[Senate Hearing 108-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2004

                              ----------                              


                       WEDNESDAY, APRIL 30, 2003

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 11 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
    Present: Senators Stevens and Inouye.

                         DEPARTMENT OF DEFENSE

                            Medical Programs

STATEMENT OF LIEUTENANT GENERAL JAMES B. PEAKE, SURGEON 
            GENERAL, UNITED STATES ARMY

             OPENING STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. Just to advise the chairman of the 
committee, I have just been advised Chairman Stevens is at the 
White House meeting with the President. He will be slightly 
delayed, so in his behalf I'd like to welcome you to our 
hearing this morning to review the Department of Defense (DOD) 
medical programs, facilities and the health program.
    As you know, under the chairman's leadership, this 
subcommittee has a long history of supporting and protecting 
the medical needs of our military. As our soldiers, Marines, 
airmen, and sailors are deployed in harm's way, our military 
health system is vitally important. We have all been captivated 
by the scenes displayed on television 24 hours a day, enabling 
the public to witness our military in action.
    What we do not see is the entire force health protection. 
Our military health care covers all the bases from the TRICARE 
program, medical treatment facilities, predeployment physicals, 
medics and field hospitals to the continued monitoring of our 
military personnel in the field and after they return. These 
all are essential pieces to the health of our military.
    Over 24,000 medical personnel have been deployed in support 
of Operation Noble Eagle and Enduring Freedom and Iraqi 
Freedom. Unfortunately, the services have been granted limited 
authority to backfill those positions, and cannot afford to 
contract all the additional support that is needed. In order to 
address some of these shortfalls, Congress provided additional 
funding in the fiscal year 2003 supplemental appropriations for 
the medical treatment facilities and care for the service 
members and their families at home.
    At this morning's hearing, I hope the committee will hear 
how the fiscal year 2004 budget request addresses our medical 
treatment facilities, and our medical care, and how we do deal 
with the potential gap in resources if the current OPTEMPO 
remains as high during fiscal year 2004. And so we look forward 
to a frank and open discussion this morning with our panels.
    In particular, we will want to look into the status of the 
next generation contracts for TRICARE, our force health 
protection system, optimization, and the rising costs of health 
care, among others. I'd like to thank our chairman for 
continuing to hold hearings on these issues, which are very 
important to our military and their families.
    If I may, I'd like to call upon the first witness, 
Lieutenant General James Peake, Surgeon General for the United 
States Army.
    General Peake. It is an honor to represent Army medicine 
before you today. Once again, it is the support of this 
committee that it has given to the care of soldiers and their 
families, support of the committee for military medical 
infrastructure to train the medical force, their research over 
an extended period of time that really has allowed us to field 
items like advanced skin protectant, or chem/bio protective 
systems for medical units, or vaccines to protect the soldiers, 
or for hemostatic dressings.
    That support has paid off for the men and women injured and 
wounded in the service to their nation. Wounded soldiers have 
been treated far forward with surgical teams that we really 
didn't have during Desert Shield, Desert Storm. They moved 
rapidly back through our combat support hospitals, now 
modularly configured hospitals. They flew back on Blackhawk 
medevac helicopter fleet, not the old UH-1s, military 
helicopters, including the UH60 Limas with specially designed 
patient care compartments facilitating in route care.
    Our soldiers have been strategically evacuated with 
critical care teams back to Landstuhl or Rota. I had the honor 
of pinning a Purple Heart on one of our noncommissioned 
officers at the burn unit at Fort Sam Houston last week. Both 
arms were outstretched with fresh skin grafts. The burns on his 
face were extensive and covered with silvadene cream which had 
its genesis from the burn research unit in years past.
    He told me about each of his men, and he told me about the 
tremendous care that he received as he and they moved back from 
the theater of operations on Army hospitals on the U.S.N.S. 
Comfort back to Landstuhl, and at the burn unit.
    I can tell you that the soldiers with me that were taking 
care of him stood taller as he related the story to us.
    That burn unit is another story. It is an institute for 
surgical research working not only on burns, but on the 
physiology of injury. It is where some of the work on 
hemostatic bandages is going on now, where we have done key 
studies on orthopedic consequences of land mines. There they 
deal with trauma every day as part of the Trauma Consortium in 
San Antonio. It is commanded by Colonel John Holcomb, a trauma 
surgeon with our special operations forces in Somalia during 
Blackhawk Down.
    The issue is key people at the right places who understand 
not only the environment in which we work, but the bonds of 
soldiers in combat. Key people in the right places like the 
Ranger doc whose hand of Private First Class (PFC) Lynch would 
not let go of during her rescue, medics at the tip of the 
spear.
    At Walter Reed, our land mine center of excellence is a 
strong partnership with the Veterans Administration as we look 
at the long-term care and leveraging the very best care across 
the country. As we do all of this, military medicine is 
resetting the TRICARE contract, looking to improve the service 
we give with fewer regions, with some functions returning to 
the direct care system in 2004 with the national pharmacy 
coverage, to improve portability and all of that is important 
to taking care of our soldiers, but also in keeping a full and 
rewarding practice for those doctors that are in Iraq today 
taking care of patients.
    It is fundamental to our medical readiness and medical 
retention. Our joint training programs at places like Walter 
Reed and Wilford Hall and San Diego are the force generators of 
our medical force of the future. The care we give in such 
places as the 121 Hospital in Korea or Fort Irwin or Fort Polk 
or on a distant battlefield is linked to the quality base that 
those centers provide.
    As always, this committee's support for keeping the full 
spectrum of military medicine of a quality befitting our 
soldiers, sir, and their families, is appreciated by all of us 
here and by those across the world serving our Nation.
    Things as important and as big as the things we talked 
about, things as important as being able to purchase clothing 
for our soldiers as they are evacuated back from military 
treatment facilities or the authority recently authorized in 
the supplemental in that allow military families to see their 
patients that are in military treatment facilities (MTFs), and 
for us to be able to facilitate that. And so for the little 
things, sir, and the big things, we thank you for your support 
and the chance to be with you today.

                           PREPARED STATEMENT

    Senator Inouye. I thank you very much, General Peake. May I 
now call on Vice Admiral Michael Cowan, Surgeon General of the 
Navy.
    [The statement follows:]

