Army
and return of overseas troops are accounted for in that model?
Secretary Casscells. Mr. Reyes, I will be able to share the
detailed analyses that Admiral Robinson mentioned in just a few
weeks' time.
I can say, as a general matter, that Grow the Force and
Grow the Army initiatives are generally paid for by the Army,
not by the defense health program.
The defense health program pays for the bulk of the
replacement and maintenance of these facilities, but those two
initiatives are really line initiatives.
We work closely with the services, for example, Fort Bliss,
as you know, and Fort Sam Houston, which are both impacted by
multiple Army initiatives, transformation, Grow the Force and
so forth.
So all the cards are on the table when we make the--when
the military health system makes its decision.
As you know, it is a process that the surgeons and I
jointly devised and we jointly participate in with our staffs,
equal votes. And I must say these are some tough calls, but we
have ended up in unison on these so far.
What we hope to be able to tell you in a few weeks is the
detailed results of that as part of the President's budget and,
hopefully, a year from now, those who will still be with you,
like General Schoomaker, will be able to tell you whether the
capital investment decision model is, in fact, the plus that we
think it is right now.
Right now, it is promoting communication and transparency
and unity. So far, it looks good.
Mr. Reyes. Well, it doesn't look too good from where I am
sitting, because Fort Bliss is about to quadruple in size, in
troop size. We are going to have 100,000 to 125,000 people that
are going to depend on the facility there, which was designed
to accommodate about 12,000 troops.
So my concern, and this is why I asked the question, my
concern is being up there as the next priority, because if we
are not, then we are not going to have a medical facility ready
and prepared for all the troops that get assigned to Fort
Bliss.
I had a discussion with General Schoomaker earlier on that
and he has promised to get back to me on several questions that
I had. But there has got to be a way to factor into your
formula, into your decision, facilities like mine that don't
have adequate medical facilities and are going to grow the way
they are.
So I hope you take that into account and I am going to
follow up with both you and General Schoomaker in the next week
or so.
Secretary Casscells. Yes, sir. May I just follow on and say
that my medical privileges as an Army Reserve doctor are at
William Beaumont and I know it well. I know its shortfalls.
That was where my pre- and post-deployment experiences were. I
have been a patient there, and I absolutely agree with you.
I can only say that our understanding with the Army now is
that they have got that covered, but it is our obligation
collectively to make sure that that comes true.
Mr. Reyes. Very good. Thank you.
Thank you, Mr. Chairman.
Mr. Ortiz. Thank you so much.
I would like now to allow members--I am sorry.
Mr. Kline, do you have a question?
Mr. Kline. I do, Mr. Chairman, thank you very much. I will
just get the answer for the record once I ask for a nod.
General Schoomaker, you mentioned there are three services,
and, of course, there are, that provide medical services. But
there is a fourth service that uses those medical services,
generally, in the responsibility of the admiral.
But I know, from my past experience, there are a lot of
Marines who live down at Quantico who go to Fort Belvoir
because there is no Naval hospital at Quantico, and we are
building a new facility there, as we are BRACing Walter Reed
and so forth.
And I just want to be reassured that CIDM and the system is
accounting for that fourth service.
And there will not be time for an answer, because we have
got a vote. But if the system accounts for that, then we are on
track. But it is an Army hospital. It has got a lot of Marines
and other service, but particularly because there is a very
large Marine contingent at Quantico, if somebody will just tell
me that the system has accounted for that.
[The information referred to can be found in the Appendix
on page 77.]
Secretary Casscells. Absolutely, absolutely.
Admiral Robinson. It not only does, because Guam is a
number one priority partly because of the Marine growth at----
Mr. Kline. I understand that, but that is because of
Marines living there at Guam. This is a little bit different
situation.
We have got a vote. I am going to yield back, but I would
like to follow up with your staffs on how that works.
Thank you.
Mr. Ortiz. Thank you so much.
What I would like to do is to allow other members who
couldn't be here to submit questions for the record, and I know
that there are many questions.
I wonder if my good friend, the chairwoman of the
personnel--do you have any statement?
Thank you so much. You were outstanding witnesses today.
The hearing stands adjourned.
[Whereupon, at 3:14 p.m., the subcommittees were
adjourned.]
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A P P E N D I X
March 18, 2009
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March 18, 2009
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
March 18, 2009
=======================================================================
RESPONSE TO QUESTION SUBMITTED BY MR. KLINE
Secretary Casscells. The respective priorities of each component of
the Military Health System (MHS) have been reflected in the efforts to
develop and employ the Capital Investment Decision Model (CIDM).
Representatives from the Surgeons General of the Army, Navy, and Air
Force actively participated in the development of the CIDM. They
collectively helped establish the evaluation criteria and business
rules associated with the CIDM. The Capital Investment Proposals that
were submitted for evaluation and prioritization were all generated by
the staffs of the Surgeons General and reflected their highest
priorities at the time of submission in May of 2008. One of the key
evaluation factors for each proposal was alignment with elements of the
MHS Strategic Plan, developed in concert with the Assistant Secretary
of Defense (Health Affairs) and Surgeons General. Every effort has been
made, and will continue to be made, to ensure the priorities of each of
the Military Services find voice in the process to identify, evaluate,
and prioritize medical capital investments in the MHS.
