[House Hearing, 112 Congress]
[From the U.S. Government Printing Office]
[H.A.S.C. No. 112-19]
HEARING
ON
NATIONAL DEFENSE AUTHORIZATION ACT
FOR FISCAL YEAR 2012
AND
OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS
BEFORE THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
SUBCOMMITTEE ON MILITARY PERSONNEL HEARING
ON
MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST
EFFICIENCIES
__________
HEARING HELD
MARCH 15, 2011
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
MIKE COFFMAN, Colorado ROBERT A. BRADY, Pennsylvania
TOM ROONEY, Florida MADELEINE Z. BORDALLO, Guam
JOE HECK, Nevada DAVE LOEBSACK, Iowa
ALLEN B. WEST, Florida NIKI TSONGAS, Massachusetts
AUSTIN SCOTT, Georgia CHELLIE PINGREE, Maine
VICKY HARTZLER, Missouri
Jeanette James, Professional Staff Member
Debra Wada, Professional Staff Member
James Weiss, Staff Assistant
C O N T E N T S
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CHRONOLOGICAL LIST OF HEARINGS
2011
Page
Hearing:
Tuesday, March 15, 2011, Military Health System Overview and
Defense Health Program Cost Efficiencies....................... 1
Appendix:
Tuesday, March 15, 2011.......................................... 35
----------
TUESDAY, MARCH 15, 2011
MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST
EFFICIENCIES
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 3
Wilson, Hon. Joe, a Representative from South Carolina, Chairman,
Subcommittee on Military Personnel............................. 1
WITNESSES
Green, Lt. Gen. Charles Bruce, USAF, Surgeon General, U.S. Air
Force.......................................................... 12
Robinson, VADM Adam M., USN, Surgeon General, U.S. Navy.......... 9
Schoomaker, LTG Eric B., USA, Surgeon General, U.S. Army......... 6
Stanley, Hon. Clifford L., Ph.D., Under Secretary of Defense for
Personnel and Readiness........................................ 4
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for
Health Affairs................................................. 5
APPENDIX
Prepared Statements:
Davis, Hon. Susan A.......................................... 42
Green, Lt. Gen. Charles Bruce................................ 109
Robinson, VADM Adam M........................................ 82
Schoomaker, LTG Eric B....................................... 59
Stanley, Hon. Clifford L., Ph.D., joint with Hon. Jonathan
Woodson, M.D............................................... 44
Wilson, Hon. Joe............................................. 39
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Dr. Heck..................................................... 131
Questions Submitted by Members Post Hearing:
Mrs. Davis................................................... 135
Dr. Heck..................................................... 144
MILITARY HEALTH SYSTEM OVERVIEW AND DEFENSE HEALTH PROGRAM COST
EFFICIENCIES
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Tuesday, March 15, 2011.
The subcommittee met, pursuant to call, at 10:03 a.m., in
room 2212, Rayburn House Office Building, Hon. Joe Wilson
(chairman of the subcommittee) presiding.
OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM
SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL
Mr. Wilson. Ladies and gentlemen, I would like to welcome
everyone to the Military Personnel Subcommittee hearing today
on the Military Health System [MHS] overview and Defense Health
Program cost efficiencies.
And today, the subcommittee meets to hear testimony on the
Military Health System and the Defense Health Cost Program for
the fiscal year 2012. I would like to begin by acknowledging
the remarkable military and civilian medical professionals who
provide extraordinary care to our service members and their
families along with veterans, here at home and around the
world, often in some of the toughest and most austere
environments.
I have recently returned from Balad and Bagram where I am
always appreciative of the professionals who have saved so many
American, Iraqi, and Afghani lives. I have firsthand knowledge
of their dedication and sacrifice from my second son, who has
served in Iraq and is now an orthopedic resident in the Navy,
but we are joint service. As a grateful dad, as a military
family, I was reassured to the medical care available for my
Army son and my Air Force nephew who also both served in Iraq.
The subcommittee remains committed to ensuring that the men
and women who are entrusted with the lives of our troops have
the resources to continue their work for future generations of
our most deserving military beneficiaries. Even in this tight
fiscal environment, the Military Health Care System must
continue to provide world-class health care to our
beneficiaries and remain strong and viable in order to maintain
that commitment to future beneficiaries.
The Department of Defense [DOD] has proposed several
measures aimed at reducing the cost of providing health care to
our service members and their families and military veterans.
While I appreciate that your plan is a more comprehensive
approach than previous cost cutting efforts, the challenge here
is to find a balance between fiscal responsibility while
maintaining a viable and robust military health care system.
We must be sure to remember these proposals have complex
implications that ``go beyond beneficiaries.'' They also affect
the people who support the defense health system, such as local
pharmacists, as health care employees at hospitals and
contractors. The subcommittee has a number of concerns about
the Department's initiatives. To that end, we would expect the
Department's witnesses to address our concerns, including
first, the proposed TRICARE Prime fee increase for the fiscal
year 2012, while appearing to be modest, is a 13 percent
increase over the current rate.
DOD proposes increasing the fee in the out years based on
an inflation index. You suggest 6.2 percent but it is not clear
which index you are using now and in the future. Second, you
plan to reduce the rate that TRICARE pays the sole community
hospitals for inpatient care provided to our Active Duty,
family members, and veterans.
Several of these hospitals are located very close to
military bases; in fact some are right outside the front gates,
especially important for 24-hour emergency care. What analysis
have you done to determine whether reducing these rates will
affect access to care for our beneficiaries and in particular
the readiness of our Armed Forces? I would also like our
witnesses to discuss the range of efficiency options that were
considered but not included in the President's budget.
I would appreciate hearing your views on the recent GAO
[Government Accountability Office] recommendations included in
their report on Federal duplication, overlap and fragmentation.
GAO made recommendations regarding establishing a unified
medical command and for the DOD to finally jointly modernize
their electronic health record system with the Veterans
Administration.
In addition, I would like to hear from the military
surgeons about efforts they are taking within the military
departments to increase the efficiency of the health care
systems and reduce cost. I would also like the military
surgeons' views on areas where additional efficiencies can be
gained across the DOD health system.
The Department of Defense, just last week, recently
announced they have hired Governor John Baldacci, the former
Governor of Maine, to undertake a full-scale review of the
military health care and the impacts of military health care on
the forces. I would appreciate hearing from Dr. Stanley the
considerations for this review and what the Department hopes to
gain from Governor Baldacci's efforts. I am concerned.
First of all, I have faith in Dr. Stanley. He is a graduate
of South Carolina State University. So I know of his
capabilities. Why is having a military health care czar not a
duplication of the duties already assumed by Under Secretary
Stanley and Assistant Secretary Woodson?
Finally, I would like to make it clear that in the effort
to reduce the cost of military health care and find
efficiencies in the military health care system, we must never
lose sight of the population that the military medical system
serves. The members of the Armed Forces and their families who
currently serve and those who served as veterans for a full
career in the past warrant the best health care system
available. Reducing cost must never result in reduced quality
of the availability, or the availability of health care they
earned and they deserve.
I hope that our witnesses will address these important
issues as directly as possible in their oral statements and in
the response to Members' questions. Before I introduce our
panel, let me offer Ranking Member, who is a distinguished
former chairman of this subcommittee, Congresswoman Susan Davis
an opportunity to make her opening remarks.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 39.]
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you. Thank you, Mr. Chairman. And thank
you for summarizing many of the issues that are before us
today, I look forward to hearing from Under Secretary Stanley
and Assistant Secretary Woodson on their views on the status of
the military health care system, particularly the TRICARE
program and their efforts to improve the care that we are
providing to our service men and women, retirees, survivors,
and their families.
Assistant Secretary Woodson, we welcome you. We are
delighted that you are here. And I understand that it is your
first testimony before this subcommittee. I am pleased that the
Senate finally confirmed you as the Assistant Secretary for
Health Affairs. The Department is confronting many issues and
having you there is important if we are to be successful in
facing those challenges.
I also look forward to hearing from our Surgeon Generals,
General Schoomaker and Admiral Robinson, thank you very much
for your service. And I know that both of you, I believe, are
retiring this year. So we will miss you. It has been a pleasure
working with both of you over the past several years.
The last 10 years of conflict have taken a toll on our
forces, and in particular those who serve in our military
health care system. The constant demand on the system and the
successes that we have seen both on the battleground and back
home here in the States have been remarkable and a testament to
your leadership.
General Green, welcome back to you, sir. With the departure
of General Schoomaker and Admiral Robinson, of course, you
would be the most senior Surgeon General and I look forward to
continuing to work with you.
While I suspect that the majority of this hearing will
focus on the Department of Defense's health care proposals that
were included in the budget, this hearing will probably be one
of the only hearings on health care that we will have prior to
the subcommittee and committee markup.
So as such, it is important that members of the
subcommittee have an understanding of all the challenges that
the military health care system is facing, not just the
budgetary constraints. Our military personnel and their
families are under constant pressure and challenges. And access
to quality health care should not be on that list of concerns.
I look forward to your testimony on how we are caring for
our injured, ill, and wounded and what can be done to continue
to improve the military health care systems.
Thank you, Mr. Chairman.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 42.]
Mr. Wilson. Thank you, Mrs. Davis.
We have five witnesses today. We would like to give each
witness the opportunity to present his testimony and each
Member an opportunity to question the witnesses. I would
respectfully remind the witnesses that we desire that you
summarize to the greatest extent possible the high points of
your written testimony in 3 minutes. I assure you that your
written comments and statements will be made part of the
record.
And, of course, first we want to welcome the Honorable Dr.
Clifford L. Stanley, the Under Secretary of Defense for
Personnel and Readiness [P&R], Dr. John Woodson, Assistant
Secretary for Defense for Health Affairs and this--Doctor, I
know it is your first appearance so we are delighted to have
you here. And Lieutenant General Eric Schoomaker, the Surgeon
General of the Department of the Army and General, thank you
for your distinguished career. And this is your last appearance
and we just wish you well in your future career.
And Vice Admiral Adam Robinson, the Surgeon General of the
Department of the Navy and indeed General Robinson, thank you.
This, too, I can see the big smile on your face which means
this is your last appearance here. And we appreciate your
service and thank you for in every way, for your service. And
then soon to be the senior Surgeon General amazingly enough,
Lieutenant General Charles Bruce Green, the Surgeon General of
the Department of the Air Force.
And at this time, Dr. Stanley, you may begin.
STATEMENT OF HON. CLIFFORD L. STANLEY, PH.D., UNDER SECRETARY
OF DEFENSE FOR PERSONNEL AND READINESS
Secretary Stanley. Good morning and thank you, Mr. Chairman
and members of the committee, I really do appreciate this
opportunity to appear before you today to discuss the future of
the Military Health System, particularly our priorities for the
coming year.
Dr. Woodson, the Surgeon Generals and I look forward to
discussing our health care plans for 2011 and 2012. At the
outset, I just want to acknowledge the performance and courage
of our military medical professionals serving in combat
theaters. For service members wounded in combat, their
likelihood of survival after a medic arrives remains at
historic and unmatched levels.
For those seriously wounded service members who require
months, years and sometimes a lifetime of medical
rehabilitation and treatment, we are committed to ensuring that
they and their families receive the finest evidence-based
medical services available in this country. And we are working
ever more closely with our colleagues in the Department of
Veterans Affairs [VA] to ensure our activities are better
coordinated to include the disability evaluation process, the
sharing of personnel and health information and collaboration
on our future electronic health record.
In addition to the efficiencies that we will discuss today,
I have asked the former Governor and former Representative John
Balucci--Baldacci, excuse me, from Maine to help us work in a
deep dive review of health care and wellness. Dr. Woodson and
our Assistant Secretary of Defense for Health Affairs ensures
that the military health care system runs smoothly every day.
But I have asked the Governor to pursue a four azimuth deep
dive approach which is focusing on readiness, improve health
population, patient experience and care and lastly, cost. And
with that, I would turn to Dr. Woodson. Before I do that, I
would like to also thank the subcommittee for the tremendous
support you provide the Department for our service members and
their families, particularly the Military Health System. Thank
you.
[The joint prepared statement of Secretary Stanley and Dr.
Woodson can be found in the Appendix on page 44.]
Mr. Wilson. Next, we have Dr. Woodson.
STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS
Dr. Woodson. Mr. Chairman, Ranking Davis and members of the
committee, thank you so much for this opportunity to appear
before you today. I will briefly elaborate on Dr. Stanley's
opening statement. I have had the privilege of serving the
Military Health System both in uniform as an officer and
physician and in my current role as senior medical advisor to
the Secretary of Defense.
This system has shown time and again that it is a vibrant,
learning organization capable of self-improvement and rapid
incorporation of lessons learned into both our combat and
peacetime endeavors.
In our combat theaters, Dr. Stanley has already noted the
historic rates of survival among those who are injured. I would
also point out the reductions in disease and injuries through
improved public health and preventative medicine strategies.
Thanks to the ongoing support of Congress, we are continuing to
invest deeply in medical research and development on the most
challenging medical issues we are confronted with from the war.
We are accelerating the delivery of our scientific findings
from the laboratory to the bench--to the battlefield to include
prevention, diagnosis, and treatment for both visible and
invisible wounds of war. We are also making important
investments in how we deliver care to all of our beneficiaries.
The Patient-Centered Medical Home is a transformative effort
within our system.
We have enrolled more than 655,000 beneficiaries to date,
with promising results in the use of preventive services,
reducing emergency room [ER] use, and provision of more timely
care. In addition to our investments in readiness, improved
population and improved service to our patients, we also have
proposed some changes that will allow us to more responsibly
manage our cost.
Our efficiency initiatives share the responsibility for
cost controls among all of the participants including us
internally at Health Affairs and TMA [TRICARE Management
Activity], among provider communities and with our
beneficiaries for whom we propose a very modest change to
select out-of-pocket costs.
Throughout our proposals, we have taken steps to protect
those who are enrolled in existing programs or who have special
circumstances that must be considered and protected. Our
proposed budget helps keep fidelity with our core principles.
We will never lose our focus on our commitment to all the men
and women who serve our Armed Forces, their families, those who
have served in the past and present, and those will serve in
the future.
We are proud to represent the men and women who comprise
the Military Health System and we look forward to your
questions this morning.
[The joint prepared statement of Dr. Woodson and Secretary
Stanley can be found in the Appendix on page 44.]
Mr. Wilson. Thank you very much.
And General Schoomaker.
STATEMENT OF LTG ERIC B. SCHOOMAKER, USA, SURGEON GENERAL, U.S.
ARMY
General Schoomaker. Chairman Wilson, Ranking Member Davis,
distinguished members of the committee, thanks for permitting
me to talk with you today about the dedicated men and women of
the Army Medical Department who bring value and inspire trust
in Army Medicine.
Despite over 9 years of continuous armed conflict, for
which Army Medicine bears a heavy load, every day our soldiers
and their families are kept from injuries, illnesses, and
combat wounds through our health promotion and prevention
efforts; and are treated in a state-of-the-art fashion when
prevention fails; and are supported by an extraordinarily
talented medical force including those who serve at the side of
the warrior on the battlefield.
We are a member of this Military Health System team
committed to partnering with soldiers and families, and
veterans to achieve the highest level of fitness and health for
all. And we have been leaders in innovation for trauma care and
preventive medicine that have saved lives and improved the
well-being of our warriors and improvements that have really
changed even clinical practices in the civilian sector. We are
focused on delivering the best care at the right time and
place.