        Prepared Statement of Lieutenant General James B. Peake

    Mr. Chairman and Members of the Committee, I am Lieutenant General 
James B. Peake. I thank you for this opportunity to appear again in 
front of your committee. This is my third time before you as the Army 
Surgeon General and each time it has been a different environment of 
challenges. Each has underscored the importance of Army Medicine 
specifically and military medicine in general.
    All around the world, Army medical personnel are serving in 
splendid fashion to carry out our mission of supporting America's Army 
as it defends freedom.
    That a soldier could be severely wounded in Afghanistan on a Monday 
and on Saturday night be at Walter Reed Army Medical Center in 
Washington, D.C., telling me of his care at the forward surgical team 
in Afghanistan, his movement to the combat support hospital in 
Uzbekistan; the transit through the Air Force facility at Incerlick, 
Turkey, and the operation he got at Landstuhl, Germany--all in less 
than a week--is nothing short of miraculous.
    The Army fighting for freedom in Iraq has confidence in its medical 
support. While we help carry out national policy in that arena, we also 
carry on other missions. We are providing quality medical assistance in 
over 20 countries today. Medics are helping keep the peace in the 
Balkans, standing guard in Korea and Europe, supporting anti-terrorist 
efforts in the Philippines, training on medical assistance missions in 
Central America and supporting assistance missions in Africa.
    We made visible progress in the past year transforming our field 
medics into the new 91W Healthcare Specialist Military Occupational 
Specialty. I am frankly excited at the increase in emphasis on medical 
skills that can mean the difference between life and death for a 
soldier on the battlefield.
    To continue this success between the garrison and field units is 
paramount. Visiting the 25th Infantry Division in Hawaii, I walked the 
lanes for combined Expert Infantry and Expert Field Medical Badge 
testing. It reaffirms the unique link that we in the Army Medical 
Department (AMEDD) have with those who close with and destroy the 
enemy, and underscores the need to hone medical skills as we are doing 
with the 91W program.
    This marriage between garrison and field operations is also where 
we need to go for the longitudinal, digital record of patient care. We 
are not where we need to be, but we have an exciting axis of advance 
with CHCS (Composite Health Care System) II and the linkage with the 
corresponding theater system, CHCS II (T). I am anxious to see the 
Stryker Brigade at Fort Lewis demonstrate the use of the hand held 
input devices at the level of the medic, in garrison or in the field. 
This device digitizes the key information of the patient encounter at 
the first level of care and will follow that patient, ensuring that 
vital information is archived and longitudinally available, to enhance 
his or her care wherever in our system he receives his follow on care. 
Resourcing this transformational process will create the model for 
health care across the nation.
    We have transformed 28 percent of Corps and Echelon Above Corps 
medical force structure through the Medical Reengineering Initiative 
(MRI). The transformed units promote scalability through easily 
tailored capabilities-based packages that result in improved tactical 
mobility, a reduced footprint and an increased modularity for flexible 
task organization.
    MRI supports the Army Legacy and Interim Forces and is the 
organizational ``bridge'' to the Objective Medical Force. MRI enables 
supported Army, Joint Force, Interagency and Multinational leaders to 
choose among augmentation packages that result in rapid synchronization 
of enabling medical capabilities.
    Within the Army Reserve, this force structure results in improved 
personnel readiness due to reduced personnel requirements. It also 
improves the average age of Army Reserve hospital equipment sets, due 
to redistribution of newer sets against reduced requirements. We must 
keep moving along this path to improved responsiveness.
    Medical Research and Materiel Command is making great progress in 
equipping medics to serve with the transformed Army of the future on 
expanded, technology-dense, rapidly-changing battlefields.
    Some of the recent initiatives include:
  --The Forward Deployable Digital Medical Treatment Facility, a 
        research platform to develop lighter, more mobile field 
        hospitals using new shelters and technology. Plans are for two 
        to four soldiers to be able to carry and set up a tent and all 
        the equipment in it. The facility will include a wireless local 
        area network and a communication system interoperable with the 
        Warfighter Information Network architecture.
  --Portable oxygen generators to avoid the necessity of transporting 
        numerous 150-pound canisters of oxygen to field medical units. 
        We have already seen the value of this as we prototyped into 
        Afghanistan.
  --The Telemedicine and Advanced Technology Research Center is 
        exploring how personal digital assistants can be used to 
        improve medical record keeping, give providers instant access 
        to medical information and patient histories, alert providers 
        of lab results, speed the flow of information and shorten the 
        time medics on the battlefield must spend filling out forms. 
        One deploying brigade has been outfitted with a prototype of an 
        electronic ``dog tag'' to make sure we understand how this 
        might change our business practice and improve our record 
        keeping in the ground combat scenario.
  --The U.S. Army Medical Materiel Development Activity and Meridian 
        Medical Technologies developed an improved autoinjector for 
        nerve-agent treatment shots, which was approved by the Food and 
        Drug Administration last year. The injector allows a soldier to 
        inject atropine and 2 pralidoxime chloride through the same 
        needle. Compared to older equipment, it will take up less 
        space, is easier to carry, easier to use and puts the drugs to 
        work faster.
    The Interim Brigade Combat Teams are beginning to receive the first 
Stryker Medical Evacuation Vehicles. With a top speed of 60 miles an 
hour, this armored ambulance will be able to keep up with the fight. It 
can carry four litter patients or six ambulatory patients, and allows 
basic medical care to be provided during transport. The excitement is 
palpable in our young soldiers who have had their first hands on 
experience with this vehicle. They see it designed with enroute care in 
mind; a medical vehicle that can keep up with the force, share a 
common, maintainable platform, and link to the common operating picture 
with those they support.
    The deadly potential of chemical, biological, radiological, nuclear 
or high-yield explosive (CBRNE) weapons has been known for centuries, 
but never before has the threat seemed as evident or as imminent.
    This history underscores the importance of the medical system as 
the front line of defense. In the past year we have emphasized the 
training of all Army Medical Department (AMEDD) personnel to ensure we 
have the edge when it comes to responding to the threat of terrorism 
using CBRNE weapons. The Army Medical Department Center and School has 
prepared exportable, tailored and scalable courses for use at medical 
treatment facilities; it is addressing CBRNE in every short and long 
course; and addressing CBRNE casualties in every ARTEP (Army Training 
and Evaluation Program) unit testing program.
    Among the course changes:
  --AMEDD soldiers common skills.--In addition to long-established NBC 
        defense skills and buddy aid, all AMEDD soldiers get CBRNE 
        orientation and patient decontamination training.
  --Advanced Individual Training and functional courses.--Military 
        specialty training courses and specialized skill courses have 
        incorporated specialty-specific CBRNE instruction, including 
        both classroom and field exercise segments.
  --Leadership courses.--These now include basic, intermediate or 
        advanced Homeland Security classes including information about 
        the Federal Response Plan, the Army's CBRNE role and leader 
        skills required by the audience.
  --Primary Care courses.--Army medics are learning CBRNE first-
        responder skills. CBRNE training for physicians, nurses, 
        physician assistants and dentists is part of officer basic 
        training. ``Gold standard'' courses, such as the Medical 
        Management of Chemical and Biological Casualties, and Medical 
        Effects of Ionizing Radiation, are being incorporated into 
        physician/physician assistant lifecycle training plans.
  --Postgraduate Professional Short Course Program (PPSCP).--These 
        courses now embody course-specific CBRNE training, plus a Web-
        based ``Introduction to CBRNE'' review that is now a 
        prerequisite for PPSCP enrollment. The interactive program is 
        available at www.swankhealth.com/cbrne.htm. It provides both 
        narration and text, with additional details available at the 
        click of a mouse. It includes a history of CBRNE incidents, the 
        nature of the terrorist threat, descriptions of agents and 
        symptoms, a glossary of terms and links for additional 
        information.
    Our AMEDD Center & School is also developing and disseminating 
exportable products, including emergency-room training materials; a 
SMART (Special Medical Augmentation Response Team) training package; a 
CBRNE mass-casualty exercise program for medical treatment facilities; 
ARTEP tests that embody CBRNE challenges; and proficiency testing 
materials.
    A three-day CBRNE Trainer/Controller course was held in San 
Antonio, Texas. It brought in 226 people from all Army medical 
treatment facilities--including caregivers and officials charged with 
planning emergency-response plans. The audience was schooled on both 
clinical aspects of managing CBRNE casualties and the organizational 
aspects of managing CBRNE mass-casualty emergencies. Attendees went 
home with materials they can use to deliver CBRNE instruction to their 
colleagues, guidance for developing CBRNE emergency plans that meet 
Joint Commission on Accreditation of Healthcare Organizations 
standards; and scenarios and evaluation guidelines for CBRNE exercises.
    Planners at the U.S. Army Medical Command have drafted formal 