With respect to Quantico, the Navy provides medical support to the
Marines and operates the existing medical facilities on the
installation, including the Branch Health Clinic and smaller clinics at
the Officer Candidate School and the Basic School. The ongoing
initiative to ``grow the Marine Corps'' will result in modest increases
of approximately 300 per year to the levels of officers and officer
candidates that receive training at Quantico. This increase is not
sufficient to significantly augment the existing medical facility
infrastructure or provide inpatient services at Quantico.
The National Capital Region (NCR) is one of the largest and most
complex markets in the MHS. The NCR is also experiencing profound
change resulting from Base Realignment and Closure (BRAC): Walter Reed
Army Medical Center will close; the current National Naval Medical
Center will expand and become the Walter Reed National Military Medical
Center; and the obsolete hospital at Fort Belvoir will be replaced with
the most robust community hospital in the Department of Defense's
(DOD's) inventory. Construction of the new facilities is well underway
at Bethesda and Fort Belvoir. To support coordinated execution of the
changes wrought by BRAC and manage the market-wide delivery of health
care services, DOD established a Joint Task Force. The Joint Task Force
will continue to assess demand within the market and will allocate
resources to facilities in the NCR to best meet that demand. Should the
Joint Task Force eventually determine the need to further expand
medical capability in or around Quantico, it will pursue the
appropriate facility or operational solution. But, for the foreseeable
future, specialty care, hospital services, and inpatient care will
continue to be provided at the hospital on Fort Belvoir. [See page 22.]
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=======================================================================
QUESTIONS SUBMITTED BY MEMBERS POST HEARING
March 18, 2009
=======================================================================
QUESTIONS SUBMITTED BY MR. WILSON
Mr. Wilson. I have heard that a major problem with military medical
construction projects is that by the time the facility opens its door
for the first time it is already either too small or not properly
designed to accommodate the current and future population it is meant
to serve. How does the new prioritization process produce a facility
better aligned to the population it is intended to serve?
Secretary Casscells. Reducing the ``time to market'' required to
bring new medical facilities online is a challenge faced in both the
public and private sectors. The increasingly rapid evolution of health
care technology, information systems, and clinical practices makes
accurate forecasting of facility size and configuration extremely
difficult.
One of the stated goals of implementing the new Capital Investment
Decision Model (CIDM) is expediting the planning and acquisition of
military medical facilities. The template used by the Army, Navy, and
Air Force for submission of proposed capital investments has been
standardized and simplified. CIDM has emphasized increasing the use of
parametric cost estimating in lieu of devoting the time and resources
necessary to attain a 35% design. Less specificity on the exact size
and content of a proposed facility is required prior to submission for
approval. CIDM encourages the execution of more parallel activities and
acquisition strategies such as design/build, in which the designer and
builder work together. This contrasts with the more traditional design/
bid/build approach, which relies on a sequential processing of tasks
that in turn extended the time to market.
There are other initiatives underway by the Military Health System.
The United States Army Corps of Engineers and the Naval Facilities
Engineering Command intend to expedite the delivery of Department of
Defense medical facilities. Successful implementation of CIDM is one of
many efforts that, hopefully, will reduce the potential for a
misalignment of facility capability with the needs of the population.
Mr. Wilson. How does the new Capital Investment Decision Model
(CIDM) differ from the process used by the Department of Defense (DOD)
and the Military Services to develop priorities for nonmedical military
construction? What is the benefit of having a unique process for
medical construction?
Secretary Casscells. The Military Health System (MHS) needed a
rational, transparent, and structured method to evaluate competing
priorities for a finite pool of military construction (MILCON)
resources. Prior to implementation of the CIDM, a satisfactory process
did not exist to prioritize candidates for MILCON funding. There was
not a reliable procedure to rank order potential MILCON investments
that reflected both the needs of each Military Service as well as the
strategic imperatives of the MHS overall. The CIDM is similar to the
manner the Department of Veterans Affairs (VA) has ranked their
proposed facility projects for several years. As is the case with the
MHS, the VA must also use a rational and structured process to identify
its highest priorities across a large, complex organization with
multiple stakeholders.
The processes employed by the Military Services and other entities
within DOD to prioritize their respective MILCON programs vary and may
be influenced by such factors as size, scope, complexity, and culture.
Each component establishes their own business rules and evaluation
criteria consistent with particular needs as they strive to meet
individual challenges in setting priorities and allocating resources.
However, several components have adopted the same approach and employed
the same commercial software product, Decision Lens, as the MHS. For
example, Decision Lens is used by the following entities to support
their respective decision-making in the areas noted:
Joint Staff
Budget Allocation, Capabilities Planning, IT
Selection, and Source Selection
National Geospatial Intelligence Agency
Budget Allocation, IT, Human Resources, and
Intelligence Analysis
United States Navy--Commander, Navy Installations
Command
Budget Allocation
United States Army Special Operations Command
Budget Planning
United States Air Force Research Lab
Strategic Planning, Budget Allocation for Research
and Development
United States Navy N6--SPAWAR--NETWARCOM--PEO C4I
IT Capital Planning and Portfolio Management
The logic and approach to the CIDM is not unique to DOD or the
Federal Government. The basic concept of using transparent evaluation
criteria within a structured process to determine priorities is logical
and has been employed in varying forms throughout the public and
private sectors. It has proven to be particularly useful for the MHS
for several reasons. Typically, medical facilities are some of the most
expensive and complex buildings within the DOD. Health care is one of
the most dynamic fields of endeavor, subject to constant change in
medical technology, information systems, clinical practice, diagnostic
techniques, and patient and family expectations. Few other facility
types within the DOD inventory must address the challenges of cost,
complexity, and dynamism. In today's challenging environment, the MHS
needs an approach to the capital investment decision making process
that is transparent, logical, structured, and addresses the needs of
each of the Military Services and MHS. Implementing the CIDM last year,
and continuously striving to improve future versions, will help ensure
precious medical MILCON resources are used to their best advantage.