I would like to talk about our work through the lens of the
five E's: Enduring, Early, Effective, Efficient, and an
Enterprise fashion. We have an enduring commitment to care
through initiatives such as the Warrior Care and Transition
Plan and the Soldier Medical Readiness Campaign Plan.
We have an enduring responsibility alongside our sister
services in the Department of Veteran Affairs to provide care
and rehabilitation for wounded, ill and injured for many, many
years to come. We have a warrior transition command in the Army
Medical Department under the leadership of Brigadier General
Darryl Williams, many of you have met him. He is a key in our
provision of care and provides a centralized oversight for the
Army's Warrior Care and Transition Program.
Our focus is on investing soldiers and families with
dignity, respect, and self determination to successfully
reintegrate them either back into the force or into the
community. Since we stood up the first warrior transition units
in June of 2007, more than 40,000 wounded, ill, and injured
soldiers and their families have either progressed through or
are currently in care, and we have returned over 16,000
soldiers to the force.
We have also created a Soldier Medical Readiness Campaign
that has been brought about because of the rising cost of
health problems in our force, especially within the Reserve
Components. Among its many goals under the leadership of Major
General Rich Stone, a mobilized Reserve Component physician
from Michigan there to identify the medically non-ready soldier
population and implement medical management programs to reduce
this medically non-ready population with an ultimate end state
of a deployment of healthy, resilient, and fit soldiers, and
increase Army medical readiness.
Those soldiers that can no longer meet retention standards
have to navigate our physical disability evaluation system.
Assigning disability has long been a contentious issue. DOD and
VA have jointly designed a new disability evaluation system
that integrates the DOD and VA processes with a goal of
expediting the delivery of VA benefits to service members. This
pilot, called the Integrated Disability Evaluation System or
IDES, began in late 2007 at Walter Reed. It is now in 16 of our
Army Medical Treatment facilities.
And it will be the DOD and VA replacement for the legacy
Disability Evaluation System. But even with this improvement,
disability evaluation remains complex and adversarial. Our
soldiers still undergo dual adjudication where the military
rates only on fitting condition and the VA rates all service-
connected conditions.
Dual adjudication is confusing to soldiers and leads to
serious misperceptions about the Army's appreciation of the
wounded, ill, and injured soldiers' complete medical and
emotional situation. And IDES has not changed the fundamental
nature of the dual adjudication process. Under the leadership
of the Army Chief of Staff and the Army G-1, we continue to
forge the consensus necessary for a comprehensive reform of the
Physical Disability Evaluation System in which the Army and the
DOD only determines fitness for duty, and the VA determines
disability compensation.
Our second strategic aim is to reduce suffering, illness,
and injury through early prevention. Army public health
protects and improves the health of the Army community through
education and promotion of healthy lifestyles, and disease and
injury prevention. The health of the total Army is essential
for readiness and prevention is the key to health.
The examples of this are the promotion of healthy
lifestyles, of achieving the highest measures of population
health measured by [inaudible], the implementation of Patient-
Centered Medical Home that you have heard about already, and I
hope you will hear more about, and the focus on, for example,
body mass index, and childhood obesity.
The Army is leading the way also in the recognition and
treatment of mild traumatic brain injury [TBI] or concussion
through an ``Educate, Train, Treat, Track'' strategy. Vice
Chief of Staff of the Army Pete Chiarelli has led personally in
this and we have refined this through General Richard Thomas,
my Assistant Surgeon General for Force Projection. We fielded
this program, which some have called the ``CPR for the brain,''
increasing the awareness and screening of concussive injury and
leading to a decrease of the stigma associated with seeking
care.
The use of evidence-based practices are aimed at the most
effective care for us, is our third strategic aim. For example,
we have harvested the lessons of almost a decade of war and now
strengthen our soldiers' and families' behavioral health and
emotional resiliency through a campaign that aligns all of the
behavioral health programs within this human dimension of the
Army's Force Generation cycle. We call this the Comprehensive
Behavioral Health System of Care. We have got now outcome
studies that demonstrate the profound value of using multiple
touchpoints in assessing and coordinating health and behavioral
health for soldiers and families across this cycle.
Coupled with the major advances in battlefield care under
the Joint Theater Trauma System which was birthed in the Army's
Medical Research and Materiel Command and the Army's Institute
of Surgical Research, we have made great strides in preventing
and managing physical and emotional wounds of war.
Additionally, we have launched a comprehensive pain
management strategy to address chronic pain that our soldiers
are focused, it is holistic, multidisciplinary, multimodal.
Utilizes art--the state-of-the-art care, and it is focusing on
non-pharmacologic practices such as incorporating complementary
and alternative therapies, like acupuncture, and massage
therapy, movement therapy, yoga, and other mind-body medical
practices.
Our fourth strategic aim is optimizing efficiencies that
you have alluded to. We do that through leading business
processes and partnerships with the other services and veterans
organizations. Ultimately, I would like to say that the
principal efficiency and cost saving step in health care is the
maintenance of health, promotion of good health, and the focus
on good clinical outcomes and evidence-based practices.
But we are also working with the DOD and the VA to create a
single electronic health record, seamlessly transferring
patient data between and among the partners to improve
efficiencies and continuity of care. We share a significant
amount of health information today. No two health organizations
in the Nation share more non-billable health information than
the DOD and the VA.
The Departments continue to standardize this sharing
activity and are delivering information technology solutions
that will significantly improve the sharing of appropriate
electronic health information.
Our fifth aim is an enterprise approach. We have
reengineered Army Medicine. We have created a Public Health
Command. And we have reengineered our regional medical commands
to align with the TRICARE regions so that we can more
efficiently provide health care in a seamless way through our
TRICARE partners.
We also have at each regional medical command, a deputy
commander who is responsible for readiness and can reach out
even to our Reserve Component elements within their area of
responsibility to ensure that all medical and dental services
are being provided and our Reserve units are optimally ready.
This is my last congressional hearing cycle as the Army
Surgeon General and the Commanding General, The Army Medical
Command. I would like to thank the committee for the
opportunities that I have been given to highlight the
accomplishments we have made, the challenges that we face, to
hear your collective perspectives regarding the health of our
extended military family and the health care we provide.
I have appreciated your tough questions, your valuable
insights, the sage advice you have offered and the deep
commitment you have all demonstrated to our soldiers and their
families. On behalf of over 140,000 dedicated soldiers,
civilians, contractors that make up my command in Army
Medicine, I would like to thank also the Congress for your
continued support in providing the resources we need for
delivering leading edge health services, and build healthy and
resilient communities.
Thank you.
[The prepared statement of General Schoomaker can be found
in the Appendix on page 59.]
Mr. Wilson. General Schoomaker, thank you very much. And
thank you for being so candid.
And Admiral Robinson, again, I am so grateful for the
briefing you provided at your very historic office. And so,
thank you for coming by today.
STATEMENT OF VADM ADAM M. ROBINSON, USN, SURGEON GENERAL, U.S.
NAVY
Admiral Robinson. Thank you very much, Mr. Chairman.
Chairman Wilson.
Congresswoman Davis.
Distinguished members of the subcommittee, I am pleased to
be with you today. And I want to thank the committee for the
tremendous confidence and unwavering support of Navy Medicine,
particularly, as we continue to care for those who go in harm's
way, their families, and all beneficiaries.
Force Health Protection is the bedrock of Navy Medicine. It
is what we do and why we exist. It is our duty, our obligation,
and our privilege to promote, protect and restore the health of
our sailors and marines. This mission spans the full spectrum
of health care, from optimizing the health and fitness of the
force, to maintaining robust disease surveillance and
prevention programs, to saving lives on the battlefield.
I along with my fellow Surgeons General traveled to
Afghanistan last month and again witnessed the stellar
performance of our men and women delivering expeditionary
combat casualty care. At the NATO [North Atlantic Treaty
Organization] Role 3 Multinational Medical Unit, Navy Medicine
is currently leading the joint and combined staff to provide
the largest medical support in Kandahar with full trauma care.
This state-of-the-art facility is staffed with dedicated
and compassionate Active and Reserve personnel who are truly
delivering outstanding care. Receiving 70 percent of their
patents directly from the point of injury on the battlefield,
our doctors, nurses, and corpsmen apply the medical lessons
learned from 10 years of war to achieve a remarkable 97 percent
survival rate for coalition casualties.
The Navy Medicine team is working side by side with Army
and Air Force medical personnel and coalition forces to support
U.S. military coalition forces, contractors, Afghan nationals,
police, army and civilians as well as detainees. The team is
rapidly implementing best practices and employing unique skill
sets such as an interventional radiologist, pediatric
intensivist, hospitalist and others in support of their
demanding mission.
I am proud of the manner in which our men and women are
responding--leaving no doubt that the historically
unprecedented survival rate from battlefield injuries is the
direct result of better trained and equipped personnel, in
conjunction with improved systems of treatment and casualty
evacuation.
We spend a lot of time discussing what constitutes world
class health care. I would like to be clear that there is no
doubt in my mind that the trauma care being provided in theater
today to our casualties is truly world class as are the men and
women delivering it. Their morale is high and professionalism
unmatched.
We also had the opportunity to visit our Concussion
Restoration Care Center [CRCC] at Camp Leatherneck in Helmand
Province. The center which opened in last--which opened last
August, assesses and treats service members with concussion or
mild TBI, mild traumatic brain injury, and musculoskeletal
injuries, with the goal of safely returning to duty many
service members as possible to full duty following recovery of
cognitive and physical function.
The CRCC is supported by an interdisciplinary team
including sports medicine, family medicine, mental health,
physical therapy, and occupational therapy. The CRCC, along
with other programs like OSCAR, our Operational Stress Control
and Readiness program, in which we embed full-time mental
health personnel with deploying marines, continues to reflect
our priority of positioning our personnel and resources where
they are most needed.
We have no greater responsibility than caring for our
service members, wherever and whenever they go. We must
understand that preserving the psychological health of service
members and their families is one of the greatest challenges we
face today. We recognize that service members and their
families are resilient at baseline but the long conflict and
repeated deployments challenge this resilience.
We also know that nearly a decade of continuous combat
operations has resulted in a growing population of service
members suffering with traumatic brain injury. We are forging
ahead with improved screening, surveillance, treatment,
education, and research. However, there is still much we do not
yet know about these injuries and their long-term impact on the
lives of our service members.
I would specifically point out that the issuance of the
directive type memorandum in June 2010 has increased line
leadership awareness of potential traumatic brain injury
exposure and mandates post-blast evaluations and removal of
blast-exposed warfighters from high risk situations to promote
recovery.
We also recognize the important of collaboration and
partnerships, and our efforts include those coordinated jointly
with the other services, the Department of Veterans Affairs,
the Centers of Excellence, as well as leading academic and
research institutions.
Let me now turn to patient- and family-centered care.
Medical Home Port is Navy Medicine's Patient-Centered Medical
Home model, an important initiative that will significantly
impact how we provide care to our beneficiaries. Medical Home
Port emphasizes team-based comprehensive care and focuses on
the relationship between the patient, their provider and the
health care team.
Critical to its success is leveraging all of our providers
and supporting information technology systems into a cohesive
team that will not only provide primary care but integrate
specialty care as well. We continue to move forward with the
phased implementation of Medical Home Port and our medical
centers and family-practice teaching hospitals, and the initial
response from our patients is very encouraging.
Both force health protection and patient and family-
centered care are supported by robust research and development
capability and outstanding medical education programs. These
are truly force multipliers. The work that our researchers and
educators do is having a direct impact on the treatment we are
able to provide our wounded warriors and helping to shape the
future of military medicine.
Finally, I would like to address the proposed Defense
Health Program cost efficiencies. Rising health care costs
within the MHS continue to present challenges. The Secretary of
Defense has articulated that the rate at which health care
costs are increasing and relative proportion of the
Department's resources devoted to health care cannot be
sustained. He has been resolute in his commitment to implement
systemic efficiencies and specific initiatives which will
improve quality and satisfaction while more responsibly
managing cost.
The Department of the Navy fully supports the Secretary's
plan to better manage costs moving forward and ensure our
beneficiaries have access to the quality care that is the
hallmark of military medicine.
In summary, I am proud of the progress we are making, but
not satisfied. We continue to see ground-breaking innovations
in combat casualty care and remarkable heroics in saving lives,
but all of us remain concerned about the cumulative effects of
worry, of stress and anxiety on our service members and their
families brought about by a decade of conflict. Each day
resonates with the sacrifices that our sailors, marines, and
their families make quietly and without bravado.
It is this commitment, this selfless service that helps
inspire us in Navy Medicine. Regardless of the challenges ahead
I am confident that we are well-positioned for the future.
Since this is my last cycle of hearings, I too would like to
extend my sincere appreciation to the committee, to the Members
and the professional staffers for all of the support, the
insights and the advice being given; it has been a true honor
being before you and actually working with you.
I appreciate the opportunity to be here today and look
forward to your questions. Thank you very much.
[The prepared statement of Admiral Robinson can be found in
the Appendix on page 82.]
Mr. Wilson. Admiral, thank you very much.
And General Green.
STATEMENT OF LT. GEN. CHARLES BRUCE GREEN, USAF, SURGEON
GENERAL, U.S. AIR FORCE
General Green. Good morning, Mr. Chairman, Representative
Davis, and distinguished members of the committee, I appreciate
the opportunity to meet with you today representing the men and
women of the Air Force Medical Service.
We cannot achieve our goals of better readiness, better
health, better care and best value for our heroes and their
families without your support, and we thank you.
Military Health System achievements have changed the face
of the war. We deploy and set up hospitals within 12 hours of
arrival anywhere in the world. We move wounded warriors from
the battlefield to an operating room within minutes and have
achieved and sustained less than 10 percent died-of-wounds
rate.
We move our sickest patients in less than 24 hours of
injury and get them home to loved ones within 3 days to hasten
recovery. We have safely evacuated more than 85,000 patients
since October, 2001, 11,300 in 2010 alone, many of them
critically injured.
The Air Force Medical Service has a simple mantra: Trusted
Care Anywhere. This fits what we do today and will continue to
do in years ahead. It means creating a system that can be taken
anywhere in the world and be equally as effective whether in
war or for humanitarian assistance.
Medics at Air Combat Command have now developed an EMEDS
[expeditionary medical support] deployable hospital that is
capable of seeing the first patient within 1 hour of arrival
and performing the first surgery within 3 to 5 hours. These
systems are linked back to American quality care and refuse to
compromise on patient safety.
Providing trusted care anywhere requires the Air Force
Medical Service to focus on patients and populations. Patient-
centered care builds new possibilities in prevention by linking
the patients to provider teams that both the patient and the
provider can be linked to an informatics network dedicated to
improving care.
Efficient and effective health teams allow recapture of
care at our medical treatment facilities to sustain currency
and continually improving our readiness insures patients and
warfighters always benefit from the latest medical technologies
and advancements.
The Air Force supports the DOD strategy to control health
care costs, and believes it is the right approach to manage the
benefit while improving quality and satisfaction. By the end of
2012, Air Force Patient-Centered Medical Home will provide 1
million of our beneficiaries new continuity of care via single
provider led teams at all of our Air Force facilities.
We will do all in our power to improve the health of our
population while working to control the rising costs of health
care.