guidance to medical treatment facilities for planning, training and 
preparing to support their installations, communities and regions 
during CBRNE incidents. They are aggressively pursuing links with other 
commands and civilian agencies to smooth the processes of 
communication, synchronization, coordination and integration needed to 
support the Federal Response Plan.
    We have organized Special Medical Augmentation Response Teams 
(SMART) to deliver a small number of highly-skilled specialists within 
hours to evaluate a situation, provide advice to local authorities and 
organize military resources to support response to a disaster or 
terrorist act. These teams, located at Medical Command regions and 
subordinate commands throughout the country, have critical expertise in 
nuclear, biological and chemical casualties; aeromedical isolation and 
evacuation; trauma and critical care; burn treatment; preventive 
medicine; medical command, control, communications and telemedicine 
systems; health facilities construction; veterinary support; stress 
management; and pastoral care.
    These teams are organized, equipped, trained and ready to deploy 
within 12 hours of notice. Their capabilities were demonstrated last 
year when seven members from Tripler Army Medical Center deployed from 
Hawaii to the Pacific island of Chuuk to assist residents injured 
during a typhoon.
    Last year patient decontamination equipment was fielded to 23 
medical treatment facilities with emergency rooms, and personnel have 
been trained in its use. With this equipment, up to 20 ambulatory 
patients an hour can be decontaminated. Another 33 MTFs will be 
similarly equipped during the current fiscal year.
    We also purchased 1,355 sets of personal protection equipment for 
emergency responders and SMART team members; and 11 chemical detector 
devices for selected medical centers and the SMART-NBC.
    We are partners with the Centers for Disease Control and Prevention 
in the Laboratory Response Network, which is augmenting a regional 
system of reference labs to quickly test and identify suspected 
pathogenic agents like anthrax. The AMEDD is designing seven high-
containment Biosafety Level 3 labs--five in the continental United 
States, one in Hawaii and one in support of our Forces in Seoul, Korea. 
Construction is scheduled to begin in September.
    The U.S. Army Medical Research Institute of Infectious Diseases 
(USAMRIID) at Fort Detrick, Md., is a great national resource of 
expertise on dealing with dangerous diseases, whether natural outbreaks 
or the result of biological warfare. When anthrax-laced letters were 
sent through the mail in 2001, USAMRIID geared up for a phenomenal 
effort to analyze thousands of samples collected from possibly-exposed 
sites, looking for the deadly bacterium. They continue to assist law 
enforcement agencies attempting to identify the criminal responsible 
for these acts of terrorism.
    USAMRIID now is partnering with the National Institute of Allergy 
and Infectious Diseases (NIAID) at Fort Detrick on biodefense-related 
diagnostics, drugs and vaccine research. This effort will marshal 
research capabilities while leveraging resources in response to the 
nation's changing needs and builds on a long, productive relationship 
in collaborative research.
    Addressing these changing needs required additional research 
infrastructure. USAMRIID is planning to expand its current facilities 
and continue its mission of research on drugs, vaccines and diagnostics 
to safeguard the health of the nation's armed forces. NIAID is set to 
construct an integrated research laboratory to implement its 
complementary mission of conducting biodefense research to protect the 
public health. The new facilities will house biosafety laboratories 
comprised of Biosafety Level 2, 3 and 4 areas.
    USAMRIID and NIAID have been joined by representatives from the 
Department of Homeland Security, the Department of Agriculture and 
other federal agencies to lay the groundwork for an Interagency 
Biodefense Campus at Fort Detrick. The interagency campus takes 
advantage of existing infrastructure and security at Fort Detrick to 
promote potential sharing of facilities and leveraging of intellectual 
capital among federal researchers studying disease-causing microbes 
that may be used as agents of bioterrorism. Construction is expected to 
take place over the next several years.
    While all this is going on, we still have a mission of operating 
hospitals and clinics, providing day-to-day health care for our 
beneficiaries. Last year we began providing care under TRICARE For 
Life, and we are preparing for a new generation of TRICARE contracts.
    It seems one cannot open a newspaper or a magazine without reading 
about the soaring cost of health care; about the escalating malpractice 
crisis that is driving physicians to leave the practice of medicine; 
about the increasing cost shifting from employer to individual; about 
the restrictive practices that third-party payers impose to be able to 
profit and survive in this market.
    We in Army Medicine coexist in that world of health-care costs. But 
we continue to place our patients first, whether we are talking about 
families, retirees or soldiers on point. The ability to respond to 
warfighters, providing care from forward surgical teams to combat 
support hospitals, depends on the quality base of our direct-care 
system.
    We are in the era of accountability--for efficiency as well as 
outcomes and quality. We have adopted a business case approach to 
justifying requirements that has established credibility for our 
efforts.
    Metrics show improvement in medical board processing, operating-
room backlogs and cancellation rates. Routine things like officer and 
NCO efficiency report timeliness; travel card payment and data quality 
show positive trends. Both Congress and the GAO have cited the AMEDD as 
a leader in health facility planning and lifecycle management.
    Recently we presented the second annual Excalibur Awards, 
recognizing excellent performance by AMEDD units and providing an 
opportunity to share information and stimulate improvements. The 
medical activity at Fort Hood, Texas; the AMEDD Center and School at 
Fort Sam Houston, Texas; the 82nd Airborne Division at Fort Bragg, 
N.C.; and the Kentucky Army National Guard's 1163rd Area Support 
Medical Company were recognized for initiatives in management of 
patients with resource-intensive medical conditions, use of satellite 
communications for extended learning, and innovative approaches to 91W 
training.
    I am confident that the restructuring of the new TRICARE contracts 
will lead to smoother business processes and better fiscal 
accountability across the Military Health System. The reduction in 
contract regions will have a direct effect on the portability issue, as 
will the national carve-out for pharmacy services. All of this is an 
important component of our ability to keep faith with the promise of 
health care for those serving and those who have served. But the 
TRICARE Contracts are only a component. The heart of our ability to 
project the right medical force with and for those we put in harm's way 
comes from our Direct Care base. The quality of the training programs, 
the focus on the unique community of soldiers with their world wide 
movement in support of our National Military Strategy, understanding 
unique stresses and strains on their families, the trust and confidence 
engendered by customer focused quality care is a force multiplier for 
the service member and the insurance for quality care on the 
battlefield. General Shinseki has established THE Army as our standard. 
It underscores the tremendous importance of our Reserve Components. The 
importance of the interplay with the direct care system of these Twice-
the-Citizen Medical Soldiers cannot be overstated. The current tempo of 
this Global War on Terrorism could not be sustained without them. The 
continuity of our system with consistent care and in the familiar 
medical environment--``Institutional Continuity of Care'' even if their 
usual doctor is deployed is important and a constant in a disrupted 
life. It is our dedicated reservists who train to this mission, and to 
whom we turn to sustain the care and continue the quality of our 
training programs that are feeding the force for the next battles in 
this Global War on Terrorism.
    We looked closely at the lessons of Desert Storm and Desert Shield 
on the use of our Reserve medical force and have implemented 90-day 
rotation to minimize the impact on the home communities and to reduce 
the potential for unrecoverable financial hardships. We have made 
extensive use of Derivative Unit Identification codes that allow us to 
identify and only mobilize the exact skill sets that we need in the 
minimum numbers to sustain the mission and targeting them specifically 
to the location where they are needed. This is in contrast to the 
wholesale mobilization of these units and later sorting out where and 
how they might be best used. Many Medical professionals want the 
opportunity to serve their country. These policies and procedures will 
enable them to stay with us in the Reserves and contribute to this 
important mission.
    We appreciate the support from this committee to improve the 
medical readiness of the Reserve components and their families. The 
Federal Strategic Health Alliance (FEDS-Heal) program is improving our 
visibility of their health care needs and the potential for allowing 
dental care during the annual training periods using FEDS-Heal would be 
a step towards improved readiness.
    The level of quality, the ingenuity, the leadership of our 
noncommissioned officers, the flexibility and agility of leaders at all 
levels meeting the unique demands of each mission, tailoring the 
capabilities packages as missions demand--all make me proud of our 
AMEDD. It is the kind of ``quiet professionalism''--as it was described 
by a senior line commander--that will assure our success in supporting 
the force as we continue to root out terrorism.
    All that I have highlighted reinforces our integration into tenets 
of General Shinseki's transformation strategy. One can only speculate 
on what this new year of 2003 might bring--where we in the Army Medical 
Department might find ourselves committed around the globe. However, 
one can confidently predict that wherever we find ourselves, we will be 
caring for soldiers and soldiers' families with excellence and 
compassion.
    I would like to thank this Committee for your continued commitment 
and support to quality care for our soldiers and to the readiness of 
our medical forces.