Mr. Wilson. I have heard that a major problem with military medical
construction projects is that by the time the facility opens its door
for the first time it is already either too small or not properly
designed to accommodate the current and future population it is meant
to serve. How does the new prioritization process produce a facility
better aligned to the population it is intended to serve?
Mr. Potochney. Reducing the ``time to market'' required to bring
new medical facilities on-line is a challenge faced in both the public
and private sectors. The increasingly rapid evolution of health care
technology, information systems, and clinical practices makes accurate
forecasting of facility size and configuration extremely difficult.
One of the stated goals of implementing the new Capital Investment
Decision Model (CIDM) is expediting the planning and acquisition of
military medical facilities. The template used by the Army, Navy, and
Air Force for submission of proposed capital investments has been
standardized and simplified. CIDM has emphasized increasing the use of
parametric cost estimating in lieu of devoting the time and resources
necessary to attain a 35% design. Less specificity on the exact size
and content of a proposed facility is required prior to submission for
approval. CIDM encourages the execution of more parallel activities and
acquisition strategies such as design/build, in which the designer and
builder work together. This contrasts with the more traditional design/
bid/build approach, which relies on a sequential processing of tasks
that in turn extended the time to market.
There are other initiatives underway by the Military Health System,
the U.S. Army Corps of Engineers, and the Naval Facilities Engineering
Command intended expedite the delivery of DOD medical facilities.
Successful implementation of CIDM is simply one of many efforts that
hopefully will reduce the potential for a misalignment of facility
capability with the needs of the population.
Mr. Wilson. How does the new Capital Investment Decision Model
differ from the process used by DOD and the military services to
develop priorities for non-medical military construction? What is the
benefit of having a unique process for medical construction?
Mr. Potochney. The Military Health System needed a rational,
transparent, and structured method to evaluate competing priorities for
a finite pool of military construction (MILCON) resources. Prior to
implementation of the Capital Investment Decision Model (CIDM), a
satisfactory process did not exist to prioritize candidates for MILCON
funding. There was not a reliable procedure to rank order potential
MILCON investments that reflected both the needs of each of the
military services as well as the strategic imperatives of the overall
MHS. The CIDM is similar to the manner in which the Department of
Veterans Affairs (VA) has ranked their proposed facility projects for
several years. As is the case with the MHS, the VA must also use a
rational and structured process to identify its highest priorities
across a large, complex organization with multiple stakeholders.
The processes employed by the military services and other entities
within DOD to prioritize their respective military construction
programs vary and may be influenced by such factors as size, scope,
complexity, and culture. Each establishes their own business rules and
evaluation criteria consistent with their needs as they strive to meet
their own challenges in setting priorities and allocating resources.
However, it is worth noting that several have adopted the same approach
and employed the same commercial software product, Decision Lens, as
the MHS. For example, Decision Lens is used by the following entities
to support their respective decision-making in the areas noted:
The Joint Staff
Budget Allocation, Capabilities Planning, IT
Selection, and Source Selection
National Geospatial Intelligence Agency
Budget Allocation, IT, Human Resources, and
Intelligence Analysis
US Navy--Commander, Navy Installations Command
Budget Allocation
US Army Special Operations Command
Budget Planning
US Air Force Research Lab
Strategic Planning, Budget Allocation for Research
and Development
US Navy N6--SPAWAR--NETWARCOM--PEO C4I
IT Capital Planning and Portfolio Management
Decision Lens also has several other clients within the Federal
Government and private industry, including the Department of
Agriculture, National Archives and Records Administration, the Nuclear
Regulatory Commission, Amtrak, and eBay.
The logic and approach to the CIDM is not unique to the DOD or even
the Federal Government. The basic concept of using transparent
evaluation criteria within a structured process to determine priorities
is logical and has already been employed in varying forms within the
public and private sectors. It is has proven to be particularly useful
for the MHS for several reasons. Typically, medical facilities are some
of the most expensive and complex buildings within the DOD. Health care
is one of the most dynamic fields of endeavor, subject to constant
change in medical technology, information systems, clinical practice,
diagnostic techniques, and even expectations of patients and families.
Few other facility types within the DOD inventory can match these
challenges of cost, complexity, and dynamism. In today's challenging
environment, the MHS clearly needs an approach to capital investment
decision making that is transparent, logical, structured and addresses
the needs of each of the military services as well as the MHS.
Implementing the CIDM last year, and continuously striving to improve
future versions, will help ensure that precious medical MILCON
resources are used to their best advantage.
Mr. Wilson. I understand that the new MILCON prioritization process
has only been in place for a short time but from your perspective how
can it be improved to better meet service priorities?