The Air Force Medical Service treasures our partnerships
with OSD [Office of the Secretary of the Defense], the Army,
Navy, Veterans Administration, civilian, and academic partners.
We leverage all the tools you have given us to improve
retention and generate new medical knowledge. We will continue
to deliver nothing less than world-class care to military
members and their families, wherever they serve around the
globe.
Thank you and I look forward to answering your questions
this morning.
[The prepared statement of General Green can be found in
the Appendix on page 109.]
Mr. Wilson. Thank you very much, General.
And as we begin questions I want to make it clear, we are
going to have a 5-minute rule and first of all it applies to
me. And we have someone very impartial who is going to be
observing this and monitoring it, Jeanette James.
And so, Ms. James, on the mark, get set, go.
With this in mind and to you, Dr. Stanley, knowing your
background, your military background and medical, and Dr.
Woodson, I have faith in both of you and I have faith in both
of you as to the oversight of military health care. And so, it
was a real surprise to me that out of the blue, last week,
there would be a military health care czar appointed, Governor
Baldacci, a former governor of Maine. And I understand he is to
conduct a 1-year review.
I truly believe that is a duplication and the General
Accountability Office just 2 weeks ago said that our government
suffers from duplication, overlap, fragmentation; and then in
light of that, a new position is created at a time where we are
all concerned about efficiencies and now we are adding a new
job, I believe, a $163,000 a year. That just doesn't seem right
to me.
And then I am also concerned and in light of this study,
why should Congress enact what you are proposing which are the
defense health cost efficiencies, if this work could be
overturned by another major reform by another party.
Secretary Stanley. First of all, Congressman and Chairman,
I thank you first of all for your confidence because the
efficiencies that we are talking about today and specifically
are de-coupled and are not directly related to what Governor
Baldacci is going to be doing.
His charge, by me, because I asked him--first of all, I
wanted to have an objective, outside look. I have looked at GAO
reports; my charge from Secretary Gates when I first joined the
Department last year was to look at P&R a little differently.
We have not really been as open as I think we should have
been with VSOs [veteran service organizations], I don't think
we have been as open as we should have been in terms of
following some of the things that have been laid out before in
terms of recommendations and I needed an outside look and I had
a Member of Congress as well a former governor now who served
two terms to help with not only the Guard, Reserve issues but
also looking at the holistic viewpoint of readiness, of
wellness, of looking at how we are going to do, you know,
patient satisfaction and then cost was the last piece.
So the duplication is not what I actually see right now,
actually I am asking Dr. Woodson to work very closely with him
as we look at the objectives assessment of this.
Mr. Wilson. And Dr. Woodson.
Dr. Woodson. Thank you for that question. I think in part
with the delay in my confirmation and sort of the inconsistent
leadership within health affairs there was a need to in fact
look at how business was conducted within health affairs.
I do not see the governor's mandate as interfering with my
statutory authorities and the efficiencies that we need to roll
out. To the extent that Governor Baldacci conducts his studies
and produces products that informs me in terms of what
additional reforms need to made, I look forward to his work.
Mr. Wilson. I am concerned too and I am glad you brought up
about confirmation. I don't believe this position goes through
confirmation; that concerns me.
General Schoomaker, real quickly with the--it is so
important about the Walter Reed Bethesda what I consider to be
merger, but I am very concerned about the level of support
provided for the wounded warriors. Will it be equal to what we
know is world class currently at Walter Reed?
General Schoomaker. Sir, we have worked--I think all the
services have worked very, very hard to ensure that that is
going to occur. We have had some very, very tight schedules and
some unexpected hurdles that we are going to have to overcome.
I feel that I should say, honestly, that there are going to
be some patients and some clinical situations in a new system
that is going to be, who are going to be facing unfamiliar
terrain. We are going to have a new physical plant, a new
organizational arrangement and a new virtual space, that is the
Electronic Health Record to deliver that care. But I can say
that we are working as hard as we can to meet those, both the
deadlines as well as the standards of high-quality care.
Mr. Wilson. Thank you, and with the 5-minute rule, Mrs.
Davis.
Mrs. Davis. Thank you.
Dr. Stanley, I understand that the Department analyzed a
number of options before it considered what proposals to put
forward to try and address the growing health care budget. So I
wondered if you could share with the subcommittee what other
proposals were considered and subsequently rejected by the
Department?
Secretary Stanley. Yes, Congresswoman Davis. The Department
did, in fact, look at other options, everywhere from curtailing
certain studies, doing curtailment on research, dealing with
not only cancer research but looking at a whole range of
options that I know that I am going to ask Dr. Woodson to help
with some of this but the bottom line is, is that over the
years, before I came, there were actually higher costs looked
at which were rejected not only by this body but also
internally looking at ways to be more efficient but also having
minimal impact or effect on our troops and affecting our Active
Duty Component.
So we looked at things that will have minimal impact on
Active Duty and at the same time not really affecting even our
retirement community or Reserve and Guard significantly, just
looking at ways to manage costs but still deliver quality care.
And that is the side, that is where we came down with these
minimal efficiencies that we are looking at.
Mrs. Davis. Dr. Woodson.
Dr. Woodson. Thank you very much for that question.
Producing efficiencies and reduction in costs in health care is
an ongoing effort, both within the Military Health System and
within civilian sector as well.
Since 2007 $1.65 billion have been saved in the Military
Health System by introducing mail-order pharmacy products,
going after Federal price ceilings, using outpatient
perspective payment systems, enhanced fraud detection, and
standardizing medical supplies and equipment.
And of course I would remind the committee that the factors
that are influencing the rise in health care include the fact
that we have an increased number of users, new products and we
have growing pharmacy use and growing utilization of health
care resources.
Now we have endeavored to streamline our practices and
produce efficiencies. We mentioned Patient-Centered Home as a
method for particularly managing chronic disease which reduces
cost but also improves quality of care. We have undergone
consolidation and initial outfitting and transition of
equipment efficiencies. We have centralized procurement of
medical equipment and devices. We have also reduced service
contracts and we continue to look at this as a source of
efficiencies and as you know we are undergoing an efficiency
evaluation to reduce 780 FTEs [full time equivalents] from
Health Affairs and TRICARE Management Activity.
We streamlined TMA, TRICARE Management Activity operations
and expanded the use of urgent care and nurse advice lines to
produce better quality of care and more efficient care.
So there have been a number of initiatives that have been
implemented and continue to be implemented, and again I would
remind the committee that between 2001 and 2008, the rise in
cost of health care was about 11.8 percent per year. We are
really desperately trying to bend that curve and produce all
sorts of efficiencies, and that is why we have considered for
fiscal year 2012 a really balanced approach to bending that
cost curve. Thank you.
Mrs. Davis. I appreciate, you know, your response. And one
of the things I was wondering about this, Surgeons General,
could you just talk a little bit about the engagement of you
all and whether you felt that there was adequate opportunity
for people to weigh in on these issues?
Admiral, did you want to----
Admiral Robinson. Yes, Congresswoman Davis. I think that
the Surgeon Generals, all of us have been brought into the
whole efficiency movement. I think that coming from Health
Affairs, we have all been tasked to look not only at what we
are doing externally with the five efficiencies that have been
named, but also the internal approach.
And it has been through, in my opinion, the Medical Home
where all three services leverage some of the efficiencies that
are occurring in terms of access to care for primary care,
integration of specialty care, having a real provider-patient
relationship 24 hours, 7 days a week, decreasing urgent and
emergency room visits, and having the ability to emphasize
prevention rather than disease care.
So, in the Medical Home Port model, what the Navy calls,
the same model that, the Medical Home is what Air Force and
Army uses also--I think that it is going to be one of those
major efficiency moves in terms of quality of care.
Yes, ma'am.
Mrs. Davis. I think my time is up. General, perhaps later
we will have a chance for your response.
Mr. Wilson. And thank you very much.
Congressman Jones of North Carolina.
Mr. Jones. Mr. Chairman, thank you very much. And my
question will be directed to Admiral Robinson and General
Schoomaker. I want to thank you first for your service, and the
many times you have testified, and the fine work you have done
for our military.
I, like most Members of Congress, I have visited Walter
Reed and Bethesda on a regular basis. And I make reference to
this article of March 9th report reveals steep increase in war
amputations the last fall.
And it seems like the last year that I have had the
privilege to visit the heroes at Walter Reed and Bethesda, that
the severity of the wounds are deeper or more severe than ever.
One being a kid that lost most of his lower body parts, the
other being a sergeant first class who on a fourth tour in
Afghanistan as he told me that day that he has always told the
young marines to walk in the boot print in front. He did and it
blew his leg off and other parts of his lower body were
injured.
My concern for those who are still in the military who are
severely wounded as well as when they leave the military, but
this panel today, and that is why I have to single out the
admiral and the general for this answer, are you satisfied that
we are where we need to be as it relates to psychiatrists in
the Army and the Navy?
Do we have an issue there that the government needs to
really reach out and try to encourage those who are graduating
from the schools, who are getting degrees in psychiatry, to
look more at trying to come into the military? Or do you feel
like the numbers are where they need to be?
My concern is--I am going to let you answer in one sec--my
concern is not only the young injured, but if they have a mom
and dad or if they have a wife and children. My concern is that
I want to make sure that they get the mental health care as
well as the physical health care.
General, I would go to you first and then the admiral
second.
General Schoomaker. Well, mindful of the time, sir, I am
going to say two things real quickly. First of all, not to
minimize or in any way to marginalize the interest that you
have in this complex injury pattern that you have seen, we have
recognized the same thing.
In fact, I have started up a task force a month or so ago
to look in greater detail under the leadership of Brigadier
General Joe Caravallo from the Southern Regional Medical
Command and Brooke Army Medical Center.
He has pulled a team together to look at the data and look
at the magnitude of the injuries that we are now seeing. We are
seeing a larger number as you have seen of complex injuries
from dismounted operations in Afghanistan with more multiple
limbs lost, and higher limbs with abdominal and genital
injuries as well.
We think this is the dark side of a good story. Soldiers
and marines are surviving even more than they have in the past.
The battlefield medicine is improving in all facets.
But what we get is a soldier, marine, sailor, airman who is
very, very severely injured. And we are focusing now on what we
need to do for them.
As far as psychological care, this is a moving target. We
have seen as Dr. Woodson talked about it, increasing
utilization especially in behavioral health across all of our
units and families.
We have increased the number of behavioral health
specialists, not just psychiatrists, but social workers,
psychologists, our nurse psychiatric workers as well as our
enlisted.
The Army has allowed us to put more of them down into
battalions and brigades. We continue to chase that; we are not
satisfied as you pointed out. The need is still there.
Mr. Jones. Admiral.
Admiral Robinson. The entire nation has a real challenge
with behavioral health needs. The military certainly has an
even increased challenge. I would say that what General
Schoomaker said is correct. I would ditto everything that he
has said.
We don't have enough psychiatrists, psychologists, social
workers, or nurse practitioners in the sense that I can always
use more. If we look at the retention rates particularly with
psychiatry, we are probably in the Navy at 72 percent.
With that said, we have spent about $240 million in
contracts. We have now about 144 more behavioral health
contractors at 14 of our MTFs [military treatment facilities].
We have billeted for an increase in social workers from 35
to about 86, which is a substantial increase. We are looking at
each facet of behavioral health, who we have, where they are
located, and how we use them. We also put them and we embed our
mental health professionals with our operational stress
control, our OSCAR teams, we put them with the deploying units
so that we can get care to people that they need immediately.
On the home front, we have FOCUS--or Families OverComing
Under Stress. It is a focus, the program is called, in which we
look at families and their behavioral health needs and the
needs of the children and spouses, et cetera.
So we are putting together, I think, across the Military
Health System a comprehensive look. Is it enough? It is all
that we have now. We can always do better. And this is the
major challenge as I said in my opening statement, a continuing
major challenge. It really is a moving target.
We are trying to stay with it. And we will never leave
those men and women behind.
Mr. Jones. Thank you, sir. Thank you, Mr. Chairman.
Mr. Wilson. Thank you.
And it is a good story. In January, I visited a young
injured marine, Corporal Kyle Carpenter. And Kyle has had
dozens of operations. He was gruesomely injured.
And he--last week it was on the front page, the newspapers
across South Carolina appearing at the South Carolina Senate
where he was on the floor. And all the members of the Senate
welcomed him and shook his hand. And he was given a hero's
deserved welcome.
Congresswoman Niki Tsongas of Massachusetts.
Ms. Tsongas. Thank you all for being here. And I have to
say I share Congressman Jones' concern. But I too have a good
story.
Last week, I visited a young first lieutenant in the Army
who had been injured by an IED [improvised explosive device] in
Afghanistan. He had sadly lost the lower portion of his leg.
But he was on a good recovery, yet another example of a very
determined young man who wants to make the best of his service
to our country and to the life that lies before him.
So, I thank you all for the great work that you are putting
in, in challenging times. But I will also wanted to start out
by commenting on the Uniformed Services Family Health Plan
[USFHP]. The USFHP had its genesis 30 years ago when the direct
care system needed help to meet the health care needs of our
military personnel, retirees, and dependents.
And since then, as you all know, they have become the
highest rated health care program in the Military Health System
based on beneficiary satisfaction with a 90.4 percent
satisfaction rate in 2009.
Their approach to patient care management with the focus on
prevention and a continuum of care has improved clinical
outcomes, decreased emergency room visits and hospital
admissions.
This health plan is a model for what we have been aiming to
do as we all struggle with the rising cost of health care. So,
I would urge that as a body, we give careful analysis to the
impact of your proposals to shift its cost to Medicare for
retirees. Simply a statement of concern.
But I have a question, Secretary Stanley and Dr. Woodson.
Secretary Gates has stated that, ``Healthcare costs are eating
the Defense Department alive.'' And according to the US News &
World Report, ``Healthcare cost as part of the Defense budget
have gone from $19 billion in 2001 to about $55 billion now,
about a 10th of the total.''
Currently the over 2 million military retiree families
enrolled in the lifetime health insurance system, TRICARE, pay
$460 per family per year for health insurance. And an
individual pays $230 per year. As we all know, these fees have
not been raised in 15 years.
With this in mind, I do believe that Congress needs to take
on the difficult task of reviewing this fee structure. It is an
issue that will have to be dealt with because of the massive
strain which has been placed on the defense budget by rising
health care cost.
However, I believe it must be done in such a way as to
minimize its impact. It would be inexcusable to deprive our
retired heroes of the health benefits they have earned.
For Active Duty personnel, the Department has different
annual deductible rates for TRICARE Extra and TRICARE Standard
on the basis of pay grade. For example, under TRICARE Standard,
the deductible is $150 per individual or $300 per family for
beneficiaries at E5 and above and $50 per individual or $100
per family if the beneficiary is under E5.
Retirement benefits vary greatly depending on how long a
person served and at what rank they retired.
One of the most significant changes made by the National
Defense Authorization Act for Fiscal Year 2000 was a lifting of
the 75 percent cap used in the calculation of retired pay for
members eligible for service retirement.
Under this calculation, a retired O10 with 45 years of
service could earn over $210,000 per year before taxes in
retirement. But an E5 with 20 years of service would earn only
around $17,000 in annual retirement pay before taxes.
Keeping this great gap in benefits in mind, I would like to
ask, has the Department seriously reviewed any proposals for a
stepped increase of TRICARE Prime fees determined on the basis
of rank at the time of retirement and retiree benefits earned.