STATEMENT OF VICE ADMIRAL MICHAEL L. COWAN, SURGEON 
            GENERAL OF THE NAVY

    Admiral Cowan. Thank you, Senator Inouye. I'm also pleased 
to be here to be able to share Navy medicine's activity and our 
plans for the future. At this time foremost on all of our minds 
is the U.S. global war on terrorism and military efforts in 
Iraq even as they wind down.
    As the men and women of the Navy and Marine Corps go in 
harm's way, I take special pride in the men and women of Navy 
medicine who are present with them on the front lines 
throughout the theater of operations and back home providing 
health protection.
    A Marine general eloquently summed all of this up by saying 
``no Marine ever took a hill out of the sight of a Navy 
corpsman.'' As we move into this new millennium, we are likely 
to be continued to be challenged by a growing variety of 
worldwide contingencies. Deployable medical assets might have 
the capability to respond to various missions. Today we are 
more flexible than yesterday.
    Our new forward resuscitative surgical systems and the 
expeditionary fleet hospitals that General Peake alluded to in 
the Army have proven their unique life and limb saving value in 
Operation Iraqi Freedom. I have been unable to document a 
single case of anyone entering our health care system who is 
more than an hour between the time he was wounded in battle and 
first received resuscitative care.
    Our wounded patients at Bethesda tell me about these rapid 
response of the first responders tending to them instantly and 
timely, and of the lifesaving surgical care nearby. Further, it 
is not just casualty response that has improved.
    The net of environmental and weapons of mass destruction 
protection that surround our deployed forces is unparalleled in 
military history. Through military medical research and 
development programs, we continue to develop and to field new 
lifesaving products, practices and policies for the best of 
force health protection.
    As only one example, individual Marines deployed to Iraq 
were equipped with a new clotting accelerator called Quick 
Clot. It is a bandage that with one hand a wounded Marine can 
open and administer immediately and effectively stemming 
hemorrhage before the arrival of any health care professionals.
    Navy medicine cares not just for deployed sailors and 
Marines, but also for their families and our retired 
beneficiaries. All of these responsibilities are carried out 
through our mission of force health protection which consists 
of four key components. That is first fielding a healthy and 
fit force.
    Second, deploying them to protect against all possible 
hazards; third, providing world-class restorative care for 
sickness or injury on the battlefield, while at the same time 
caring for those who remain at home and providing health care 
for our retirees and their families.
    To serve these diverse needs, Navy medicine has made 
substantial investments to become family centered. We believe 
that promotion of the health and welfare of the entire family 
is paramount to the health of the service member.
    Furthermore, for active duty members and their families, 
health care is a key quality of life factor affecting both 
morale and retention, and that is why I say with no sense of 
irony that family centered services such as perinatal care--
having a baby--are readiness and retention issues. One might 
think that combat support and having babies are worlds apart, 
but they are not. Our warriors love their families and cannot 
be distracted by unnecessary concerns for family's health.
    We understand that, and are dedicated to being there for 
all the health needs of the entire family. Accordingly, 
military medicine has moved away from being a system that 
provided periodic and reactive health care to one whose 
portfolio is invested in health promotion, disease prevention 
and family centered care. With our sister services and TRICARE 
partners, we are dedicated to meeting all the needs of all of 
our patients in every way.
    Finally, I would note that the global war on terrorism has 
been a watershed for military medicine, as well as for American 
medicine in general. The aftermath of the terrorist attacks of 
2001 have revealed that Americans are vulnerable in our 
homeland and that the very nature of threats against us has 
changed. We understand conventional violence. We now must 
understand chemical violence.
    We understand germs as disease. We now must understand 
germs as a weapon. We understand protecting our citizens by 
fighting our Nation's battles overseas, we now must understand 
protecting them in their own homes. Over the months and years 
to come, America's medical and public health infrastructures 
will evolve to become a defensive weapons systems in ways never 
before imagined.
    In partnership with the Nation's medical agencies, military 
medicine will play a vital part in that defensive shield 
against biological, radioactive, and chemical weapons and will 
serve our Nation well in these uncertain times. I'll end my 
opening remarks by saying I still wear the cloth of my Nation 
for 30 years and one of the reasons I do this is the privilege 
to associate with some of the finest men and women this Nation 
has ever produced.
    I was speaking to a corpsman in Bethesda, who lost his foot 
to a land mine while running to tend to a wounded Marine. When 
he appeared somewhat sad, he was consoled that certainly the 
loss of a foot would affect anyone that way, to which he 
responded, ``No, sir, that is just a foot. In fact, I have 
another one. What I'm worried about is that I do not know who's 
taking care of my Marines.''

                           prepared statement

    We can be proud of all of them, Army, Navy and Air Force as 
they serve in homeland and abroad and it is an honor to serve 
them. Thank you, sir. Thank you, Chairman Stevens.
    [The statement follows:]

          Prepared Statement of Vice Admiral Michael L. Cowan

    This has been a challenging and rewarding year for the Navy Medical 
Department. We have successfully responded to many challenges placed 
before us, and we continue to face a period of unprecedented change.
    For Navy Medicine, it meant changing our very being and even our 
motto from Charlie-Golf-One, which means in naval signal flag 
vernacular ``standing by, ready to assist'' to Charlie-Papa, ``steaming 
to assist,'' deploying with Sailors and Marines who will go in harm's 
way, taking care of the full spectrum of world events from peacemaking 
to major regional conflicts.
    It has been a decade of uncertainty, and what has emerged from the 
confusion and uncertainty is the ascendancy of enemies who know our 
military superiority, yet won't allow it to dampen their ardor to harm 
us and influence our power, prestige, economy, and values.
    Our enemies have struck with tools that are seemingly effective: 
global terrorism and asymmetrical warfare. During the years of the Cold 
War, America's paradigm was to train and prepare for war in safe 
homeland bases in our country that were protected by two large bodies 
of water. We defended the citizens of the United States by fighting our 
wars overseas. But these enemies have successfully brought the war to 
our backyard. Now the challenge is how to also protect the citizens of 
the United States in their own homes.

                        FORCE HEALTH PROTECTION

    The primary focus of Navy Medicine is Force Health Protection. We 
have moved from ``periodic episodic healthcare'' and the intervention 
and treatment of disease to population health and prevention and the 
maintenance and protection of health. This doesn't, however, change the 
physiological deterioration of the human body when pierced by a bullet. 
Medical support services are more essential than ever since those fewer 
numbers have greater responsibilities within the battle space. Take 
these complexities, and translate them into providing good medicine in 
bad places over great distances and the challenge become even more 
daunting. Yet one thing is certain--no organization in the world 
provides healthcare from the foxhole to the ivory tower the way Navy 
Medicine does.
    Force health protection can be summed up in four categories: First, 
preparing a healthy and fit force that can go anywhere and accomplish 
any mission that the defense of the nation requires of them. Second, go 
with them to protect our men and women in uniform from the hazards of 
the battlefield. Third, restore health, whenever protection fails, 
while also providing world-class health care for their families back 
home. And fourth, help a grateful nation thank our retired warriors 
with TRICARE for Life. Navy Medicine has to make all those things work; 
and they have to be in balance. Any one individual may only see a bit 
of this large and complex organization. But if each of us does our part 
right, we end up with force health protection.
    To ensure its ability to execute its force health protection 
mission under any circumstances, Navy Medicine has executed multiple 
initiatives to ensure optimal preparedness, which includes establishing 
a Navy Medicine Office of Homeland Security. The office is fully 
operational and has executed an aggressive strategic plan to ensure 
highest emergency preparedness in our military treatment facilities 
(MTF's). Its accomplishments include:
    Execution of an MTF Disaster Preparedness Assist Visit Program.--
The Navy Medicine Office of Homeland Security crafted a multi-pronged 
assist visit program to strengthen preparedness in Navy MTFs. A team of 
homeland security experts is visiting each MTF between November 2002 
and April 2004 to conduct a unique program known as ``Disaster 
Preparedness, Vulnerability Analysis, Training and Exercise'' (DVATEX). 
Through this activity, each facility receives a hazard vulnerability 
analysis to identify where they may be vulnerable to attack or the 
impact of disaster, emergency medical response training, and an 
exercise of the hospital's emergency preparedness plan is executed--a 
critical step in enhancing readiness. This, and multiple other critical 
initiatives, were funded by a mid-year Congressional supplemental 
funding action.
    Enhanced Education for Medical Department Personnel.--Well-educated 
clinicians are a critical part of homeland security. Navy Medicine sent 
over 450 physicians, nurses and corpsmen to the ``gold standard'' 
medical management of chemical and biological casualties training 
program at the U.S. Army Institute of Infectious Disease (USAMRIID). An 
extensive online training program for Navy Medical Department personnel 
on response to weapons of mass impact and emergency preparedness is in 
development at the Naval Medical Education and Training Command.
    Pharmacy Operations Emergency Preparedness.--A task force of Navy 
Medicine pharmacy experts is taking action to ensure strong emergency 
pharmacy operations and adequate stockpiles of critical medicines and 
antidotes.
    Smallpox Threat Mitigation.--Navy Medicine is leading 2 DOD 
Smallpox Emergency Response Teams (SERTs) and has executed the initial 
phase of the DOD smallpox immunization plan.