General Schoomaker. The three Services, in conjunction with the
TRICARE Management Activity, are currently working on the next version
of the medical MILCON prioritization process with the intent of using
this new process during the next program build. Areas for improvement
include refining evaluation criteria, structuring submissions to ensure
a consistent approach in addressing criteria, and accounting for the
various service equities (for example, the Army comprises 46% of the
overall medical building square footage in the Military Health System).
The evaluation criteria should separately address the different types
of medical facilities (i.e. hospitals versus medical clinics versus
dental clinics versus veterinary clinics versus medical warehouses)
rather than attempting to compare them against each other. The criteria
should validate the beneficiary populations versus the enrolled
populations when describing the required capacity, and should normalize
the infrastructure assessments across the three Services to achieve an
equivalent comparison.
Mr. Wilson. The military medical facilities at Ft. Jackson, Naval
Hospital Beaufort and Naval Hospital Charleston in South Carolina are
all at least thirty-five years old. What are your plans to either
modernize or replace these facilities?
General Schoomaker. Fort Jackson is an important installation that
supports the Army's training mission. In FY08, the Army funded a
facilities planning effort at Fort Jackson to determine whether any
gaps exist between healthcare requirements and facility capabilities.
This effort will also scope requirements to address any identified
gaps. The analysis is still underway and will culminate with the most
critical military construction requirements being prioritized in the
spring of FY10 for inclusion in future budget requests.
Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
General Schoomaker. The greatest challenge is keeping our
facilities functionally relevant to the changes in the provision of
care. Adaptability and flexibility are the keys to meeting the facility
needs of a dynamic healthcare system. A properly maintained facility
``ages'' due to the lack of proper recapitalization to meet the
changing needs. The Military Health System (MHS) recently established a
31-year capitalization rate, with the expectation of several
renovations before the 30-year mark. The decision to reduce this rate
from the original 50-year target led to a requirement to increase the
overall funding in the medical military construction program. DOD
responded by providing a significant increase in funding, which will
help us improve our facilities after years of flat funding.
Healthcare advances through improvements in technology and use of
evidence-based medicine. In many cases, improved practices and
procedures rely on equipment and infrastructure to ensure proper
clinical outcomes. A great example is the diversity of imaging, which
focused on the traditional X-ray for many years. This area has now
grown into multiple forms of imaging, to include interventional
radiology where procedures are conducted using real-time imaging. These
changes require the facility to transform to accommodate the technology
and the procedures.
Keeping pace with these changes in aging facilities requires more
frequent renovations to meet the demand. The MHS is faced with facility
functional failure, as opposed to infrastructure failure. The Army
Medical Department's aggressive approach to Facility Life Cycle
Management ensures reliable facility infrastructure, but is limited in
addressing a facility's functionality. The majority of the Army's
healthcare facilities were designed between 1950 and 1980, when our
focus was on inpatient care. Healthcare delivery has changed
significantly from inpatient to outpatient settings and now includes
new methods such as same-day surgery and mother-baby care. The
inability of some of our facilities to adjust to these changes has
rendered them functionally failing.
Maintaining relevancy in a dynamic healthcare environment requires
either more flexibility in using operations and maintenance funding
and/or a military construction program that is more adaptable to the
environment. Current budget planning cycles do not allow for rapid
adjustments. The current ``new work'' limitations for DOD facilities
severely limits the use of operations and maintenance funds to meet
rapid changes in healthcare. This leads to operating outpatient clinics
and administrative functions within inpatient spaces, resulting in high
maintenance costs, poor space utilization, and frustrated staff.
Mr. Wilson. Over the past twenty years BRAC requirements and
decisions by the military services have significantly changed the size
and type of medical facilities in the Military Health System. How well
do the remaining hospitals and clinics meet our beneficiaries' needs
and where would you make additional changes to provide the best care
possible? With so many clinics and small hospitals, how do you provide
medical personnel with the necessary experience to maintain their
clinical skills?
General Schoomaker. With the reduction in medical services
available because of BRAC and Overseas Contingency Operations, the Army
Medical Department (AMEDD) has taken steps to ensure that our
beneficiaries continue to receive the highest level of care. For
example, the AMEDD routinely cross-levels resources from areas of less
need to areas of greater need. In addition, we hire contract providers
and use TRICARE network providers in the local community.
BRAC and Grow the Army decisions drove construction and staffing
requirements to meet the expanded population's health and dental care
needs. In some cases, with the help of the DOD and Congress, we were
able to consolidate these growth requirements with additional funding
to completely recapitalize a facility instead of adopting a piecemeal
approach. The DOD also recognized the positive impact that facilities
have on the quality of care and increased the levels of funding in our
medical MILCON program. Additional actions to provide the best care
possible include continued full funding in our Sustainment account (to
ensure proper maintenance) and continued funding of a robust medical
MILCON program to address all our medical facilities beyond the current
focus on hospitals. This would include medical, dental, and veterinary
clinics.
Medical personnel within the Military Health System maintain their
clinical skills in a fashion similar to their civilian colleagues.
Licensure and credentialing criteria apply for each individual, as well
as a competency-based assessment system. This system sets certain
thresholds that medical personnel must meet to maintain credentials in
their specific specialty. If a facility is unable to supply the
resources a provider requires to perform in his/her specialty, the
provider will be moved to a location where resources remain available.