Secretary Stanley. Congresswoman Tsongas, thank you very
much for the question.
I am not aware of stepped increase look. The amount that
was chosen was considered really a minimalist approach to
addressing probably a longstanding issue of prices just not
changing, or cost or charges being, you know, put onto the
beneficiaries.
If Dr. Woodson, I am not sure if you have heard anything on
that. I haven't.
Dr. Woodson. Thank you, Dr. Stanley.
Thank you for the question. I agree that we haven't looked
at the step-wise increases because we have introduced very
modest changes. And as an administrative process, it becomes
more difficult to assess income and who should have the step-
wise increase because of that.
Even an enlisted person who retires after 20 years may
actually enter a very good-paying job. And so what they
actually make may not always relate just to their retirement
pay.
And I would just remind the committee members to reflect on
the fact that our proposals suggest modest increases for
working-age retirees. And so, we would probably have to means-
test against the issue of what their total salaries are; it is
conceivable that following retirement, as talented as our men
and women are who serve, they contribute greatly, get advanced
degrees, and may be doing quite well.
So, administratively, it would be very tough to means-test.
If we were proposing large fee increases, I would agree with
you strongly.
Ms. Tsongas. Thank you.
Mr. Wilson. Thank you, Ms. Tsongas.
And we are very grateful to have distinguished freshmen on
the committee. The first is Dr. Joe Heck of Nevada. He is
actually a staff alumnus of the Uniformed Services University
of Health Sciences.
Dr. Heck. Thank you, Mr. Chairman.
And Dr. Stanley, Dr. Woodson, Surgeons General, thank you
for being here today and thank you for your commitment to our
service men and women's health and the health of their
families.
I am going to refer to the joint written statement of Dr.
Stanley and Dr. Woodson specifically, Reserve health readiness.
You have referenced the individual medical readiness metric
that has been developed. And in your statement you quote--
``Within the Reserve Component, medical readiness is below our
benchmarks.''
And of course this is an area of great concern for me. And
it raises several issues that I would like to bring up
revolving primarily around the LHI [Logistics Health
Incorporated] contract and how that service has currently
performed for the Army Reserve.
You know, as you well know, we have units in the Army
Medical Reserve, MSUs, Mobilization Support Units, whose job it
is to accomplish the medical aspect of soldier readiness
processing when they get mobilized to their support base.
However, they are prohibited from performing that very same
service for their own Reserve counterparts on a BTA [battle
training assembly] weekend.
In your notes, you mentioned issues with minor dental
procedures and immunizations being an issue that can be readily
fixed in pre-mobilization or pre-deployment mobilization. Yet,
in my unit, I have dentists that on a BTA weekend can go out
and provide services to homeless people as a community service,
but can't examine the reservists that are in their own unit
because it is prohibited because of the LHI contract.
In immunizations, every fall, our immunization readiness
plummets because a new flu vaccine comes out and everybody's
compliance falls off until everybody gets their flu vaccine.
You would think that in a medical unit full of doctors, nurses,
and medics, we could immunize each other. But we can't even get
the vaccine because we have to put in a voucher for LHI to come
and do the immunizations.
The issues here are multiple. One, as you well recognize,
it impacts our medical readiness. Two, it impacts our ability
to perform real world training. Certainly, our doctors and
nurses are doing that in their day job. But my 68 Whiskeys, my
combat medics, they could be a janitor, they could be garbage
man, they could be a schoolteacher, and we are taking away an
opportunity for them to actually do their medical training on a
drill weekend.
We send people to a PHA [periodic health assessment]. We
send soldiers that are well and they come back to us broken.
They go in well and they come back with a P3 profile. They are
now medically non-deployable. And it takes us 6 months or more
to backtrack and get that profile lifted because the folks
doing these physicals don't understand what the profile process
is.
I am encouraged by Major General Kasulke at AR-MEDCOM [Army
Reserve Medical Command] who is starting a pilot project to
review all these things and trying to find a way to take care
of these mis-profiles. But the answer is not to have the person
come back broken to begin with.
So my questions are: I understand that the LHI contract is
up for renewal. I would like to know who has the formal
approval authority for that contract? Is the Army considering
any other options or modifications to the contract? What is the
overall cost? And how can we document whether or not the LHI
contract has provided any value-added service to our medical
readiness?
Dr. Woodson. Thank you, Congressman, for that very good
question. And I would like to take that one for the record and
get back to you with the substantive facts and answer you
specifically. I think that probably it is time for review as we
look at individual medical readiness and seeing how we can get
added value out of all of the contracts that we employ.
[The information referred to can be found in the Appendix
on page 131.]
Dr. Heck. I appreciate that. And I think it is critical
that we also look at the opportunities to allow--I mean, back
in the old days--and I guess, for the record, I should probably
disclose that the Honorable Woodson used to be my rater when he
was Brigadier General Woodson at AR-MEDCOM. And I thank you for
all those good ratings, sir.
But, you know, we need to get back to the point where our
Army Reserve medical personnel can do medical stuff on BTA
weekend and maintain their skills. In the old days, we used to
do all the physicals. And then all of a sudden there was an LHI
contract and we were prohibited from doing those same things
that we did for decades.
So, I look forward to the answers for the record, sir.
Thank you.
General Schoomaker. And, Congressman, if I could just make
one comment. I think what you described also is why we stood up
the Soldier Medical Readiness Campaign under mobilized
reservist Rich Stone. And I would welcome the opportunity to
have him come out and talk to you about that and what we are
trying to do in partnership with both the Guard and Reserve.
Dr. Heck. Okay, thank you, General. I appreciate that.
Mr. Wilson. Thank you very much. And the issues that we are
dealing with are so important for our service members,
families, and veterans. In consultation with the ranking
member, we will do a second round of one question each. But at
this time, we immediately, of course, go to Ms. Pingree of
Maine.
Ms. Pingree. Thank you very much, Mr. Chair, Secretary
Stanley, Dr. Woodson and all of the Surgeons General. I really
appreciate your service to our country, your testimony this
morning and so much of what you have been talking about are
things that I appreciate hearing about, whether it is how you
treat traumatic brain injury or using alternative methods of
care to find more ways to heal our soldiers, talking about the
medical home concept.
There are so many good things that you are doing. And I
appreciate it, and I appreciate all the work that you have
done. And I understand Chair Wilson's concern about the recent
appointment of the governor from my state, Governor Baldacci,
and his interest in making sure we are doing everything that is
as cost effective as possible.
But I do want to say that Governor Baldacci has a great
work ethic. He is very devoted to our military. He has worked
very closely with the National Guard in our state to improve
many of the practices in our state. So I look forward to him
looking for some of the efficiencies that could be found.
But I want to reiterate some of what my colleague from
Massachusetts talked about earlier. It is a deep concern for
me. I represent the state of Maine, and I am proud to represent
many Active Duty members and their families as well as military
retirees and their families. I have over 34,000 military
families and retirees that are fortunate to have access to
outstanding health care provided by U.S. Family Health Plan at
Martin's Point Healthcare in Maine.
I visited their facility. I have seen their use of the
Medical Home model of care. The beneficiaries tell me how much
they like this health care option. I mean, it has been said
many times. This is exactly where we want to go with health
care with our military retirees. And they are very happy, very
satisfied about it.
In March, I sent a letter to you stating my unequivocal
support of how this program currently works and suggesting that
I would oppose any changes that would negatively impact the
ability of them to provide care to beneficiaries, including
those aged 65 and over who have earned their health benefits
through their service to our Nation.
I am sorry to say, General Stanley, and with all due
respect, I wasn't completely pleased with your response. And
now the fiscal year 2012 President's budget request includes a
proposed legislative provision that future enrollees would not
remain on the plan upon reaching age 65. I am concerned about
this proposal, that it would eliminate access for those in
greatest need of care and their ability to receive what is the
highest rated health care plan in the military.
Let me just shorten up some of my conversation here because
I know you know exactly what my concerns are and what I am
talking about. But I want to reiterate that I am sure you know
by law, the government cannot pay more for the care of a U.S.
Family Healthcare Plan enrollee than it would if that
beneficiary were receiving care from another government
program.
So I have a hard time seeing this as anything but a cost
shift over to Medicare while destabilizing what is already a
very successful program. So I guess I would like to hear you
address that and also address my concerns that the
destabilization of this program, in my opinion, isn't
consistent with DOD's stated priorities of improved health
management and the continuity of care.
I am just not pleased about what we are doing here in the
budget. I understand the importance of cost efficiencies, but,
to me--and I guess it is a little smoke and mirrors and maybe
not going to be good for the long-term health care of the
people of my state.
Secretary Stanley. Thank you for the question,
Congresswoman Pingree. I think, as we look at what we are
proposing, that each hospital that we are working with
particularly with the Family Health Plan that we are going to
be working very closely with them because the changes first of
all may be minimal in some cases or almost barely perceptible
initially as we work, as we look at how the Medicare, you know,
the funding is worked out because you really don't want to just
unplug and move right into something that becomes a cost shift.
At the same time, we are trying to address something that
had not been addressed for a number of years in terms of how
we, you know, work with the cost and everything. So the bottom
line is we are going to work with them.
And I hear your concern and I recognize your concern. And
we are going to do our very best to work with them. I am going
to ask Dr. Woodson to address this also.
Dr. Woodson. Thank you very much for that very important
question. I think the issues that we need to remind ourselves
of is that this is not about taking a beneficiary away from
their doctor. They can continue to see their doctor. They can
continue to go to the same hospitals. But we pay about $16,000
per member per year in capitated fees to the Uniformed Services
Family Health Plans.
And it is important to note that their plan is not just
about hospital fees, but it is about the money that is also
paid to their primary care physicians, whereas, the cost to the
government for, let's say, TRICARE Prime is about $4,500 and
for TRICARE Standard is about $3,500. Just good business
practice in this day and age would suggest that we have to get
better value for the dollar.
Now, I want to say up front that we consider all of these
facilities and providers that are in the Uniform Services
Family Health Plan as great partners. We don't want to lose
them. I just think that in these tough times of budget
constraints and rising health care cost, we look at contracts
everywhere and say how can we get the best of value.
The proposal actually will save the entire Federal
Government about $300 million over about 10 years because right
now, of course, we pay about 42 percent higher in cost than we
would pay under Medicare fees. I remind you also that most of
the individuals that are Medicare eligible actually have taken
already on part B.
Ninety percent or so all ready have part B because if they
were to move or circumstances in their life cause them to shift
to other doctors, if they don't take it on at age 65, they pay
severe penalties. So the impact to any individual patient is
likely to be not that dramatic as well.
So it is about being good stewards of public money. It is
about preserving money for the future and making sure that the
Military Health System and the provisions under TRICARE remain
strong in the future for those who might serve in the future
and bringing equity, if you will, to the benefits for all
Medicare eligible beneficiaries as well as equity in terms of
how we pay all of our providers and hospitals that may serve
our men and women who have served.
So there are multiple reasons to really consider this. And
I think again, it is one of those modest changes that on the
balance says that we have looked at a number of initiatives to
produce efficiencies.
Ms. Pingree. My time is up, but thank you. I am sure----
Mr. Wilson. And, Ms. Pingree, we will get back to another
question, too. So thank you so much, very good question.
And as we conclude this first round, it is very fitting
that we have another distinguished freshman, Colonel Allen West
of Florida, who himself has had an extraordinary record of
military service.
Colonel West.
Mr. West. Thank you, Mr. Chairman, also Madam Ranking
Member, the Honorable Stanley, Honorable Woodson, General
Schoomaker, General Green, and Admiral Robinson. Thank you so
much for appearing here today.
We talked about the visible injuries that we see coming out
of the combat theaters of operation in Iraq and Afghanistan,
but one of my concerns is the unseen injury and, of course,
that is traumatic brain injury, TBI.
I have had the opportunity to visit with a gentleman by the
name of Dr. Ray Kraul down at South Florida who has been
offering hyperbaric oxygen treatments to several returning
veterans. I have had the chance to sit down with three of them
and we have seen some noticeable improvements.
About 3 weeks or so ago, I had the opportunity to sit down
and have lunch with Vice Chief of Staff General Chiarelli, and
we talked about the opportunities and the options of the
hyperbaric oxygen treatment. One of the things he said is that
there are some obstacles out there to the implementation of
this as a viable treatment for returning veterans.
And so I would like to know what are those obstacles that
are out there and how can this committee help to, I guess,
eradicate some of those obstacles so we can facilitate taking
care of our veterans?
General Schoomaker. Well, I don't think there is anything
that the committee can necessarily do for this, Congressman.
Thanks for that question. Hyperbaric oxygen is currently an FDA
[Food and Drug Administration] regulated treatment. It is not
currently approved by the FDA for treatment of either
concussive brain injury or for post-traumatic stress disorder.
We have offered through your generous funding any and all
investigators out there who are administering hyperbaric oxygen
to design and administer protocols that would test and
demonstrate the utility of this. We finally undertook those
investigations ourselves. We have currently three projects. One
has been completed at the LDS Hospital in Salt Lake City by an
international expert in hyperbaric medicine, Dr. Lin Weaver.
Its results on a non-randomized and uncontrolled study show
that hyperbaric oxygen appears safe at this point for patients
with moderate and stable brain injury. We currently are
awaiting the results of an Air Force School of Aerospace
Medicine study that has just been concluded that is controlled
and sham controlled so that we can see what the effect of the
hyperbaric oxygen is against a semblance of that administration
of oxygen, but without it. We have yet to see what the results
of that. And we are awaiting a more definitive study that will
be overseen by the Army's Medical Research and Materiel Command
that will include four or five sites across the country,
military and non-military.
So the summary of all of this is that despite a series of
published and unpublished anecdotes, there really remains no
medical evidence that hyperbaric oxygen has a therapeutic role
in the relief of symptoms of--or brain dysfunction for warriors
with post concussive syndrome, or mild traumatic brain injury,
or posttraumatic stress disorder.
And until we have that, we just can't in good conscience
provide care which is quite expensive without knowing its
ultimate safety and its utility.
Mr. West. Well, I guess the thing is when you sit down and
you do speak to some of these young men as I have that say that
it has made a difference, I think that is some pretty good
anecdotal evidence for myself.
But, you know, perhaps, Mr. Chairman, we ought to look at
seeing if we do need to send a letter over to the FDA and ask
what impediments that they are making. But we cannot, you know,
take too much time because every day some soldier, sailor,
airman, marine is going through an IED blast. And these IEDs
continue to cost much injury as far as TBI. So, hopefully, we
can put a little bit more emphasis and a little bit more speed
to this.
Thank you very much and I yield back.
Mr. Wilson. Thank you, Congressman. I look forward to
working with you in a joint letter or whatever. And I
appreciate your promotion of this issue.
We will now have a second round with everyone, a single
question. And, for me, so often we hear the bad, but there is
so much good. And military medicine really has been the best in
the world providing for care of people with brain injuries and
trauma injuries. And this applies to the civilian world of auto
accidents and these who are people who are injured in sports
injuries, additionally, prosthetics, truly the best in the
world now, our American military medicine and available to the
civilian population.
With this, I would like to know from each of the Surgeons
General what you have done in regard to cost efficiencies. Can
you give us an example of a cost efficiency on behalf of the
taxpayers of our country. And we will begin with General
Schoomaker, the senior person and then we will end up with the
junior general.