                    READINESS/CONTINGENCY OPERATIONS

    As we move into this new millennium, our Navy and Marine Corps men 
and women are called upon to respond to a greater variety of challenges 
worldwide. This means the readiness of our personnel is now more 
important than ever. Military readiness is directly impacted by Navy 
Medicine's ability to provide health protection and critical care to 
our Navy and Marine Corps forces, which are the front line protectors 
of our democracy. That's what military medicine is all about--keeping 
our forces fit to fight. Our readiness platforms include the two 1,000 
bed hospital ships, 6 Active Duty and 4 Reserve 500 Bed Fleet 
hospitals, as well as different medical units supporting Casualty 
Receiving and Treatment Ships (CRTS) and a variety of units assigned to 
augment the Marine Corps, and overseas hospitals. Navy medicine is more 
flexible now than we were even a few short years ago. Fleet hospitals 
have been modified to allow smaller and lighter expeditionary modules 
to be deployed. Yet even those are not flexible enough. Our combat 
planners are designing a more modular approach to enhance our 
operational capabilities. The ultimate goal is an ability to task and 
organize a medical force to rapidly provide support for the full range 
of potential military operations anywhere on the globe.
    I am very glad to report that the Next Generation 4/2 (DUAL SITE) 
Concept Fleet Hospital (FHSO) gained final approval in April 2002. The 
first ever-major Fleet Hospital reconfiguration and program change 
since the command's inception over 20 years ago, this achievement will 
provide a truly modular, plug and play hospital that will better meet 
the challenges of today and provide a bridge to the development of the 
``Fleet Hospital of the Future''. This month we will begin building the 
first 4/2 concept hospital as part of the Integrated Logistics Overhaul 
(ILO) of Fleet Hospital NINE and will ultimately provide greater 
flexibility and operability to the Maritime Preposition Forces. In 
addition, a design for a small 10-bed Expeditionary Surgical Unit (ESU) 
with an even smaller 4-bed Surgical Component (SSC) is being developed. 
These new, smaller products have been imbedded into the recently 
approved Next Generation 4/2 Concept Fleet Hospital for less than 
$100,000, and provides Navy Medicine with a new response package to 
meet the new threat of asymmetrical warfare by providing between Level 
II and III care. Both the ESU and SSC are intended to provide the FH 
program with its first ever air-mobile asset and will serve as the 
foundation for providing humanitarian and disaster relief. The first of 
these products was implemented with the rebuild of FH08 EMF in 
September 2002.
    Last year, Navy medical personnel supported numerous joint service, 
Marine Corps, and Navy operations around the world. We flawlessly 
performed dozens of deployments supporting the war in Afghanistan, and 
in support of our national strategy, a fleet hospital still provides 
daily health care services to the Al Qaeda and Taliban detainees at 
Guantanamo Bay, Cuba. Our medical personnel have also provided 
preventive medical services, humanitarian care and relief to many 
countries around the globe.
    Over the last few weeks, thousands of Navy Medical Department 
personnel have deployed to the 1,000 bed hospital ship USNS Comfort, to 
three fleet hospitals (in their 116 bed Marine Expeditionary Force 
Configuration) and have augmented Navy and Marine Corps forces world 
wide, many of whom are deployed in forward areas.
    Navy Medicine will continue focusing on improved contingency 
flexibility in the field and afloat. Our medical care starts right in 
the midst of battle through the service and dedication of hospital 
corpsman. Navy Hospital Corpsmen have been awarded the Medal of Honor 
more often than any specialty in the Navy. Navy-Marine Corps history is 
filled with heroic acts performed by corpsmen to reach and retrieve 
wounded Marines. As the Marines deployed to Afghanistan and now to the 
Middle East, there are always hospital corpsman with them. The ratio 
can vary according to the mission, but the ratio is around 11 corpsmen 
per infantry company, which has between 120 and 130 Marines.
    Corpsman training includes surgically opening an obstructed airway, 
field dressing battle wounds, starting IVs, patching a lung-deep chest 
wound, treating battle injuries in an environment contaminated by 
chemical or biological weapons, and immobilizing spines of Marines 
whose backs are broken by explosions.
    Navy Medicine has also established training for combat surgical 
support to enhance the capabilities of the Forward Resuscitative 
Surgical System deployment by USMC. The cornerstone is the Navy Trauma 
Training Center at LA County/University of Southern California Medical 
Center, which convened its first class in August 2002 of physicians, 
nurses and hospital corpsman tasked with far forward surgery 
operational assignments. The program is projected to train 
approximately 120-150 students annually.
    In the 1991 Gulf War, our forward units moved so quickly into Iraq 
that it took an average of two hours to get a casualty to rear-guard 
medical facilities. Navy Medicine now has trauma doctors with the 
equivalent to a six-bed emergency room, as part of the Marine Corps' 
Combat Service Support Company, that follows the front lines on trucks 
and helicopters. Navy medicine will have trauma doctors available 
within 30 to 60 minutes of an injury, which reflects our persistent 
effort to push high quality medical care close to combat. The 
physicians staffing these units are combat doctors, who the Marines 
refer to as ``Devil Docs'' in reference to the nickname ``Devil Dogs'' 
that the Marines earned in World War I. Its expected that the emergency 
and surgery teams will receive the 10 to 15 percent of casualties who 
will need immediate treatment to stay alive before they can be sent to 
more fully equipped echelon II or III facilities in the rear. These 
teams of two general surgeons, one anesthesiologist and five nurses and 
corpsmen can perform basic tests and can handle 18 casualties in 48 
hours without resupply from the rear. In just one hour, the team can 
pack up its two tents, one a holding area and the other a surgery room 
with operating lights, along with ultra-quiet power generators and X-
ray and hand-held sonogram machines.
    As your aware one of our hospital ship, the USNS Comfort, deployed 
to the Persian Gulf on 6 January 2003, and is now being fully staffed 
to provide 1,000 hospital beds, 12 operating rooms, CAT Scan capability 
and advanced medical care equivalent to university medical centers. 
Yet, the Navy's first-response medical vessel for injured troops may be 
a gray hull and not the white USNS Comfort. At the tip of the spear are 
amphibious assault ships like the USS Tarawa. They launch Marines by 
helicopter and giant hovercraft, but also serve as Casualty and 
Treatment Receiving Ships (CTRS: secondary floating hospitals). The USS 
Tarawa, comes with four operating rooms and beds for 300 patients when 
Marines are ashore. The medical team manning the facility includes 
surgeons, neurologists, anesthesiologists, nurses and hospital 
corpsmen. They know how to treat nearly every battlefield trauma, 
including gunshot wounds and exposure to chemical and biological 
attacks. Their training also included the Navy's new hand-held ``Bio/
Chemical Detection Devices. The detection devices can determine within 
minutes if Marines or sailors have been exposed to chemical agents, and 
identify the agents. Patients treated on-board are stabilized and 
transferred either to hospital ships or military hospitals in Europe or 
the United States.