Our staffing is frequently adjusted to optimize use of our providers
and to ensure all providers have the necessary experience to maintain
their clinical skills.
Mr. Wilson. I understand that the new MILCON prioritization process
has only been in place for a short time but from your perspective how
can it be improved to better meet service priorities?
Admiral Robinson. As the Navy Surgeon General, I was able to use
the new Capital Investment Decision Model (CIDM) process to clearly
articulate my views on Navy Medicine MILCON priorities for the current
budget cycle. The new evaluative process also accounts for the MILCON
priorities of my colleagues in the Army and Air Force through
decisional criteria weighting which helps ensure overall Service
priorities are considered on a level playing field. This process fully
reflects common agreement achieved to support the new Medicine MILCON
prioritization system across the Services. Current efforts underway by
the CIDM Tri-Service Working Group to refine the CIDM evaluative
process will retain this key decisional factor to ensure the Services
and Military Health System (MHS) leadership share a common
understanding of high priority Medicine MILCON needs. The CIDM process
also allows the MHS enterprise the ability to communicate those urgent
needs to leadership of the Department of Defense and beyond. The
Medicine MILCON project priority list delivered through CIDM represents
the core success of the new system over the previous allocation system
which did not capture the critical enterprise perspective required to
effectively program vital capital investments.
Mr. Wilson. The military medical facilities at Ft. Jackson, Naval
Hospital Beaufort and Naval Hospital Charleston in South Carolina are
all at least thirty-five years old. What are your plans to either
modernize or replace these facilities?
Admiral Robinson. The Medical Facilities on Fort Jackson are owned
by the Army and are under the purview of the Army Surgeon General.
The replacement facility for existing Naval Health Clinic
Charleston is in the final stages of construction, and is scheduled to
be operational by 30 Nov 2009. The replacement facility in Charleston
will be classified as a Naval Ambulatory Care Center with state of the
art ancillary services required to support our beneficiary population.
All inpatient services will be handled by the TRICARE network and
supported by local community hospitals in the area and other Military
Treatment Facilities as required.
Naval Hospital Beaufort is approaching 60 years of age and is in
need of replacement. The aging infrastructure at Beaufort is not
conducive to modern, outpatient-centric, healthcare delivery. We have
developed planning and programming documents for a 17 bed, 233,847
square foot replacement hospital and have submitted them to Office
Assistant Secretary of Defense, Health Affairs/Tricare Management
Activity for project consideration within the Defense Health Program
Military Construction Program. We have also secured site approval on
Marine Corps Air Station Beaufort for the replacement facility.
Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
Admiral Robinson. Aging infrastructure is not conducive to modern,
outpatient-centric healthcare. Aged facility designs are not energy
efficient and create dysfunctional flow for both healthcare providers
and patients alike. Further, modern healthcare legislation and
accreditation practices such as the Americans with Disabilities Act,
Health Insurance Portability and Accountability Act, and Joint
Commission on Accreditation of Healthcare Organizations are major
drivers for current Military Health System (MHS) space requirements.
Worth mentioning is the vast change in healthcare architecture and
engineering. Modern healthcare design and construction has led to
better patient outcomes and satisfaction. Modernizing our facilities
will greatly complement our efforts to provide world-class medicine
moving forward. Finally, aged infrastructure prevents us from taking
full advantage of new medical technologies and equipment that enhance
health outcomes in similar populations across the United States.
Mr. Wilson. Over the past twenty years BRAC requirements and
decisions by the military services have significantly changed the size
and type of medical facilities in the Military Health System. How well
do the remaining hospitals and clinics meet our beneficiaries' needs
and where would you make additional changes to provide the best care
possible? With so many clinics and small hospitals, how do you provide
medical personnel with the necessary experience to maintain their
clinical skills?
Admiral Robinson. Navy Medicine is committed to meeting the health
care requirements of our beneficiaries by maintaining a well-qualified
and robust complement of health care providers. Although Base
Realignment and Closure (BRAC) may ultimately alter the size and scope
of the health care services provided at medical treatment facilities
(MTFs), those changes are addressed and mitigated by Navy Medicine
during the BRAC planning process. In those instances where MTFs are
reduced in capability and capacity, the delivery of health care is
complemented by civilian-based provider networks established through
the TRICARE Program.
As active participants in the Joint Commission accreditation
process, we embrace the Joint Commission standards that focus on
maintaining the clinical skills of our providers. Joint Commission
standards include the Focused Provider Performance Evaluation (FPPE)
and Ongoing Provider Performance Evaluation (OPPE) programs. To
maintain an infrequently used skill, a provider can go to another
facility for temporary additional duty (TAD) where the patient volume
and MTF capacity and capability exist.
In the event that medical procedures cannot be safely supported
with the required staff and resources at a facility, those privileges
will not be granted to the provider and the medical procedure will not
be performed. Upon the providers transfer to another MTF, the provider
participates in FPPE to assure clinical competency.