General Schoomaker. Sir, what we have focused on a lot
within Army Medicine is standardization of practices, both
administrative and clinical practices. It has been widely
discussed both in the private sector as well as in government
medicine that elimination of unwarranted variation in
practices--clinical practices and administrative practices--
will squeeze out a lot of waste in the system.
We have focused very hard on that. We have also used a
business case model for all of our hospitals and clinics in
which commanders are encouraged to target health promotion and
health improvement as a way of preventing preventable
hospitalizations, ER visits and the like.
And, finally, I would say that all of us here--and we
commend the Air Force for their lead on this--have embraced the
Patient-Centered Medical Home, which we think is going to be
transformative in bringing into the primary care sector both
ready access continuity, because many of our patients seek
continuity where we think they are looking for access alone,
and a fusion site for behavioral health, for pain management
and many of the other things that we are doing that will
ultimately result I think in better and healthier people,
better and healthier communities and reduction and cost over
all.
Mr. Wilson. Thank you.
Admiral.
Admiral Robinson. Thank you very much for the question. In
addition to what General Schoomaker said--I am not going to
repeat that--many of the Navy initiatives are along the same
line. We have also taken some internal looks. And partnering
with the Applied Physics Lab at Johns Hopkins and also the
Center for Naval Analyses, we have come through and looked at
business practices and also clinical practices in our medical
treatment facilities across the enterprise.
We are taking an enterprise approach, having industrial
engineers come through, look at the orthopedic departments and
how we have patient flows at Balboa or Camp Pendleton, how we
have access to care for the patient, how we then work them
through our system, how we could do that more efficiently, not
only from a patient perspective, but also from a provider
perspective.
I am talking about from the corpsman, from the nurses, from
the physicians, from everyone on that team. So we are trying to
take an enterprise look at how we can implement that across the
board and doing what Eric said in terms of the standardization
of practice so that we can reduce the variation.
Additionally, in the financial world and I, not being a
financial expert, am blessed to have a really excellent Navy
Medicine controller who has instituted a great deal of effort
at standardization of how we in fact do our financial
accounting, how we do our audits and how we look at the
financial program's execution. He has been sensational and
there is so much more that I can't describe, but he has been
sensational and has become a real best practice for not only
the Department of the Navy but also the Department of Defense.
So he is being utilized and a lot of his programs are being
utilized there.
Those two business practices, that industrial engineering
and the way we do our financials across the gamut within Navy
Medicine have produced efficiencies and savings that have
really made a much better enterprise approach to the way we do
Navy Medicine.
Mr. Wilson. Thank you, and General.
General Green. We have looked at several different things.
We actually decreased our headquarters manning to increase the
manning back to the hospitals trying to recapture care. We have
looked at standardizing our practice. Part of the Medical Home
was to basically look at support staffing ratios and put some
of the nursing staff back into hospitals again, based on
business case analysis to bring the care back in.
We have had systems looking at our ORs [operating rooms]
and at our emergency rooms basically trying to maximize the
efficiency to increase access. We have seen at some of our
bases as much as a 40 percent increase in the surgical cases
that can go through our ORs by recapturing care. Under the
Patient-Centered Medical Home, the satisfaction is up, the
continuity jumps from about 40 percent to 70 percent, and we
end up encouraging the providers to work at the top of their
license based on changes to their practice.
I would tell you that the partnerships that we are doing
are based on bringing care back into the direct care
facilities, both for currency and to decrease cost in terms of
what is going to the private sector. And finally, the efforts
in disease management and case management across all three
services are reducing care cost. In fact, in one case out at
Hill Air Force Base we have saved probably $400,000 in reduced
utilization by diabetics based on the output and the efforts to
try to case manage.
Mr. Wilson. Thank you all very, very much, and Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman. One thing that I would
like to mention is I hope that we will have an opportunity to
look at mental health issues overall, whether or not we are
providing the support to encourage people to go into those
fields and also a look at some of the research and development
that has been done, and whether or not we are utilizing those
dollars well and coordinating those efforts in a way that we
really do know what has happened over the last number of years,
because we have certainly put a lot of effort into that and I
would like to take a look at that and see how it is really
affecting our service members and their families.
But I wanted to go back to Ms. Pingree's question, I think
generally because the new proposal really could have an impact
on our Active Duty members and because there is in the proposal
we are reducing possible payments to Sole Community Hospitals,
and those hospitals may of course decide to limit TRICARE
participation due to the reduced rates. And so I am wondering,
and this goes really I think to General Green, whether or not
the Air Force has particularly engaged with Sole Community
Hospitals outside of Air Force bases to assess the impact of
this proposal on the beneficiaries in those communities, and if
you are confident that the proposal will not severely impact
them.
In addition to the concerns that I think a lot of our
Members are going to have because there are certain Members,
communities that are more affected by this than others, we also
know that those hospitals that have many cases of
disproportionate share hospitals also even in urban communities
might be affected by this. So I am wondering if you could
address it, General Green and perhaps others quickly. What do
we know about that and what can we anticipate could be the
impact on our beneficiaries?
General Green. Eight of the 20 hospitals that have over 5
percent of their income based on admissions are from Air Force
areas and so, when you look at those, about 4 of those
facilities actually are in the 10 percent to 15 percent range
for us. We are not the highest, but it is a concern.
The reality of the implementation is that we have had
longstanding partnerships with these organizations. We believe
that the care will still continue to go to these organizations.
As you change the payment and bring it in line with payment
elsewhere in the country in terms of how we receive care, we
believe that the implementation is conservative enough in terms
of the basically bringing online over a 4-year period that we
can look at it, work with the local facilities and if
necessary, work with Health Affairs in terms of any type of
transitional changes in payments to make certain that this is
sustainable.
Our belief is that this is a reasonable approach to try and
bring this back in line with what is going on elsewhere in the
Nation and obviously remains to be seen, particularly with
these hospitals where it is a large portion or a larger portion
of their income.
There should be no effect on our beneficiaries because
their care would still go to the same areas. They just would be
at the rate of payment that is provided at every other site
where they might go and seek care if they were out of that
area. And so the question is going to be does it end up
affecting the facilities to the point where despite the long-
term partnerships, they feel they have to change the mix of
patients, and so we will be watching that very closely.
General Schoomaker. Yes, I would echo those comments. Two
of the 20 are Army-centric including a hospital in the
community that our Secretary of the Army represented at one
point, and I think everything that General Green said applies
to the Army as well and we have been reassured by Dr. Woodson
that the financials of this will be looked at very carefully
and that we won't erode the relationship that we have with
these hospital systems.
Dr. Woodson. Thank you for that question. I think I want to
emphasize that we are willing to reach out proactively to these
hospitals to look at their revenue streams and how they will be
impacted. We do have the ability as the law is allowed to pay
Medicare rates when practicable and if it turns out in a
situation that there is hospital that is providing needed
services and there are no other hospitals, adjustments can be
made. So I want to emphasize that in fact we are going to be
proactive about this. We want to be fair about this. But again,
we need to in this day and age, make sure that all of our
contracts are really looked at carefully and add value and--as
well as quality in terms of the care that is provided.
Mr. Wilson. Thank you very much. We now go the Mr. Jones.
Mr. Jones. Thank you, Mr. Chairman. And my question in just
a moment would be for you Admiral Robinson. I appreciate the
question by Congressman West. I remember 10 years ago I think I
was briefed by Dr. Harch from LSU about hyperbaric oxygen as a
treatment for head wounds. And I know I had a conversation a
couple of years ago, I cannot remember the Air Force officer,
about where the research is going and I appreciate your
statement, General Schoomaker, that my concern or interest is
this--Admiral Robinson, I know that--and I want to thank
Admiral Mullen.
Quite frankly, I brought this up at a full hearing about a
year ago about hyperbaric chamber down at Camp Lejeune. We do
have one at Camp Lejeune. And I believe that they are in the
process now preparing to be part of a pilot program to treat
marines down at Camp Lejeune which I am grateful for.
Help me understand when--I understand the need for studies,
please understand I do realize they are very, very important.
But when would the military get to a point after the study by
the Air Force, maybe the Army, I don't know that. Maybe the
Navy as well. When did you get to a point that the studies say
and I will tell you why, then I am going to let you answer, I
have called numerous moms and dads whose sons and a couple of
daughters had been in the hyperbaric chamber for treatment.
What really sticks with me and I want to use this before and
then you answer please, sir.
I called Colonel Bud Day who won the medal of honor in
Vietnam, and he told me that his grandson had a severe brain
injury from Iraq I believe at that time, and he was just not
satisfied with the treatment, and at his own expense, he sent
his grandson to LSU to Dr. Harch and I know I will never forget
what Colonel Day said to me. He said that, ``I will go anywhere
I need to go to testify that this treatment has given my
grandson a quality of life that he would never have had if he
had not had the hyperbaric treatment.''
So now this--was the question--I just remember. When do we
get to the point that we say, meaning Department of Defense,
that this protocol does help, it does work?
Admiral Robinson. Congressman Jones, thanks for the
question. This has been for me as a Surgeon General of the Navy
a 4-year question. We have looked at hyperbaric oxygen and Dr.
Harch who has been at several meetings and I have met him many
times and looked at his results.
We have invited him to come through and participate
firsthand in our double-blinded studies so that we can get away
from the anecdotal results of individual patients, families,
and other anecdotal lessons, and we can get down to what we
have to have from an objective and a definitive way so that we
can base clinical practice guidelines both for the Military
Health System and also for the private sector. We need to base
those therapies on objective clinical data that cannot be
influenced by opinions of people who have benefited, but we
can't prove that benefit in a scientific way. So we need to
employ a scientific method.
What we have done, and I can say that after in my fourth
year as Surgeon General, we now have studies--we are now
beginning to produce data from competent studies that look at,
number one, hyperbaric oxygen seems to be safe, so I think that
that is a clear improvement in terms of our knowledge. And now
we need to go and look more deeply at the Air Force study and
that study has been completed, but the analysis has not been
done. So I think we are very, very close to getting more data.
I think when we can get some studies on the record that
actually look at the efficacy of hyperbaric oxygen therapy, I
think at that point we can simply say, that is an effective
treatment, it is not an effective treatment, but it is a
treatment that can be utilized in complementary medical ways so
that people who may benefit from it can use it, it certainly
not going to harm them. We will have an array of answers.
I think we are literally months away from getting there,
but it normally takes--and this is one of the issues with
medicine--it normally takes time to get to where we need to be
and we have to base it on a scientific method unless, in order
to keep from having everything become a clinical practice
guideline, things that are not proven. So the scientific method
is being utilized in this way.
Mr. Jones. Thank you, Admiral. Thank you, Mr. Chairman.
Mr. Wilson. Thank you and next we go to Ms. Pingree of the
great state of Maine.
Ms. Pingree. Thank you, Mr. Chair. Thanks for the
opportunity to discuss these issues with you again in a second
round. And I just want to say again, I understand how well you
are all doing your job and the importance of all of you looking
for cost efficiencies in what you do as we face a difficult
time with the budget deficit. And also where there is a lot of
examination of the military budget and looking for places where
we can cut.
And maybe my first comment really is more to my fellow
committee members than to all of you, but I might see more
places to cut the fat in the military budget than others of my
colleagues, but I am deeply concerned that we are going after
medical care for both our Active Duty personnel and our
retirees when I think there are other places to make more
effective cuts. So I know you have to do your job and look for
those cuts, but almost everything that is before us today,
either myself or one of my colleagues has mentioned a concern
about, whether it is the changes to TRICARE, how we are going
to deal with some of our Sole Community Hospitals. I have two
in my district, there are four in our state of only 1.2 million
people in a state where we have almost a fifth of our citizens
are either Active Duty or retired military.
So there is a very big dependence on this system in our
state and I am worried about that particular program. So for
me, many of the efficiencies that you are talking about are
going to reduce the level of medical care to the people who
have served us, to whom we have made a huge promise. And there
is going to be, I think, a reduction in the services that they
receive, so I just--I know you have to do your job, but I don't
like it and I don't think it is all necessarily good.
And the only other program that hasn't been brought up
today but I might ask you to comment on is the pharmacy co-pay.
I have seen a little bit about that and know that some of the
co-pays will be reduced through using mail order pharmacies. I
have concerns about that as well because I do believe that
people get better care when they go directly to a pharmacist in
their community, that is where we catch a lot of redundancies
or problems with the medications that people are taking,
particularly with retirees.
So, in my opinion, having to go to mail order to get your
pharmaceutical products is not necessarily always good
treatment or good service. And one of the things I might ask is
how much the Department is doing to negotiate for better prices
with the pharmaceutical companies and bringing costs down in
that way as opposed to this other option? That was my question,
if you have got any comments about that.
Dr. Woodson. We continue to have efforts to negotiate with
pharmaceutical companies. I think in fact that the mail order
advances care because there is a large percentage of retail
prescriptions that are never picked up and there are breaks in
terms of the supply of medications.
Our proposal not only reduces the cost, but it ensures
timely supply of medicines and, of course, linked with our
concept of the Patient-Centered Home, they have a team of
health care providers that can counsel, coach, monitor their
medicines. We have new electronic databases that highlight
medication to medication interactions and notify practitioners
of medications that may be unsafe.
So, I think there are a number of things that we are doing
that are going to enhance the quality of care while reduce the
costs and provide a better service for the beneficiaries.
Ms. Pingree. I appreciate your perspective on that. That is
useful information in thinking about the program. Back to the
question of negotiating, is that an active activity that goes
on today, to negotiate for cost-cutting? We still continue to
pay some of the highest prices in the world in this country for
prescription drugs and I know the military has done a better
job of bringing down the costs, but I just--I wonder how
engaged we are in the process and how much resistance there is
to it?
General Schoomaker. Ma'am, I am told that is a commodity
that is managed through the Defense Logistics Agency and the
center in Philadelphia. And I am told that the Department of
Defense has some of the most favorable cost profiles of any
organization in the United States because of our--because of
leveraging volume.
Ms. Pingree. Great. I will take up that issue with them.
Thank you again for your answers today.
Mr. Wilson. Thank you and I share your appreciation of
local pharmacists too. We will conclude with Dr. Joe Heck.
Dr. Heck. Thank you, Mr. Chairman. And not to belabor the
issue, but I am going to go back to TBI. First, I appreciate
the Surgeons General and the academic rigor with which their
reviewing the HBOT [hyperbolic oxygen therapy] issue and
please, I encourage you and implore you to keep that academic
rigorous approach before we make a determination on its
application.
No matter how that turns out and no matter what treatment
process we have in place for TBI, my biggest concern is
identifying the soldier, sailor, airman, marine who has TBI.
Based on my deployment to Iraq, when young guys were getting
their bells run so many times that they had the MACE [Military
Acute Concussion Evaluation] card memorized, it no longer
became a valid screening tool because they knew the answers
before I asked them.
When I came back, it spurred me to write my joint forces
staff college paper on TBI entitled ``Re-thinking the Treatment
Paradigm'' and that was 3 years ago last month. I don't think
we have come that far in 3 years, as far as we should have, in
being able to recognize folks suffering from MTBI [mild
traumatic brain injury].
I know there was an initiative underway that everyone pre-
deployment was supposed to get cognitive assessment, the ANAM
[Automated Neuropsychological Assessment Metric] or equivalent.