                          PERSONNEL READINESS

    Navy Medicine tracks and evaluates overall medical readiness using 
the readiness of the platforms as well as the readiness of individual 
personnel assigned to those platforms. One of our measures of readiness 
is whether we have personnel with the appropriate specialty assigned to 
the proper billets; that is, do we have surgeons assigned to surgeon 
billets and operating room nurses assigned to operating room nurse 
billets, etc.
    The readiness of a platform also involves issues relating to 
equipment, supplies and unit training. Navy Medicine has developed a 
metric to measure the readiness of platforms using the Status of 
Resources and Training System (SORTS) concept tailored specifically to 
measure specific medical capabilities such as surgical care or 
humanitarian services. Using the SORTS concept, Navy Medicine has 
increased the readiness of 34 ``Tier 1'' deployment assets by 23 
percent.
    Navy Medicine also monitors the deployment readiness of individual 
personnel within the Navy Medical Department. Feeding the SORTS system 
is a program known as the Expeditionary Medical Program for 
Augmentation and Readiness Tracking System (EMPARTS), which Navy 
Medicine uses to monitor the deployment readiness of individual 
personnel and units within the Navy Medical Department. Personnel are 
required to be administratively ready and must meet individual training 
requirements such as shipboard fire fighting, fleet hospital 
orientation, etc. Individual personal compliance is tracked through 
EMPARTS.
    Augmentation requirements in support of the operational forces have 
significantly increased. Our Total Force Integration Plan utilizing 
both active and reserve inventories has greatly improved our ability to 
respond to these requirements. Navy Medicine's demonstrated commitment 
to supporting the full spectrum of operations is mirrored in our motto 
``steaming to assist'' and is in full partnership with the Navy's 
``Forward Deployed, Fully Engaged'' strategy.
    I also believe that in order to achieve Force Health Protection we 
need a metric for measuring the health readiness of our fighting 
forces. This measure must be beyond the traditional ``C-Status 
metric'', which lacks a true measure of one's health. Navy Medicine has 
developed a measure of individual health, which will also facilitate 
our measure of population health. Our model has been accepted by the 
Office of the Assistant Secretary of Defense, Health Affairs, and is 
being expanded for use by all the Services. A final version of the 
model and a Health Affairs policy memorandum is expected in a few 
weeks. In short, the model develops a metric that categorizes an 
individual's readiness status in one of four groups. The categories to 
be used include: Fully Medically Ready; Medically Ready with minor 
intervention; Unknown (i.e. no current evaluation or lost medical 
record) and Medically Not Ready. Each active duty member will fall into 
one of the four categories. The elements that will decide what category 
an individual falls into includes: Periodic health assessments, such as 
the physical exam, deployment limiting conditions, which include 
injuries, or long term illnesses, dental readiness using the same 
standards that have always been established, Immunization status and 
possibly vision evaluations and individual medical equipment like gas 
mask eye-glass inserts. The software needed to collect and track the 
data has already been developed and is compatible with current data 
systems. Readiness data can either be entered via SAMS (Shipboard 
automated medical system) or through our Navy Medicine on-line program. 
The information can also be stored in the DEERS database. Secure 
individual readiness data will therefore be available from SAMS, DEERS 
or Navy Medicine on-line. Reports will array data by command and drill 
down to an individual, and can be accessed by line leadership.
    I am also pleased to report that we recently implemented a new 
Reserve Utilization Plan (RUP) that has optimized our use of reservists 
during peacetime and contingencies. The Medical RUP is Navy Medicine's 
plan for full integration of Medical Reserves into the Navy Medical 
Department. The RUP is being currently used to support the allowed 50 
percent reserve augmentation of our deployed active duty staff and 
matches up reserve specialties with the needed services at each of our 
hospitals.

                               OUR PEOPLE

    People are critical to accomplishing Navy Medicine's mission and 
one of the major goals from Navy Medicine's strategic plan is to 
enhance job satisfaction. We believe that retention is as important if 
not more so than recruiting, and in an effort to help retain our best 
people, there has been a lot of progress. Under our strategic plan's 
``People'' theme, we will focus on retaining and attracting talented 
and motivated personnel and move to ensure our training is aligned with 
the Navy's mission and optimization of health. Their professional needs 
must be satisfied for Navy Medicine to be aligned and competitive. 
Their work environment must be challenging and supportive, providing 
clear objectives and valuing the contributions of all.
    All Navy Medicine personnel serving with the Marine Corps face 
unique personal and professional challenges. Not only must they master 
the art and science of a demanding style of warfare, but they must also 
learn the skills of an entirely separate branch of the armed services. 
Whether assigned to a Marine Division, a Force Service Support Group, 
or a Marine Air Wing, Navy medical personnel must know how Marines 
fight, the weapons they use, and the techniques used to employ them 
effectively against harsh resistance. To excel in this endeavor is an 
accomplishment that should be recognized on a level with other Navy 
warfare communities.
    As we work to meet the challenges of providing quality health care, 
while simultaneously improving access to care and implementing 
optimization, we have not forgotten the foundation of our health care--
our providers. We appreciate and value our providers' irreplaceable 
role in achieving our vision of ``Navy Medicine being the provider of 
choice by achieving superior performance in health services and 
population health.''
    Within each of our medical facilities there has been an overall 
initiative to reward clinical excellence and productivity and to ensure 
that those who are contributing the most are receiving the recognition 
they deserve. Additionally, selection board precepts now emphasize 
clinical performance in the definition of those best and fully 
qualified for promotion.
    I would like to report to you on the status of our corps:

Medical Corps
    The Medical Corps is currently manned at approximately 101 percent. 
This number is deceptive because there are several critical specialties 
in which undermanning is high and needs to be watched to avoid 
impacting our ability to meet wartime requirements and provide INCONUS 
casualty medical care: Anesthesia (82 percent manned), General Surgery 
(72 percent manned), Pathology (82 percent manned), Dermatology (83 
percent manned), Diagnostic Radiology (79 percent manned) and Radiation 
Oncology (80 percent manned). Because the average loss of providers 
exceeds the currently programmed input, shortages are expected in 
fiscal year 2005 in Anesthesiology, General Surgery and its 
subspecialties, Urology, Pathology, Radiology, Gastroenterology, and 
Pulmonary/Critical Care. We are also monitoring specialties in which 
we're currently overmanned. Because of the nature of medical training, 
it can take from 8 to 12 years to train a medical specialist. Various 
training and accession programs feed that pipeline and loss rates are 
often hard to project. We have improved our management oversight of 
those communities and will continue to seek improved means of meeting 
end-strength goals.
    In order to compete in the marketplace for a limited pool of 
qualified applicants for medical programs, and to retain them once they 
have chosen the Navy as a career, adequate compensation is critical. 
The civilian-military pay gap that has always existed has increased 
steadily, which makes it almost impossible to recruit or retain 
physicians in these high demand specialties. Strategic increases in the 
use of Incentive Special Pay, Multiyear Specialty Pay and use of 
Critical Skills Retention Bonuses that correspond to the Navy's medical 
specialty shortages may help improve retention in these critically 
manned specialties.