Navy Medicine incorporates a Quality Assurance system and robust
Graduate Medical Education programs to maintain provider skills and
meet the health care needs of our beneficiaries. The Navy Medicine
Quality Assurance system provides continuous monitoring of the medical
practice of every privileged provider. Trends and deficiencies are
identified for corrective training. In addition to the informal TAD
training noted above, Navy Medicine has initiated a formal Professional
Update Training program that coordinates periodic clinical training to
ensure that specialists maintain their clinical skills when the
circumstances of their current assignment do not provide cases in
sufficient numbers or diversity to maintain all the clinical skills
required by their clinical privilege sheets. Navy Medicine also engages
centers of excellence, fostering internal and external partnerships,
and leverages our Navy Fellowship Training Program to provide our
physicians with training in the latest treatment and surgical
modalities.
Currently, Navy Medicine is focused on improving the integration of
health care delivery between the MTFs and the civilian networks. Our
main objective is to improve the continuity of patient and family-
centered care as patient care is provided in multiple venues. This area
represents an opportunity of improvement for the entire Military Health
System, including our civilian partners.
Mr. Wilson. I understand that the new MILCON prioritization process
has only been in place for a short time but from your perspective how
can it be improved to better meet service priorities?
General Roudebush. The Capital Investment Decision Model (CIDM) was
developed by TMA and the Services to assist in prioritizing future
capital investments across a diverse Defense Health Program (DHP)
facility inventory. Lessons learned from CIDM 1.0, the model used to
prioritize the FY10-15 DHP MILCON POM, are being incorporated into CIDM
2.0--building on our successes with selection criteria and overall
process. It is important to recognize that CIDM provides a baseline
priority list to be further shaped by variables that may include
alternative budget constraints, incremental versus phased or full
funding guidance, or supra-departmental ``must-pay'' project inserts.
Various scenarios may be presented to the Service Deputy Surgeons
General and the DASD (Health Affairs) for consideration. Their
recommendation going forward to the Service Surgeons and ASD (HA)
provides for a full vetting/advocacy of Service-specific priorities.
While CIDM 2.0 is not intended to exclusively address AFMS priorities,
it provides a reasonable and appropriate balance of our needs against
those of our sister Services and TMA.
Mr. Wilson. The military medical facilities at Ft. Jackson, Naval
Hospital Beaufort and Naval Hospital Charleston in South Carolina are
all at least thirty-five years old. What are your plans to either
modernize or replace these facilities?
General Roudebush. Since these are Navy facilities, the Air Force
defers the response to the Navy.
Mr. Wilson. What are some of the challenges of providing world-
class medicine in aging facilities?
General Roudebush. The challenges in delivering world-class
medicine within our aging facilities occur in four major categories;
patient safety, technology integration, cost, and functional
efficiency. In aging facilities, ensuring patient safety becomes
increasingly challenging. Infection control is a major facet of patient
safety. Numerous studies have shown that modern air handling systems
decrease the risk of hospital acquired infections, and the installation
of anti-microbial surfaces can also decrease hospital acquired
infections. Another aspect of patient safety is minimizing falls, which
can be accomplished through proper facility design.
Integrating new technologies is difficult, with many of our legacy
facilities having limited floor-to-floor heights that preclude larger
duct sizes, fiber optic backbones, and enhanced air handling for rooms
with the latest equipment.
The financial burden of higher sustainment costs necessary to
provide world-class medicine in older, often re-purposed, former
inpatient facilities has been significant. In one study of 3 bases with
former hospitals operating or proposed to operate as clinics, the
estimated additional cost for maintaining the outmoded and oversized
infrastructure was $29.5M per year.
Clinics operating in former hospital chassis often maintain excess
emergency generators, medical gas systems, inefficient air handling
systems, steam boilers, and nurse call systems. Functional efficiency
is compromised due to operating in ``as-is'' inpatient footprints.
Clinicians cannot optimize their practice when operating around
existing load bearing walls, tight column grids, and inefficient
circulation patterns. While this issue is challenging, we appreciate
that Congress has provided funding to make targeted renovation
investments where appropriate and replacement when necessary.
Mr. Wilson. Over the past twenty years BRAC requirements and
decisions by the military services have significantly changed the size
and type of medical facilities in the Military Health System. How well
do the remaining hospitals and clinics meet our beneficiaries' needs
and where would you make additional changes to provide the best care
possible? With so many clinics and small hospitals, how do you provide
medical personnel with the necessary experience to maintain their
clinical skills?
General Roudebush. Our beneficiaries tell us we are doing extremely
well. Their satisfaction rate for the past 6 consecutive years has been
the highest among 50 leading healthcare plans according to independent
Wilson Health Information surveys. We've accomplished this through the
care we provide in our Military Treatment Facilities and our Managed
Care Support Partnerships. These complementary means of healthcare
delivery have allowed us to optimize our services as directed by BRAC
while still delivering a world-class benefit to our military families
through our civilian partners when needed.
The Air Force Medical Service is undertaking two additional
strategies to further optimize services, the Family Health Initiative
(FHI) and Surgical Optimization. The two primary goals for these
programs are to enhance access and continuity of services to our
population, and increase the complexity of the patients seen. FHI
utilizes a patient centered medical home model to provide appropriate
staffing. This model makes the coordination of all a patient's care the
primary focus of the team and is led by a Family Practice Physician.
Surgical Optimization combines AFSO 21 advanced management and
production techniques to decrease operating room changeover time
resulting in a greater throughput of surgical cases. This increase in
cases bolsters the currency of surgeons and their staff. It also
improves outcomes through increased proficiency of surgical techniques.