Where are we in that process in making sure that everybody
before they deploy has a baseline cognitive assessment done so
that we can find the small changes when they come back.
And then specifically going back to my heart of hearts in
the Reserve side of the house, it seems it is the reservists
that are getting lost to the follow-up. They get home, get
irritable. The spouse or family member saying, ``Well, he is
just reintegrating. We got to, you know, this is his re-
acclimation process.'' Three months later, he is still
irritable and then somebody starts to think, ``Well, maybe it
is something more than just he has been gone for a year.'' But
by that time, we have lost 3 months of intervention.
So again, the status of the cognitive assessment pre-
deployment and what are we doing to make sure we don't lose
reservists to follow-up or it just gets brushed aside as they
are just getting reintegrated or re-acclimated.
General Schoomaker. Let me take a stab at this if I might,
Congressman. First of all, I think we have come a long way in
the last few years especially with the publication as was
referred to earlier of the decision type memorandum.
Early in the war as you may recall, we had clinical
practice guidelines in the battlefield, but they were not
mandatory in their application and we failed to recognize that
the soldier, the marine, the sailor, the airman who was
actively engaged in battle and was part of the team was very
reluctant to leave formation, and would celebrate their
survival of an IED but then would go right back in the fight.
We now have a mandatory screening tool down range. In our
recent trip to Afghanistan, we looked at its application and
how well we are complying with it. We are seeing very good
acceptance by combatants, by their small unit leaders, all the
way up to General Petraeus himself. And with resiliency centers
such as the one that Admiral Robinson mentioned, and we have
seven in eastern Afghanistan and southern Afghanistan, we are
seeing rapid turnaround.
So, we have mandatory screening of a clinical diagnosis
only, as you know, at this point and then we apply tools like
the ANAM, the Automated Neurocognitive Assessment Module, to do
longitudinal tracking of whether they are recovering. We have
done studies now with the ANAM down range with fresh casualties
to be able to know that as a screening tool, it is insensitive
and nonspecific. It misses about a quarter to a third of those
who are concussed and it includes about 50 percent of people
who aren't concussed.
We are doing a head to head evaluation between the ANAM and
the impact tool that the National Football League uses and so
many high schools use right now. But you are absolutely right.
Right now, we have no single definitive test for the diagnosis
other than the clinical diagnosis of concussion. But we are
being very much more aggressive. And right over the horizon we
see biomarkers and other tools that we think will be useful.
Dr. Heck. Thank you very much. Admiral, did you want to
answer that?
Admiral Robinson. I think that General Schoomaker was very
comprehensive. I will add one piece. We also have the NICOE
[National Intrepid Center of Excellence] and the Defense Center
of Excellence that is devoting a great deal of research efforts
both in the basic science areas and in the areas of trying to
understand how we can diagnose and then how we can assess and
treat traumatic brain injury.
Now, I am not going to mix the two, but PTS is also there
and it is on the continuum. But I am going to stay with the
TBI. So I think that we are not only doing the in-theater
assessments, we are reporting the data, we are actually
compiling data, reporting it. I think that General Schoomaker
has emphasized the concussion part because concussion as a
clinical diagnosis is at least something we can diagnose and
follow as opposed to just TBI which becomes a little bit more
difficult to define and understand.
But with the ANAM and with the MACE, with our professionals
trained, with the Uniformed Services University deployment
psychology group training our professionals, just in time
training as they go over into theater, and with adequate data,
having the concussion restoration centers, multicomprehensive
teams, I think we are going to get at least a look at who has
been involved, how we can do a longitudinal look at them and
make sure that we can at least follow them even if we can't do
a lot in terms of understanding how it works now. We don't
understand this completely, but we are not going to let it go.
Mr. Wilson. Thank you and I would like to again point out
how much we appreciate all of you being here today,
particularly General Schoomaker, Admiral Robinson. We want to
wish you Godspeed in your future endeavors and again, I think
it has been so illuminating and we want the best for our
military, military families and veterans.
At this time, we are adjourned.
[Whereupon, at 11:48 a.m., the subcommittee was adjourned.]
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A P P E N D I X
March 15, 2011
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
March 15, 2011
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[GRAPHIC(S)] [NOT AVAILABLE IN TIFF FORMAT]
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
March 15, 2011
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RESPONSES TO QUESTIONS SUBMITTED BY DR. HECK
Dr. Woodson. The contracting authority for the contract is the U.S.
Army Medical Research Acquisition Activity; the office of the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness administers the contract. (The Reserve Health Readiness
Program (RHRP) is a Department of Defense (Health Affairs) program
developed by Force Health Protection and Readiness, and executed by its
contractor, Logistics Health Inc. (LHI).)
Unless the Service Components request new services (for example,
mental health assessments) to augment their readiness, we do not plan
to modify or re-compete this contract at this time. The Reserve Health
Readiness Program (RHRP) contract for medical and dental readiness
services was awarded to Logistics Health Inc. in September 2007, after
a full and open competition, for a base year and four option years. The
contract is currently in its third option year. The fourth option year,
if exercised, will conclude at the end of September 2012.
The contract for the five-year period is capped at $790,295,941(the
total value of the orders against the contract cannot exceed that
amount).
We can and have documented such value added.
According to the most recent data from the Office of the Surgeon,
U.S. Army Reserve Command, readiness rates have never been higher. From
October 2008 to March 2011, the percentage of Army Reserve soldiers
with a current Periodic Health Assessment (PHA) has risen from 45
percent to 88 percent; achieving dental readiness rose from 53 percent
to 75 percent; and current immunizations increased from 34 percent to
79 percent. The percent that are medically ready to deploy immediately
or within 72 hours has similarly risen from 24 percent to 64 percent.
Overall, the RHRP contract provides a broad array of services in
response to requests by the Service Components to assist them in
achieving medical readiness. The contract provides the PHA, Post-
Deployment Health Reassessment, Mental Health Assessment, dental exam,
dental treatment, and other Individual Medical Readiness services that
satisfy key deployment requirements and supplement the Services' own
efforts. Services are provided at the request of the Reserve Components
and implemented per their guidance. The annual dental examinations,
annual PHAs, and current immunizations for each Service member are
required Department of Defense elements for medical readiness.
For Fiscal Year 2010, RHRP providers addressed approximately
650,000 reservists and guardsmen across all Military Services--
conducting 218,000 dental examinations, 255,000 PHAs and 372,000
immunizations. Each of these adds value to medical readiness. [See page
21.]
?
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
March 15, 2011
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QUESTIONS SUBMITTED BY MRS. DAVIS
Mrs. Davis. Several of the reserve components continue to see
issues with medical readiness of its force. To ensure the readiness of
its force, the Air Force National Guard and Reserve requires its
personnel to be medically ready or they are not allowed to participate
in drill or training exercises. Should this requirement be extended to
the Army, Navy and Marine Corps? If not, what efforts should be
undertaken to ensure the medical readiness of the reserve component?
Secretary Stanley. No, not at this time and we do not recommend any
change to the current policy. Preventing service members from attending
drill or AT may compound the problem. Many commanders use these active
duty periods for readiness activities that include medical and dental
appointments. There are also certain aspects, such as annual preventive
health assessments (PHA), which require members to meet face-to-face
with military health providers.
Mrs. Davis. If not, what efforts should be undertaken to ensure the
medical readiness of the reserve component?
Secretary Stanley. The instructions may be drafted to ensure
members can drill or be placed on orders to complete their medical/
dental requirements, but will not drill for training until the issues
are resolved.
Reservists may be placed on military orders for the purpose of
receiving military medical/dental evaluation, or examination.
Reservists receiving medical/dental care during a tour of duty will be
voluntarily retained on Active Duty orders to continue treatment.
Reservists not on military orders may be placed on invitational travel
orders when directed by appropriate military medical authority to
receive an examination or evaluation by military medical/dental
facilities to meet military requirements. Invitational travel orders
may also be issued to those reservists receiving military medical/
dental care at military medical treatment facilities for the purpose of
medical/dental appointments.
Reserve or Active Duty medical units do not extend, authorize the
extension of, or issue military orders, or invitational travel orders.
Order issuance or an extension is the responsibility of the commander.
Mrs. Davis. Can you explain what impact the current continuing
resolutions are having on the Military Health System and on your
particular Service?
Dr. Woodson. While the Department worked vigorously to ensure that
such stopgap funding measures would not directly impact patient care,
the resolutions create inefficiencies hinder effective planning efforts
and exacerbate the operational challenges associated with supporting
mission requirements. For example, to limit the level of expenditures
during the continuing resolution periods, the MHS undertook several
actions including delayed hiring actions, restricted acquisitions,
deferred life cycle replacements of medical equipment, and limited
supply replacements.
Mrs. Davis. Health care costs of the Department continue to grow,
and is a concern both to the Department and the Congress. Can you break
down for the subcommittee, the cost growth figures over the past ten
years? For example, could you determine how much of the health care
cost growth is due to the increase in end strength for the Army and
Marine Corps over the past several years, vice an increase in health
care utilization among the population vice an increase in eligible
beneficiaries returning to the system? If so, would you please provide
that information to the subcommittee?
Dr. Woodson. Excluding Overseas Contingency Operation (OCO)
funding, health care costs for the Department grew approximately $30
billion from Fiscal Year (FY) 2000 to FY 2010.
Generally speaking, 35 percent of that increase was due to medical
inflation; 36 percent was due to congressionally mandated benefits
(with TRICARE For Life being the major contributor); 10 percent was due
to the higher percentage of retirees and their families who are now
using the Military Health System (MHS) as their primary coverage; and
20 percent was due to higher utilization and greater intensity of care
among beneficiaries using the MHS.
Over that ten-year period, the number of beneficiaries unrelated to
OCO funding has remained relatively stable or slightly declining, so
the effect of total population was a small (less than 1 percent)
reduction. However, the reduction would have been greater if the Army
and Marine Corps end strength had not increased. Those increases have
returned 1 to 2 percent of the population to the overall growth.
Mrs. Davis. What are the strategic issues that the subcommittee
should be looking at to ensure the success of the military health
system?
Dr. Woodson. The leadership of the Military Health System (MHS) has
developed a strategic framework around which we assess our performance
across four critical priorities: Readiness, Population Health, Patient
Experience and Cost.
For each of these priorities, we have developed a series of
specific goals, metrics and measures. At the center of our framework is
readiness--our primary mission and obligation. There are two core
questions pertaining to this priority: (1) Are the members of the Armed
Forces medically ready to engage in combat (or non-combat) operations?
(2) Are the medical forces ready to provide the full-spectrum of
medical operations worldwide?
Based on our experience this past decade, we believe the answer is
``yes'' to each of these questions. We recognize that sustaining top
performance requires continuous investment in medical research,
technology, education and information, modernization and human capital
management.
Our other strategic issues--population health, patient experience,
and responsibly managing the cost of care--are interdependent
priorities. We measure performance against ourselves over time and
against leading civilian standards in each of these areas.
Fundamentally, we must improve the health of our population in order to
better manage costs. Cost control is nearly impossible with a
population engaging in unhealthy behaviors, and we are seeking to
change behaviors for all 9.6 million of our beneficiaries.
Mrs. Davis. Nearly two years after the original protest was filed,
the Department recently announced the T3 award in the South, which has
been protested again. What efforts is the Department taking to ensure
that lessons learned from T3 are not repeated in T4, and can we expect
that all of the T3 contracts to be successful resolved before the
Department engages in T4?
Dr. Woodson. Lessons learned are collected and documented in the
final phases of the acquisition process. The documented lessons learned
from previous acquisitions become key inputs to the planning phase for
subsequent acquisitions. In other words, lessons learned from the
original T-1 TRICARE contracts influenced the TNEX acquisition strategy
which, in turn, influenced the T-3 strategy. Lessons learned from the
TNEX acquisition were collected by a consultant contractor through a
process that included surveying, interviewing participants and
publishing a final report. TMA has hired a consultant contractor to
perform an after-action review of the T-3 source selection evaluation
process, and may seek a final report comparable to the TNEX product.
All of this information and the Government Accountability Office (GAO)
decisions will be provided to the T-4 acquisition strategy team. That
team will develop an acquisition plan for T-4 that incorporates all the
lessons learned and GAO findings. In addition, one of the objectives of
the Peer Review process required by OUSD(AT&L)/DPAP policy is to
facilitate the sharing of lessons learned and best practices across the
Department of Defense. All the T-3 and T-4 acquisitions are subject to
the Peer Review process.
The first T-3 contract award for the North region included health
care delivery options through March 31, 2015 and the ability to add
another calendar year of performance. The South and West regions will
include option periods that run through at least March 31, 2017. The
re-evaluation of the West will take a minimum of six and half months,
but will be accomplished well before the T-3 NORTH contract expires.
There should also be ample time to accommodate any directions from the
on-going GAO review of the South region award.
Mrs. Davis. Several of the reserve components continue to see
issues with medical readiness of its force. To ensure the readiness of
its force, the Air Force National Guard and Reserve requires its
personnel to be medically ready or they are not allowed to participate
in drill or training exercises. Should this requirement be extended to
the Army, Navy and Marine Corps?
Dr. Woodson. No, not at this time and we do not recommend any
change to the current policy. Preventing service members from attending
drill or AT may compound the problem. Many commanders use these active
duty periods for readiness activities that include medical and dental
appointments. There are also certain aspects, such as annual preventive
health assessments (PHA), which require members to meet face-to-face
with military health providers.
Mrs. Davis. If not, what efforts should be undertaken to ensure the
medical readiness of the reserve component?
Dr. Woodson. The instructions may be drafted to ensure members can
drill or be placed on orders to complete their medical/dental
requirements, but will not drill for training until the issues are
resolved.
Reservists may be placed on military orders for the purpose of
receiving military medical/dental evaluation, or examination.
Reservists receiving medical/dental care during a tour of duty will be
voluntarily retained on Active Duty orders to continue treatment.
Reservists not on military orders may be placed on invitational travel
orders when directed by appropriate military medical authority to
receive an examination or evaluation by military medical/dental
facilities to meet military requirements. Invitational travel orders
may also be issued to those reservists receiving military medical/
dental care at military medical treatment facilities for the purpose of
medical/dental appointments.
Reserve or Active Duty medical units do not extend, authorize the
extension of, or issue military orders, or invitational travel orders.
Order issuance or an extension is the responsibility of the commander.
Mrs. Davis. Can you explain what impact the current continuing
resolutions are having on the Military Health System and on your
particular Service?
General Schoomaker. The numerous continuing resolution (CR)
extensions caused a general disruption of operations across the command
this year. Despite ASD (HA) and OSD (Comptroller) efforts to respond to
OMB's numerous data calls to validate Service Medical Department
requests for exception apportionment, the temporary, short-term budgets
caused activities to defer spending to preserve resources for must-fund
bills like payroll. Although clinical service delivery was not
compromised at any time, it appears that this behavior did contribute
to a slow-down in the growth rate of program improvement required to
meet the demands of a larger Army with increased benefits, utilization,
and Wounded, Ill, and Injured workload.
CR limitations and associated administrative processes have had the
following impact:
Slowed down program improvements in access initiatives
designed to match capacity to escalating demand resulting from
increased end strength, rising utilization, benefit enhancement, and
increasing level of effort to manage and process Wounded, Ill, and
Injured.