Dental Corps
    Despite continued efforts to improve dental corps retention, the 
annual loss rate between fiscal year 1997 and fiscal year 2002 
increased from 8.3 percent to 11.8 percent. Current projections for 
fiscal year 2003 predicts a 12.6 percent loss rate. These numbers 
represent higher actual and projected loss rates compared with similar 
data from last year. In addition, declining retention rates of junior 
officers has negatively impacted applications for residency training, 
which have dropped 16 percent over the last five years. The significant 
pay gap compared to the civilian market and the high debt load of our 
junior officers seem to be the primary reasons given by dental officers 
leaving the Navy.

Nurse Corps
    Closely monitoring the national nursing shortage and increasing 
number of competitive civilian compensation packages, Navy Medicine 
continues to meet military and civilian recruiting goals and 
professional nursing requirements through diversified accession 
sources, pay incentives, graduate education and training programs, and 
retention initiatives that include quality of life and practice issues. 
Successful tools have been the Nurse Accession Bonus, Certified 
Registered Nurse Anesthetist Incentive Pay, Board Certification Pay, 
and Special Hire Authority; it is imperative that they are continued in 
the future years to meet our wartime and peacetime missions. In 
addition, clinical and patient care needs are continuously evaluated to 
target our education and training opportunities in support of specific 
nursing specialties, such as advanced practice nurses, nurse 
anesthetists, nurse midwives, and perioperative nurses. Over the past 
2-3 years, CRNAs have been successfully retained in the Navy, creating 
a consistent fill of available billets based on a variety of factors. 
The combination of special pays (Incentive Specialty Pay and Board 
Certification Pay), lifting of practice limitations, and a focus on 
quality of life issues have been the major factors for this success. 
The most recent Critical Skills Retention Bonus has had a positive 
influence on CRNAs staying beyond their obligated service period.

Medical Service Corps
    Medical Service Corps (MSC) loss rates in general are relatively 
stable at about 8.5 percent, but as with the rest of the Navy, were 
lower than that in fiscal year 2002 (6 percent). Loss rates vary 
significantly between specialties however, and are not acceptable in 
all MSC professions. A key issue for this Corps is increasing 
educational requirements and costs. Many of our health professionals 
incur high educational debts prior to commissioning. Recent increases 
in loan repayment requirements causes issues for many junior level 
officers trying to repay their education loans. Additionally, the 
increasing number of doctoral and masters level requirements for the 
various healthcare professions is beginning to put a strain on the 
Defense Officer Personnel Management Act (DOPMA) promotion constraints 
for this Corps, an issue we will be monitoring. Currently our critical 
specialties to recruit and retain are optometry, pharmacy, clinical 
psychology, social work, entomology, and microbiology. When funded, we 
expect the new pharmacy and optometry special pays to help our 
retention in those two communities. Further we have begun using the 
Health Profession Loan Repayment Program for some specialties and are 
having success with it.

Hospital Corps
    Within the Hospital Corps, we are currently under-manned, defined 
as being below 75 percent, in seven Navy Enlisted Classifications 
(NECs). In the operational forces, USMC reconnaissance corpsman are 
currently manned at 53.8 percent. In the MTFs, cardio-pulmonary 
technicians are staffed at 74.3 percent, occupational therapy 
technicians 63.2 percent, bio-medical repair technicians 66.3 percent, 
psychiatric technicians 72.4 percent, morticians 50 percent and 
respiratory technicians at 73.5 percent. In the Dental technician 
community, we are currently under-manned in the dental hygiene 
community at 63.1 percent. An enlistment bonus for hospital corpsman 
and dental technicians would assist in competition with the civilian 
job market.

            Medical Special Pays
    The primary mission of the Military Health System (MHS) is Force 
Health Protection. This readiness focus involves programs to ensure we 
maintain a healthy and fit force, providing medical care in combat. The 
MHS also has an important peace time mission of providing health 
services to active duty members and other beneficiaries. In order to 
provide these services, the MHS must retain health providers that are 
dedicated, competent and readiness trained. This challenge is 
particularly difficult because uniformed health professionals are 
costly to accession, train, and are in high demand in the private 
sector.
    It's essential for the MHS to maintain the right professionals, the 
right skill mix and the right years of experience to fulfill our 
readiness requirements. Continued military service is not only based on 
pay, but also the conditions and nature of the work. Yet, adequate 
compensation must be provided. One of the major tools used to retain 
providers are special and incentive pay bonuses.
    National Defense Authorization Act of fiscal year 2003 (NDAA 03) 
set new upper limits for specific medical pays. Where as this act 
delineates the dollar limits at which pays may be paid; it leaves the 
administration of these pays to the Assistant Secretary of Defense for 
Health Affairs and the Services. The administrative policy for special 
pays is accomplished through a tri-service effort where specific 
manpower needs for each service and community pay is evaluated and 
applied to an annual tri-service pay plan. It is this pay plan that 
determines at what pay levels will be paid for specific specialties at 
any given time. Currently there have been no decisions or budgetary 
inputs to provide for any increase in these pays for fiscal year 2003 
or fiscal year 2004.
    Workgroups both within each service and as a tri-service collective 
are examining the application of special pays to include increases 
utilizing the new upper pay caps. However, it is too early to comment 
on possible applications.

          UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES

    As the Executive Agent of the Uniformed Services University of the 
Health Sciences (USUHS), I would like to comment on the extraordinary 
achievements of the University in 2002. USUHS granted 163 Medical 
Degrees for a current total of 3,268 uniformed physician graduates 
since the first USUHS graduation in 1980. USUHS graduates, with 
retention averaging twenty years of active duty service, now represent 
over 22 percent of the total physician officers on active duty in the 
Armed Forces. And, as provided to the Congress during 2002, the median 
length of non-obligated service for physician specialists in the 
Military Health System, not including USUHS graduates, is 2.9 years; 
however, the median length of non-obligated service for USUHS graduates 
is 9 years. Thus, USUHS graduates are exceeding the original 
expectations of Congress when the university was established, thus 
ensuring physician continuity and leadership for the military health 
care system. In addition, a total of 183 Masters of Science in Nursing 
Degrees have been granted since the establishment of the USUHS Graduate 
School of Nursing in 1993; and, 728 Doctoral and Masters Degrees have 
been granted through the USUHS School of Medicine Graduate Education 
Programs.
    The military unique curricula and programs of the Uniformed 
Services University, successfully grounded in a multi-Service 
environment, draw upon lessons learned during past and present-day 
combat and casualty care to produce career-oriented physicians, 
advanced practice nurses, and scientists with military unique 
expertise. The USUHS-unique training centered in preventive medicine 
and combat-related health care is essential to providing superior force 
health protection and improving the quality of life for our service 
members, retirees, and families. USUHS also provides a significant 
national service through its continuing medical education courses for 
military physicians in combat casualty care, tropical medicine, combat 
stress, disaster medicine, and the medical responses to weapons of mass 
destruction (WMD).
    Four USUHS activities, internationally recognized by the emergency 
responder and health care communities, stand by ready to provide cost-
effective, quality-assured WMD-related training and consultation. The 
Casualty Care Research Center; the Center for Disaster and Humanitarian 
Assistance Medicine; the Center for the Study of Traumatic Stress; and, 
the Armed Forces Radiobiology Research Institute have established 
credibility in providing military unique expertise covering four areas 
of WMD-related concerns: (1) the preparation of emergency responder 
communities; (2) ensuring communication and assessment of military 
medical humanitarian assistance training; (3) addressing traumatic 
stress of both civilian and uniformed communities during WMD-related 
incidents; and, (4) the development of medical radiological 
countermeasures to include the provision of unique training for the 
response to radiological emergencies.
    I am pleased to report that USUHS has begun collaborative efforts 
with the Department of Veterans Affairs on its WMD-related educational 
and training programs. As directed by H.R. 3253, The Department of 
Veterans Affairs Emergency Preparedness Act, Public Law 107-287, VA 
education and training programs on medical responses to terrorist 
activities, shall be modeled after programs established at USUHS. The 
cost-effective provision of quality-assured, web-based training and 
expertise for the medical response to WMD for the emergency and health 
care provider communities is ready to be transmitted from the USUHS 
Simulation Center located in Forest Glen, Maryland. I look forward to 
the further development of these collaborative efforts and the future 
contributions of USUHS.