The Air Force Medical Service has developed a variety of training
programs to ensure our health care providers remain the best trained
and equipped in the world. The Air Force Expeditionary Medical Skills
Institute's Center for Sustainment of Trauma and Readiness Skills (C-
STARS) is a medical training program embedded in three civilian
academic trauma centers. C-STARS is a skills sustainment platform with
multiple affiliations to refresh or hone trauma and reconstructive
surgical skills. A newer training platform, Sustainment of Trauma and
Resuscitation Skills-Program (STARS-P) has begun at five other
locations. STARS-P is a readiness skills verification training platform
providing personnel the opportunity to perform clinical rotations
several weeks annually at host facilities for the purpose of skills
sustainment. Training is also accomplished using no cost Training
Affiliation Agreements (TAAs) with civilian or other sister-service
facilities to include VA Sharing Agreements. Since 2006, the AF has
entered into over 262 TAAs for clinical proficiency and sustainment
training. Another trend is using Simulation Laboratories (SIMLABs)
utilizing high quality human-like training models. The Air Force has a
network of simulation laboratories to enhance skills sustainment. Each
year AFMS personnel retain professional licensure and certification
status by attending civilian conventions/symposia or military formal
training courses to obtain continuing education. Humanitarian missions
also expose our practitioners to pathology and challenging cases that
improve diagnostic and clinical skills when treating a large number of
patients in a short time period.
______
QUESTIONS SUBMITTED BY MR. KISSELL
Mr. Kissell. I represent the Fort Bragg area. Fort Bragg is
projected to grow from just 57,000 military personnel assigned in 2006
to just under 70,000 by the end of fiscal year 2011. These numbers, of
course, do not include all of additional family members that will come
with these 12,000+ soldiers. Now, Womack Army Medical Center is a
relatively new and unquestionably beautiful facility, but it doesn't
seem large enough for our current population on Fort Bragg, let alone
the growth we're expecting over the next few years. For example, the
emergency room waiting area is tiny, with something like twenty chairs.
What analyses have the Army done to assess the capacity of the current
facility, and what plans have been made to ensure that the military
personnel assigned to Fort Bragg, and their families, will have access
to the care they need?
General Schoomaker. Based on the projected population growth at
Fort Bragg, the Army has planned and programmed medical military
construction projects totaling $141M to support the projected increase
of Soldiers and Family members. These projects include: an addition/
alteration to the Robinson Health Clinic ($18M, FY 08), a new Primary
Care Clinic ($27M, FY 10), a new Blood Donor Center ($4.8M, FY 10), a
new Behavioral Health clinic ($32M, FY10), and an addition/alteration
to Womack Army Medical Center (WAMC) that will expand the Emergency
Department, Women's Health, Pediatrics, Pharmacy Services, and various
other departments ($59M). This addition/alteration is desired in the FY
12 program following completion of the new Behavioral Health Clinic,
which is programmed in FY 10. That stand-alone facility will remove
Behavioral Health Services from WAMC to accommodate staffing increases
and allow for the expansion of hospital-based functions, such as the
Emergency Department.
Once completed, the MILCON projects will significantly expand the
medical infrastructure at Fort Bragg. Approximately 65% of the Fort
Bragg growth in population has already been realized. A dedicated
recruitment effort has led to filling 82% of the new positions
identified to support this population. In the interim period while
MILCON construction is ongoing, WAMC is coordinating with Pope Air
Force Base to assume control of the Pope Clinic in July 2010. This will
provide a partial expansion of primary care until the new clinic is
built. In 2008, WAMC completed a construction project that converted
12,700 square feet of storage area into administrative and educational
space which freed approximately 16,000 square feet of clinical space.
Currently, WAMC has initiated a renovation project that converts seven
former administrative offices into treatment rooms for the Emergency
Department. Additionally, we relocated the TRICARE offices to provide
the Emergency Department a secondary waiting room and an additional 10
offices or exam rooms.
The most profound change has been the development of the Warrior
Transition Battalion (WTB), which at Fort Bragg has grown to four
companies. Until the Warrior Transition Complex is completed, the
hospital has dedicated over 20,000 square feet of clinical space to the
WTB. Clinical services for all beneficiaries, not just the Warriors in
Transition, continue to improve and expand. At Fort Bragg, prominent
examples are Traumatic Brain Injury (TBI) treatment and research, and
the Pain Clinic's advanced technology and multidisciplinary alternative
therapies. Behavioral health services are another area of growth that
is defined by the population's increase as well as the population's
increasing needs.
In summary, the Army has assessed the projected population growth
at Fort Bragg and is implementing actions to provide all the necessary
health care services to support these beneficiaries.
Mr. Kissell. And since we are talking about how medical military
construction is centrally managed by Health Affairs/TRICARE Management,
is it the Army's responsibility or Health Affairs' responsibility to do
these analyses?
General Schoomaker. The US Army Medical Command (MEDCOM) conducts
the detailed analyses required to develop medical military construction
requirements. These analyses include facility requirements, staffing
requirements, and the right mix of personnel skills to ensure we
properly support our beneficiary population. MEDCOM provides our
completed analyses and facility requirements to Health Affairs/TRICARE
Management Activity for prioritization and programming.