Strained internal compliance with BRAC-directed project
milestones and/or validation of BRAC-related ``incidental'' costs at
several locations due to artificial budget execution masking actual
conditions.
Delays in the augmentation of Occupational Health/
Industrial Hygiene capability to address previously neglected remote
area services for the Army's at-risk civilian workforce.
Delays in Initial Outfitting and Facility transition of
medical treatment facilities generated by extensive investment in
MILCON and renewal projects in previous years.
Delays in implementation of the enhanced, integrated
Disability Evaluation System designed to streamline disability
processing of separating service men and women.
Delayed full-scale implementation of the Comprehensive
Pain Management Plan.
Mrs. Davis. Given the reductions in the Services recruiting and
retention budgets, how are you ensuring that we continue to recruit and
retain the qualified medical providers that are necessary to support
the military health care system?
General Schoomaker. The mission to recruit our military health care
providers rests with United States Army Accession Command. To date, we
have received no indication of any significant funding constraints
placed upon them that would affect recruitment of health care
professionals. We have no indication that there will be any reduction
in the number of health care recruiters in the field or that the
funding to support them will be significantly decreased.
The Office of The Surgeon General is working diligently to maintain
the level of funding support for the health professions officer special
pays that are critical to the recruiting and retention efforts of the
past years. As the Assistant Secretary of Defense for Health Affairs
converts the Services programs from the legacy Special Pays to the
Consolidated Special Pays, we do not anticipate any support for growth
within these pays; however, we believe that in the near term we will be
able to maintain the status quo. This includes support for the Health
Professions Officer Accession and Retention Bonuses for Clinical
Psychologists, Clinical Social Workers, Physician Assistants, and
Veterinarians, as well as the Critical Wartime Skills Accession Bonus
for Physicians and Dentists.
Mrs. Davis. As your Services move toward the Patient-Centered
Medical Home (PCMH) concept, how will deployments of providers impact
this process? Will PCMH providers need to be civilian or contract
providers in order to maintain continuity of care?
General Schoomaker. By limiting the size of our PCMH teams to 3-5
Primary Care Providers and ensuring a variable mix of military,
civilian and contract providers, the Army decreases the impact of a
military provider's deployment and relies upon the PCMH team to provide
the patients with continuity of care. One of the core principles of the
PCMH model is to ensure that there is a standardized, consistent and
continuous relationship between the patient and the PCMH team which
includes the assigned provider as well as the designated support staff.
Under this model, providers deploy with the units to which they are
assigned, providing Soldiers continuity of care before, during, and
after the deployment. The Army does have a number of providers who will
deploy with other units and in these situations other providers in the
PCMH provide coverage during the deployment.
Mrs. Davis. Where are [we] on the transition and closure of Walter
Reed, and is the Army, Navy, and the Joint Task Force on National
Capitol Region Medical (JTF CAPMED) prepared to ensure an orderly
transition by September of this year?
General Schoomaker. The majority of the medical Base Closure and
Realignment (BRAC) construction at both the Bethesda and Fort Belvoir
sites is complete. Current progress indicates that they will be
finished in time to transition patients and clinical functions from
Walter Reed Army Medical Center (WRAMC) by September 15, 2011. The
Army, JTF CapMed, and the other Services are working together to ensure
an orderly transition. Patient care and patient safety remain the top
priorities related to the move and all stakeholders continue to pay
close attention to the timeliness and milestones necessary to achieve
the final moves.
Mrs. Davis. The U.S. Olympic Committee's Paralympic Military
Program provides our wounded warriors the ability to compete in several
adaptive sports. However, I understand that funding challenges may
affect the future of this program. What efforts, if any, are the
Services taking to ensure that such opportunities continue for our
wounded warriors?
General Schoomaker. The Army leverages the U.S. Olympic Committee's
(USOC) Paralympics' Military Program as a critical complement in our
efforts to improve the quality of life of our injured Soldiers while
they are on active duty and during their transition to civilian life.
The Army is addressing the future funding challenge by pursuing funding
through the Defense Health Program for Adaptive Non-Clinical
Reconditioning Activities (ANCRA). ANCRA includes Warrior Games
participation and associated costs, pre-Warrior Games clinics and
training camps, adaptive adventure training, the Army Center for
Enhanced Performance (ACEP) trainers, and adaptive equipment. The goal
is to instill ANCRA into the warrior care rehabilitation process.
Mrs. Davis. The Integrated Disability Evaluation System (IDES)
started as a pilot program, and has recently been expanded across the
country. While the program goals are to reduce the time wounded
warriors spend going through the disability process, I understand that
timelines have actually increased. What are the challenges each of your
medical systems have been seeing as the IDES program has been
implemented? What improvements have been made under the program? What
challenges still remain under the program?
General Schoomaker. The Army population that requires entrance to
the physical disability evaluation system continues to grow and
challenge our capacity to process them in a timely manner. The Army
continues to take the necessary steps to address the challenges of the
IDES program and has implemented numerous practices and process
improvements to improve physical disability evaluation processing
times. These improvements include: the development and implementation
of a new IDES Narrative Summary format; implementation of the Medical
Evaluation Board (MEB) processing guidance to standardize the MEB
processes; assignment of dedicated MEB Physicians; improving staffing
shortages; the implementation of the electronic Medical Board (eMEB) in
July 2010; and the development of the IDES Implementation Plan that
requires Senior Commanders play a central role in certifying that a
IDES site is fully resourced, staffed, trained and ready to meet
processing standards prior to Initial Operating Capability date. The
major challenge is that the disability evaluation system remains
complex.
Mrs. Davis. Can you explain what impact the current continuing
resolutions are having on the Military Health System and on your
particular Service?
Admiral Robinson. We continue to face challenges associated with
operating under a potential continuing resolution for the remainder of
the year, particularly in the areas of provider contracts and funding
for facility special projects. The Defense Health Program (DHP) has
taken specific actions as a result of the continuing resolution
including: reducing the number of hours for patient care provider
contracts; limiting medical facilities sustainment/maintenance
contracts to only ``life safety'' implications; deferring life cycle
replacement of medical equipment; maximizing utilization of existing
inventory of supplies and medicines; and limiting quantity of
replacement pharmaceuticals. We continue to work with ASD (HA) to
mitigate adverse effect on the quality and timeliness of healthcare
provided to military members, retirees, and their families.
Mrs. Davis. Given the reductions in the Services recruiting and
retention budgets, how are you ensuring that we continue to recruit and
retain the qualified medical providers that are necessary to support
the military health care system?
Admiral Robinson. Navy active duty (AC) medical recruiting has been
successful in attaining overall accession goal in FY09 and FY10, and
retention has been relatively stable across all health professions.
Recruiting is projected to meet most FY11 goals for active component
Medical Corps officers; however, direct accession physicians and
dentists present challenges. Recruiting medical and dental students for
the Health Professions Scholarship Program (HPSP) is the most vital
contributor to Navy physician and dentist inventory, accounting for
more than 80 percent of active duty accessions into the Medical and
Dental Corps. Medical and dental HPSP accessions have been successful
over the past two years due, in large part, to a $20,000 signing bonus.
Targeted special and incentive pays and bonuses are offered at
critical career points to incentivize retention behavior. Medical
Special and Incentive pays are critical to maintaining Navy Medicine
professional inventory--doctors, dentists, nurses, psychiatrists,
clinical social workers, and other providers.
Direct appointment recruiting of physicians and dentists for both
active and reserve forces remains a challenge, primarily because these
healthcare professionals have well-established medical practices and
are very well compensated in the civilian market. Interrupting their
civilian medical careers is often personally and financially
unattractive to many private medical providers. In the case of both AC
and RC Physician and Dentist recruiting, a credible recruiting bonus is
critical to attracting these professionals.
We continue to evaluate the financial incentives within budgetary
constraints to target specific communities that are, and will remain,
critical to our mission.
Mrs. Davis. As your Services move toward the Patient-Centered
Medical Home (PCMH) concept, how will deployments of providers impact
this process? Will PCMH providers need to be civilian or contract
providers in order to maintain continuity of care?
Admiral Robinson. As Navy continues to implement the Patient-
Centered Medical Home (PCMH) model, we are seeking to structure the
teams in a way that sustains deployment of military providers in
support of operational commitments, while ensuring continuity of care
for Navy beneficiaries assigned to the PCMH team.
Navy's approach has been to build PCMH teams that have both
military and civilian (civil service and contract) assets integrated.
Ideally, 50 percent of staffing on a Navy PCMH team is civilian,
ensuring stability within the team that can withstand deployments,
supports continuity while providing patient and family-centered care.
When an active duty PCMH provider deploys, Navy Medical Treatment
Facilities (MTFs) are encouraged to use a strategy successfully applied
at other sites. A contract provider is hired to cover the deployed
provider's panel of patients (in a locum tenens type arrangement) and
works within the PCMH team during the provider's absence. This allows
the patient to keep the same primary care manager (PCM) during the
deployment, but have identified coverage during their PCM's absence;
patients can be notified of their PCM's pending deployment, length of
absence and the provider providing temporary coverage using blast
secure patient messaging.
When the deployed provider returns to the MTF, patient's can once
again be notified regarding their pending return using secure
messaging; the contract provider can then be utilized elsewhere in the
MTF to cover another provider's practice while they deploy.
Mrs. Davis. Where are [we] on the transition and closure of Walter
Reed, and is the Army, Navy, and the Joint Task Force on National
Capitol Region Medical (JTF CAPMED) prepared to ensure an orderly
transition by September of this year?
Admiral Robinson. Navy is committed to the successful transition of
the new Walter Reed National Military Medical Center (WRNMMC) onboard
the campus of the National Naval Medical Center, Bethesda. This
realignment is significant and we are working diligently with DoD's
lead activity, Joint Task Force Medical--National Capital Region, NSA
Bethesda and WRAMC staff to ensure we are on track to meet the Base
Realignment and Closure (BRAC) deadline of 15 September 2011.
Mrs. Davis. The U.S. Olympic Committee's Paralympic Military
Program provides our wounded warriors the ability to compete in several
adaptive sports. However, I understand that funding challenges may
affect the future of this program. What efforts, if any, are the
Services taking to ensure that such opportunities continue for our
wounded warriors?
Admiral Robinson. All Service components collaborate with
organizations outside the United States Olympic Committee (USOC),
including Paralyzed Veterans of America, Challenged Athletes
Foundation, Team Semper Fi (which supports Sailors, as well as
Marines), Disabled Sports USA and the Lakeshore Foundation. These,
along with numerous other adaptive sports organizations, offer
competition opportunities and training in adaptive athletics for
wounded warriors. Additionally, Navy Safe Harbor has appointed an
Adaptive Athletic Program Manager and Headquarters Transition
Coordinator, to include adaptive athletics opportunities in the
rehabilitation plans of Sailors. In FY11, Safe Harbor has executed two
adaptive athletic training camps at Naval Base Port Hueneme, CA.
Mrs. Davis. The Integrated Disability Evaluation System (IDES)
started as a pilot program, and has recently been expanded across the
country. While the program goals are to reduce the time wounded
warriors spend going through the disability process, I understand that
timelines have actually increased. What are the challenges each of your
medical systems have been seeing as the IDES program has been
implemented? What improvements have been made under the program? What
challenges still remain under the program?
Admiral Robinson. The IDES process is achieving the primary goals
that were intended when this process was designed in 2007. Most notable
of these goals is that our Sailors and Marines receive both their post-
service military and Veterans Administration benefits on the first day
authorized by law. This eliminates the ``benefits gap'' experienced
under the previous DES system. To achieve this significant benefit, the
IDES process has the secondary impact of keeping our service members in
uniform for a longer period of time. This is a concern because the
length of time needed to process cases has direct proportional adverse
impact on the services' readiness for their military mission. Those in
the IDES spend longer in uniform which, for any given end-strength,
reduces the number of active duty available for unrestricted
assignment. Therefore, in the near term a principle focus must be on
reducing the amount of time consumed by the process itself without
debasing what we do for our Wounded, Ill and Injured (WII) service
members.
The simplest and most direct means of monitoring the IDES process
is through the observation of case flow--the time service members'
cases spend transiting the IDES' waypoints. Tracking and evaluating
process time brings clarity for resourcing decisions and process
improvements. To this end, based on a review of data from IDES
operations over the past six months (period ending March 31, 2011), we
would like to reduce the average time taken by the Medical Evaluation
Board (MEB) Phase of the IDES by approximately 100 days. However, since
some of the processing events occurring within this phase are
controlled by the Military Treatment Facilities (MTFs) and some are
controlled by the Veterans Administration, reducing the average MEB
Phase time requires both Departments to ensure resources and internal
processes are aligned to support timeliness goal.
To significantly reduce the overall processing time, Navy Medicine
has implemented four main improvement initiatives. Navy Medicine has
highlighted MTF MEB timeliness as a Strategic Goal, providing increased
awareness by reviewing monthly metrics. Development of a SharePoint
tool will allow for enhanced program management of data between the MTF
and Veterans Tracking Application data. Thorough evaluation of MTF
business practices and throughput has allowed for identification for
appropriate resourcing to address areas of need. Additionally,
innovations to leverage existing programs, technologies, and resources
are ongoing, such as the use of Armed Forces Health Longitudinal
Technology Application (AHLTA) electronic medical record vice narrative
summaries. Finally, the Department of the Navy has recommended specific
changes to ``remodel'' the IDES. This IDES Remodel allows us to keep
what is good about the current IDES process while making needed
improvements and renovations. The recommended IDES Remodel can be
implemented under current laws, avoids any post-service benefit gap,
maintains the service member's due process rights and can be completed
in significantly less time required by the current IDES process. This
remodel is currently under review by both DoD and the VA for possible
near-term implementation. By seizing process design change
opportunities, properly resourcing the processes we decide to deploy
and better leveraging existing capabilities, both the WII service
member and readiness for our military mission will benefit.
Mrs. Davis. Can you explain what impact the current continuing
resolutions are having on the Military Health System and on your
particular Service?
General Green. Contracting: The Air Force Medical Service (AFMS) is
holding $62M in contracting actions until we have an approved budget.
The more we delay passing an appropriations act, the more pressure and
undue burden is placed on the Air Force Base Contracting Office to get
the contracting documents processed once a full budget is received.
Restoration and Modernization (R&M): The AFMS programmed $61.4M for
R&M projects. Under the numerous FY11 Continuing Resolutions (CRs), the
AFMS has only released $34M for emergency military treatment facility
repairs or time sensitive facility renovation. Additionally, the AFMS
has approximately $120M in estimated R&M projects that still need to be
completed. If full year funding is not received in FY11, the AFMS will
be forced to put R&M projects at risk to fund higher priority issues.
Withheld R&M funds will be used to offset lack of funding for patient
care and other urgent bills. If CRs continue, the AFMS may not be able
to fund R&M in FY11. The lack of FY11 funding will simply push the
requirement into FY12 at a potentially higher cost.
Medical Equipment: The AFMS has minimized medical equipment
purchases to emergency items only during the numerous CRs. AFMS
programmed $75M and have currently only funded $2M for emergency
equipment buys to prevent mission stoppage and prevent patient safety
issues.
Administrative: The numerous CRs place an exorbitant amount of
extra work to process documents. It is comparable to having six fiscal
year closeouts in one year.
Mrs. Davis. Given the reductions in the Services recruiting and
retention budgets, how are you ensuring that we continue to recruit and
retain the qualified medical providers that are necessary to support
the military health care system?
General Green. Reductions in the recruiting and retention budgets
for the Services add to a challenging environment for accessing and
retaining health care professionals. Air Force (AF) recruiting is
limited by many of the same shortages the Nation faces in health care
professions such as: nursing, general surgery, family practice,
psychology, and oral maxillofacial surgery. Our recruiting difficulties
lie in accessing fully qualified professionals, not our training
pipelines. We face keen competition for fully qualified specialists
from the private sector and other Federal agencies where multiple
deployments are not an issue, such as the Department of Veterans
Affairs hospitals and the Public Health Service. Also, there are
significant pay disparities between military and private sector
employers, especially those surgical specialties crucial for wartime
support. These disparities hinder our ability to retain experienced
providers. The changing demographics of health professions with
increased numbers of women entering the profession, who may be less
inclined to choose military service, provide a challenging environment
in which to recruit. Additionally, current data suggests less than 7
percent of eligible graduates consider entering military service.
Using feedback from exit interviews and informal counseling as well
as our experiences with various incentives, the Air Force Medical
Service (AFMS) confronts the recruiting and retention challenges in a
three-pronged approach addressing: (1) education, (2) compensation, and
(3) quality of life.
(1) Education: Due to historical difficulties recruiting fully
qualified specialists, the AFMS deliberately places increased emphasis
and funding into educational scholarship opportunities rather than
continually focusing on a manpower intensive program that has shown
only moderate success. With this change, we have found great success in
``growing our own,'' either through the scholarship programs or through
training in the Uniformed Services University of Health Sciences
(USUHS). Historically the highest retention occurs when we control the
educational environment and service obligations associated with these
advanced training programs. The Health Professions Scholarship Program
(HPSP) is a resounding success with over 1,400 students currently
enrolled, projected to be 1,568 by the end of this fiscal year. As
reflected in the DOD budget for FY13, AF has a programmed budget to
support an ultimate increase to 1,666 students. We have also optimized
our enlisted commissioning programs, such as the InterService Physician
Assistant Program (37 graduates per year) and the Nurse Enlisted
Commissioning Program (50 graduates per year). Additionally, the AF
receives small numbers of new health professionals through other
training venues, such as the Airman Education Commissioning Program,
Reserve Officer Training Corps, and United States Air Force Academy.
The Nurse Transition Program is a robust recruiting tool. It provides
an incentive for new graduates to consider AF nursing as a career
option upon graduation. However, there are various limitations with our
training programs. As a result of fiscal guidance from AF and Congress,
under Section 2124 of Title 10, HPSP enrollment DoD-wide is capped at
6000 students. USUHS programs have physical constraints of the facility
and academic accreditation constraints of oversight committees. Third,
enlisted commissioning programs are constrained by the number of
training-years programmed and funding against all enlisted training.
Even with these limitations, education has proven the most successful
avenue of accession and retention of health professionals.
(2) We also seek to entice fully qualified specialists into the AF
and retain them through competitive compensation using accession
bonuses and other financial incentives. Under the auspices of Health
Affairs, the AF has funded accession bonuses and incentive pays to
target fully qualified specialists in selected areas. For FY11, the AF
has sufficiently budgeted $13M towards accession bonuses for personnel
in fully qualified critical specialties based on historical rates of
accession. Historically, as outlined in the first paragraph and under
section (1), above, our physician and dental specialist accession
bonuses have been of limited success due in part to statutory bonus
restrictions, as section 301d and 301e of Title 37 are mutually
exclusive of section 302k and 302l of Title 37. Because these accession
bonuses cannot be taken with a multiyear special pay, only 2 of 22
fully qualified physicians entering in FY10 took the accession bonus.
Our dental officer recruiting had limited success with 10 of 14 fully
qualified dentists accessed in FY10; however, none of them took the
accession bonus due to the statutory restrictions. In contrast, with
new accession bonuses and incentive pays, our nursing program had great
success with 296 selected out of 290 requirements. Overall, we have
found compensation helps, but does not entirely ease the burden of
multiple deployments. As we migrate our compensation portfolio under
the new pay authority of section 335 of Title 37, we will be able to
initiate specialty pays for the mental health care providers and other
critical wartime or shortage specialties that previously were excluded
from accession and incentive pays. We feel this move will be of great
benefit to the Air Force and military health care in general, allowing
targeted accession bonuses, incentive pays, and retention bonuses to
address the manning shortages in the health professions. Due to the
complexity of medical specialty and incentive pays and entitlements,
the scheduled migration of these contractual agreements under the
Assistant Secretary of Defense, Health Affairs, will take time to fully
implement. In general, recruiting success of many fully qualified
specialists without accessions bonuses is extremely limited.
(3) Finally, no recruit enters, and few medical providers stay in
the military, without discussing quality of life issues, whether this
is family services, medical practice, educational or leadership
opportunities, or frequency of moves and deployments. We address many
of these issues amongst the AF agencies. Ongoing AFMS projects include
the Family Health Initiative, which is a medical model that better
leverages our personnel. In addition, we are building force sustainment
models in collaboration with AF Manpower and Personnel, evaluating
promotion opportunities, and developing a more proactive approach to
provide additional opportunities for advancement. In specialties with
increasing wartime deployments, we are better able to distribute the
deployment requirements more evenly among our members. Restructuring of
our medical groups and the deliberate force development of our
personnel allow increased opportunities for all health professions to
become leaders in the AF.
We remain committed to providing the best in health care for our
Nation' s military and their family members through enhanced recruiting
and retention efforts maximizing the tools provided for education,
compensation and creative quality of life efforts of new health
professionals.
Mrs. Davis. As your Services move toward the Patient-Centered
Medical Home (PCMH) concept, how will deployments of providers impact
this process? Will PCMH providers need to be civilian or contract
providers in order to maintain continuity of care?
General Green. PCMH providers do not need to be civilian. In the
Air Force Medical Service most of the PCMH providers are active duty
and roughly 10% of these providers are deployed at any given time. In
the past year, we have averaged 32 family physicians deployed, with
overlap of rotations transiently raising this level as high as 40-45
for periods of 1-2 months. With a current workforce of 299 family
physicians in clinical billets, this is over a 10 percent loss of
family physicians. This loss is compounded by the fact that our current
fill rate for active duty family physician billets is 78.6 percent.
Hiring of replacements for these deployed providers with overseas
contingency operations (OCO) funding has met with varied success
depending on location. At locations where hiring has occurred, the
impact on PCMH has been lessened. The presence of these civilian
providers who fill in for the deployed provider decreases the impact,
but there is still an impact on continuity. At locations where hiring
has not occurred, these deployments cause not only loss of continuity,
but also some diminution in access to care.
While the use of civilian and contract providers in Air Force
military treatment facilities (MTFs) is and will continue to occur, we
have a large number of Air Force MTFs in locations where hiring of
quality civilian providers has consistently been difficult. As such, we
will continue to balance the use of active duty providers in addition
to civilian and contract providers.
Mrs. Davis. The U.S. Olympic Committee's Paralympic Military
Program provides our wounded warriors the ability to compete in several
adaptive sports. However, I understand that funding challenges may
affect the future of this program. What efforts, if any, are the
Services taking to ensure that such opportunities continue for our
wounded warriors?
General Green. We budgeted approximately $85K to support the 2011
Warrior Games to cover coaching support and travel expenses for our
athletes attending the two Air Force training camps.
With the help of OSD, we have funded adaptive equipment for
archery, track and field, aquatic lifts for swimming pools, basketball,
volleyball, and a variety of cardio equipment for our wounded warriors
and customers with disabilities. In addition, we send 20 Air Force
personnel each year to Penn State University to received training on
inclusive recreation. Penn State University provides them with
fundamental skills sets which allow them to offer programs and services
to meet the needs of Air Force community members with disabilities. We
will continue to support programs serving our wounded warriors.
Mrs. Davis. The Integrated Disability Evaluation System (IDES)
started as a pilot program, and has recently been expanded across the
country. While the program goals are to reduce the time wounded
warriors spend going through the disability process, I understand that
timelines have actually increased.
General Green. The legacy Disability Evaluation System (DES) which
includes a separate Department of Defense (DoD) and Veterans Affairs
(VA) process, takes 500 days to completely process a service member's
case through the DES. The estimated timeline for processing cases
within the IDES is 295 days however, the Air Force is currently
processing cases within 340 days; a 160 day improvement from the legacy
DES. While the IDES timeline has drastically decreased to less than a
year, the AF is committed to continue and improve the IDES process. We
expect the timeline for the IDES process to continue to decrease as we
implement ``lessons learned'' from the other sites during the rollout
process.
Mrs. Davis. What are the challenges each of your medical systems
have been seeing as the IDES program has been implemented?
General Green. Within the Air Force Medical Service (AFMS), the
greatest challenge is completing the Medical Evaluation Board (MEB)
package that is ultimately submitted to the Informal Physical
Evaluation Board (IPEB). There are several variables affecting the
completion of the MEB package. They are:
Completion of the Compensation and Pension (C&P)
examination from the VA:
Predominantly, these exams are complete, but there are
instances when a health condition has not been thoroughly
evaluated and/or another condition is identified requiring
further examination before the MEB Narrative Summary (NARSUM)
can be written.
Military Treatment Facility (MTF): Continuity of care is
sometimes a challenge. For example, if a physician deploys or changes
duty stations before completing a NARSUM, a new physician must be
assigned the case and allowed time to become familiar with the medical
history before writing the NARSUM.
Unit Commander: The MEB package must include input from
the Airman's unit commander. The Commander's letter provides the IPEB
with insight on the Airman's health condition such as, how it affects
his or her ability to perform duties, and the impact on the
distribution of workload within the unit. If the Commander's input is
not received in a timely manner, the Physical Evaluation Board Liaison
Officer (PEBLO) must track it down before forwarding the MEB package.
Line of Duty (LOD) determinations: For Reserve Component
members, the health conditions that caused the MEB referral must be
accompanied by a LOD determination to determine if the injury or
illness was incurred in the LOD and was not as a result of negligence
or misconduct. Delays in completing the LOD determination will
inadvertently delay the MEB package.
Mrs. Davis. What improvements have been made under the program?
General Green. Within the AFMS, PEBLOs are being encouraged to be
more proactive in securing the NARSUM from military physicians and to
engage the Medical Director's for assistance before the MEB becomes
late. For MTFs with increasing MEB workload, additional PEBLOs are
being hired or other assigned personnel from within the MTF are being
directed to assist with case management and/or administrative
requirements. Additionally a comprehensive training website is already
available for the PEBLOs. The website includes MEB guidance, training
slides, and other tools. Lastly, training for physicians involved in
the MEB process has also been developed. Physicians may access
pertinent information under the AFMOA SGH Link on the Knowledge
Exchange, which is a separate location from the PEBLOs.
Mrs. Davis. What challenges still remain under the program?
General Green. The main challenge is the time it takes to process
Airmen through the IDES. Although the IDES has drastically improved its
timeline, the overall IDES process remains cumbersome and lengthy. To
improve the overall IDES process, OSD (P&R) directed a working group
comprised of all the Services, in collaboration with the VA, to focus
on reducing the IDES timelines. Other improvement objectives are to
properly resource activities and better leverage existing capabilities
to ensure Airmen with service-incurred or service-aggravated
disabilities are expeditiously processed through the IDES.
Mrs. Davis. Your testimony indicates that the Air Force will begin
to add 36 full-time Special Needs Coordinators at 35 medical treatment
facilities to assist families with a special needs child. Since these
coordinators are not expected to be brought on-board until October of
this year, what is currently in place to assist families with special
needs?
General Green. There are currently Special Needs Coordinators
appointed by the Medical Treatment Facility (MTF) Commanders at each
MTF available to assist sponsors and special needs family members.
These have traditionally been Mental Health officers who performed this
role as an additional duty. Given the increased demands now seen for
Mental Health, Air Force (AF) determined additional manning is needed
to provide dedicated support to uniformed personnel who have a special
needs child or spouse. Additionally, AF is incorporating the use of
existing Health Care Integrators, Case Managers or Utilization Managers
to provide specific support to families with special needs until the
new coordinator being brought on board is in place and to provide
support at those installations that will not receive a full-time
Special Needs Coordinator.
______
QUESTIONS SUBMITTED BY DR. HECK
Dr. Heck. Who is the formal approving authority for the LHI
Contract?
Dr. Woodson. The contracting authority for the contract is the U.S.
Army Medical Research Acquisition Activity; the office of the Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness administers the contract. The Reserve Health Readiness
Program (RHRP) is a Department of Defense (Health Affairs) program
developed by Force Health Protection and Readiness, and executed by its
contractor, Logistics Health Inc. (LHI).
Dr. Heck. Is the Army considering any other options or
modifications to the contract?
Dr. Woodson. No. Unless the Service Components request new services
(for example, mental health assessments) to augment their readiness, we
do not plan to modify or re-compete this contract at this time. The
Reserve Health Readiness Program (RHRP) contract for medical and dental
readiness services was awarded to Logistics Health Inc. in September
2007, after a full and open competition, for a base year and four
option years. The contract is currently in its third option year. The
fourth option year, if exercised, will conclude at the end of September
2012.
Dr. Heck. What is the overall cost of the contract?
Dr. Woodson. The contract for the five-year period is capped at
$790,295,941 (the total value of the orders against the contract cannot
exceed that amount).
Dr. Heck. How can we document whether or not the LHI contract has
provided any value added service to our medical readiness?
Dr. Woodson. According to the most recent data from the Office of
the Surgeon, U.S. Army Reserve Command, readiness rates have never been
higher. From October 2008 to March 2011, the percentage of Army Reserve
soldiers with a current Periodic Health Assessment (PHA) has risen from
45 percent to 88 percent; achieving dental readiness rose from 53
percent to 75 percent; and current immunizations increased from 34
percent to 79 percent. The percent that are medically ready to deploy
immediately or within 72 hours has similarly risen from 24 percent to
64 percent.
The Reserve Health Readiness Program (RHRP) contract provides a
broad array of services in response to requests by the Service
Components to assist them in achieving medical readiness. The contract
provides the Periodic Health Assessment (PHA), Post-Deployment Health
Reassessment, Mental Health Assessment, dental exam, dental treatment,
and other Individual Medical Readiness services that satisfy key
deployment requirements and supplement the Services' own efforts.
Services are provided at the request of the Reserve Components and
implemented per their guidance. The annual dental examinations, annual
PHAs, and current immunizations for each Service member are required
Department of Defense elements for medical readiness. For Fiscal Year
2010, RHRP providers addressed approximately 650,000 reservists and
guardsmen across all Military Services, conducting 218,000 dental
examinations, 255,000 PHAs, and 372,000 immunizations. Each of these
adds value to medical readiness.
The Army Reserve leadership uses the RHRP almost exclusively for
its medical readiness services. According to the most recent data from
the Office of the Surgeon, U.S. Army Reserve Command, its readiness
numbers have never been higher. From October 2008 to March 2011, the
percentage of Army Reserve soldiers with a current PHA has risen from
45 percent to 88 percent, achieving dental readiness rose from 53
percent to 75 percent, and current immunizations increased from 34
percent to 79 percent. The percent that are medically ready to deploy
immediately or within 72 hours has similarly risen from 24 percent to
64 percent.
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