______
QUESTIONS SUBMITTED BY MS. BORDALLO
Ms. Bordallo. My question is about how the Navy, in conjunction
with the TRICARE Management Activity and the Department of Defense's
Office of Health Affairs, developed the requirements for number of beds
and services that will be added as a result of the renovations. It is
my understanding that the current requirement will only increase the
number of beds by eleven and given that the military build-up will
include, at the very least, 8,000 additional Marines and 9,000 family
members, is that an adequate enough requirement to meet the demands
with increased personnel on Guam? I understand from your testimony that
Navy implemented the Capital Investment Decision Model (CIDM) in 2008
which will impact Fiscal Year (FY) 2010 projects. If the CIDM were
implemented early, would that have potentially altered the requirements
for the hospital?
Admiral Robinson. The CIDM, which was employed for the first time
last year, identified replacement of the United States Naval Hospital
on Guam as the highest priority for medical military construction
funding. The CIDM is used to prioritize competing proposals and not to
develop specific facility requirements. Navy medical planners, in
concert with others, analyzed the specific requirements for the
replacement facility and determined the appropriate mix of capabilities
required to support the needs of the projected population. The planning
process was continuously updated as the scope of the Guam military
build-up was refined. It is unlikely that implementing CIDM prior to
2008 would have altered the requirement for the new hospital.
Ms. Bordallo. Additionally, can you comment on the anticipated
level of increase in specialty care that might be offered on Guam as a
result of the increased military presence on Guam as well as
renovations to the facility that will allow such services to be
offered? Many of my constituents have concerns about the current level
of services that are available at the Naval Hospital and see the
military build-up as an opportunity to attract additional specialty
care services to the island.
Admiral Robinson. The United States Naval Hospital, Guam
replacement facility will support delivery of a broad range of primary
and specialty care services. The new hospital will provide 42 inpatient
beds for provision of intensive care, general medicine, surgery,
orthopedics, obstetrics, urology, ophthalmology, proctology,
otorhinolaryngology, behavioral health, and oral surgery. It will
operate four operating rooms and two rooms dedicated to performing
Caesarian Sections. Robust diagnostic imaging will include magnetic
resonance imaging (MRI) and computerized axial tomography (CT) scan
capabilities as well as full laboratory and pharmacy capacity. In
addition to a Level III emergency room, outpatient capabilities will
include a variety of primary and specialty care services, including
diet and wellness, dermatology, nuclear medicine, physical therapy, and
environmental health.
The new community-based Outpatient Clinic now under construction
will increase the range of potential for sharing with the Department of
Veterans Affairs (VA). Its location adjacent to the new hospital will
increase both the visibility of the clinic and its accessibility to VA
beneficiaries.
Ms. Bordallo. To what extent has the Department of Defense worked
with the Department of Veterans Affairs pursuant to Section 707 of H.R.
5658, the House-passed National Defense Authorization Act for Fiscal
Year 2009? Are there any issues of concern regarding the development of
these implementation guidelines?
Secretary Casscells. The DOD and the DVA studied a combined federal
health facility as identified in H.R. 5658, Section 707, but the DVA
decided they could not support a joint effort. Therefore, planning and
programming of Naval Hospital Guam replacement was performed with
Presidential Executive Order 13214 (dtd 28 May 2001) and Public Law
108-136, Section 583 as the drivers for extensive collaboration with
the DVA from a health facility perspective. The planned replacement of
Naval Hospital Guam accounted for all workload currently performed in
support of the robust resource-sharing agreements in place between Navy
and the DVA for inpatient, specialty, diagnostic, and ancillary
services. In addition, the DVA is currently constructing a new
Community-Based Outpatient Clinic on a convenient site provided by the
Navy to the DVA immediately adjacent to the Naval Hospital campus. The
DVA designed their new outpatient clinic to enhance DVA primary care
capabilities to better serve the Guam veterans.
Ms. Bordallo. I am wondering why the Department of Defense has not
designated Guam or the other territories, specifically Puerto Rico as a
Prime Service Area for military retirees to be eligible to receive
TRICARE Prime? If specialty care services will not increase to cover
all the needs of our local retiree population isn't there a benefit to
extending TRICARE Prime to the territories? I see this as a key quality
of life measure and as a commitment to those who served our nation.
Secretary Casscells. It is recognized under 32 CFR Sec. 199.17,
(a), (3), the Assistant Secretary of Defense (Health Affairs) has the
authority to modify the scope of the TRICARE program as implemented
outside the 50 States and the District of Columbia. Currently, TRICARE
Prime is not available as an option for retired service members and
their eligible dependents in the territories of Puerto Rico and Guam.
Navy Medicine recognizes the tremendous contribution and sacrifice
that all of our current and prior military members and their families
have endured to serve our Nation. They deserve a generous health care
benefit in recognition of their important service. The extension of
TRICARE Prime in Puerto Rico and Guam for retired service members and
their eligible dependents may improve the health of those members as a
result of improved access to care, and would create parity of health
care benefits with those beneficiaries residing in the 50 States and
the District of Columbia.
If implemented, the broader challenge will remain in meeting the
specialty care requirements in remote locations with limited local
health care resources. The TRICARE program relies heavily on civilian-
based provider networks to augment and support the Direct Care System
(Military Treatment Facilities--MTFs) in meeting their mission. Any
actions taken to expand or change the health care benefit in Puerto
Rico and Guam must be carefully reviewed to consider the impact on
existing resources, both civilian and military.
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