   ESTABLISHMENT OF THE NAVAL MEDICAL EDUCATION AND TRAINING COMMAND

    The Naval Medical Education and Training Command (NMETC) was 
established under the command of a Flag Officer, as a result of BUMED 
realignment activities. NMETC is going to be a central source of 
learning that will act as a catalyst for web based education and 
training initiates available to our staff on a world wide basis. The 
Command's mission also dovetails well with CNO's Task Force Excel (TFE) 
initiative, whose cornerstone is the stand up of primary organizations 
with responsibility for training, education, human performance/
development, and alignment of resources and requirements. Current Navy 
Medicine training staff is conducting a gap analysis between NMETC key 
functions, and those functions envisioned in CNO's training commands, 
in collaboration with TFE staff.

                          FAMILY CENTERED CARE

    Our health system must remain flexible as we incorporate new 
technologies and advances in medical practice, struggle to maintain our 
facilities, optimize our health care delivery, embrace new health 
benefits, enhance patient safety, and increase our ability to provide 
care to beneficiaries over age 65 in the coming months. Navy Medicine 
has been working tirelessly to maintain our superior health services in 
order to keep our service members healthy and fit and ready to deploy 
while providing a high quality health benefit to all our beneficiaries. 
As you know, healthcare is an especially important benefit to service 
members, retirees and family members. It is an important recruitment 
and retention tool. For active duty members and their families it's one 
of the key quality of life factors affecting both morale and retention. 
A deployed service member who is secure in the knowledge that his or 
her family's healthcare needs are being met is without question, more 
effective in carrying out the mission. Additionally, the benefits 
afforded to retirees are viewed by all as an indicator of the extent to 
which we honor our commitments.
    I'm proud of the cultural transformation Navy medicine has 
undertaken in support of Family Centered Care. Our patients, our Navy 
leadership, and Navy medicine understand that if we want to evolve 
beyond being a reactive health care system--with periodic, episodic, 
reactive healthcare--we have to make our customers partners in their 
care. Our goal is to be a proactive health system with the achievement 
of unprecedented levels of population health, the ultimate measure of 
our success. But we can't get there if patients aren't comfortable with 
their healthcare. We can't achieve higher states of health without 
individuals being actively involved in the process. Navy medicine has 
made a commitment to the cultural transformation. We are working every 
day towards being patient-centric.
    We have placed particular emphasis on achieving customer 
satisfaction with our perinatal services. Delivering babies is a very 
important component of our force health protection. It is one of the 
richest opportunities we have to affect health behaviors, and for 
building strong families from the beginning. What better opportunity is 
there to interest our Sailors and Marines in their health than when 
they are creating a family? The Navy's Family Centered Care (FCC) 
program promotes practices that enhance patient safety, health, cost 
efficiency, and patient and staff satisfaction. Elements of the FCC 
program were derived directly from patient and staff responses to 
multiple survey instruments and convenience samples. During 2002, Navy 
Medicine demonstrated its commitment to patient-centered care by 
investing $10.2 million in the FCC program. MTFs were able to upgrade 
equipment and furniture and received enhanced maternal-infant safety 
and patient-centered care training. Our accomplishments include a Tri-
service effort to develop a uniform Family Centered Care program. We 
have collaborated with Army and Air Force Medical departments to 
develop coordinated plans since February 2002. We have also increased 
the availability of private post-partum rooms in Navy MTFs by 52 
percent from 2001, while simultaneously increasing provider continuity 
for prenatal visits to at least 75 percent in those MTFs not affected 
by the current OPTEMPO. We have deployed the DOD developed Interactive 
Customer Evaluation (ICE) system to monitor patient satisfaction with 
the FCC program and have established partnerships between the BUMED 
Perinatal Advisory Board, Health Services Organizations, and the BUMED 
Inspector General to assist in implementing and monitoring of the FCC 
program.
    We have standardized and enhanced prenatal education in all MTFs 
through the purchase of the USAF developed Spring Garden interactive 
education material and have contracted with a nationally recognized 
expert on Single Room Maternity Care to provide consultative services 
at MTFs undergoing the construction of Labor, Delivery, Recovery and 
Postpartum units. We are ensuring that MTFs review and revise policies 
to include family members at prenatal visits and at the delivery and 
are currently implementing the DOD/VA Clinical Practice Guideline for 
Uncomplicated Pregnancy in Navy MTFs.
    Finally, we have funded, filmed, and distributed marketing video 
spots, introducing patients to the Navy's Family Centered Care program.

Optimization
    Readiness, must be supported by integration and optimization 
forming what I refer to as the ``ROI concept''--Readiness, integration 
and optimization. ROI is simply our effort to be good business people. 
Our optimization efforts have met with good success and led to more 
integration in our military health system. We work with our sister 
services very closely, both within the health care system, and 
operationally. We are all utterly dependent on one another for our 
mutual success. Nothing of any significance is done alone. Further, we 
have increased our integration and cooperation in other areas. A prime 
example is our continued efforts to build mutually advantageous health 
care and business relationships with the Department of Veterans 
Affairs.
    There is no more important effort in military medicine today than 
implementing the MHS Optimization Plan to provide the most 
comprehensive health services to our Sailors, Marines and other 
beneficiaries. Optimization is based upon the pillar of readiness as 
our central mission and primary focus.
    For several years now, we have attempted to shift our mindset from 
treating illnesses to managing the health of our patients. Fewer man-
hours will be lost due to treatment of injury or illness because we 
manage the health of our service men and women, which keeps them fit 
and ready for duty. With this in mind, TRICARE Management Activity and 
the three services created an aggressive plan to support development of 
a high performance comprehensive and integrated health services 
delivery system. We took lessons learned from the best practices of 
both military and civilian health plans. The outcome was the MHS 
Optimization Plan. Full implementation of this plan will result in a 
higher quality, more cost effective health service delivery system.
    The MHS Optimization Plan is based on three tenets. First, we must 
make effective use of readiness-required personnel and equipment to 
support the peacetime health care delivery mission. Second, we must 
equitably align our resources to provide as much health service 
delivery as possible in the most cost-effective manner--within our 
MTFs. And third, we must use the best, evidence-based clinical 
practices and a population health approach to ensure consistently 
superior quality of services.
    During the last year, we accomplished a lot, both locally and at an 
enterprise level by focusing on concept education, primary care 
management techniques, clinic productivity standards, administrative 
health plan management and best practice integration. Accomplishments 
include:

Clinical Advisory Boards
Clinical Practice Guidelines
Primary Care Manager By Name implementation
Patient Safety Initiative
Population Heath Improvement Plan and Tools
Population Health Navigator
Primary Care Optimization Model
Optimization Report Care
TRICARE On-line
Clinic Business Reengineering
Provider Support Staff and Exam Rooms
Clinic Management Course
Access monitoring
Appointment Standardization
Data Quality Initiatives
Transition to New DEERS
Medical Record Control
Pharmacy Profiling
Fleet Liaison Instruction
Policy Statement to Reward Clinical Excellence

    Our Optimization funding has allowed us to pursue investment 
opportunities designed to achieve an ``Order of Magnitude Change'' 
within Navy Medicine Treatment Facilities. Over 140 field proposals 
underwent a rigorous review; those demonstrating the most significant 
Return on Investment (ROI) are being implemented:
  --Musculoskeletal initiatives at 4 sites
  --Mental Health initiative at 1 site
  --Primary Care initiatives at 4 sites
  --Pharmacy initiatives at 4 sites
  --E-Health /TRICARE On-Line
  --Webification of Navy Medicine
  --Population Health Navigator/Primary Care Optimization Model
  --Clinic Manager Course
  --Radiology Residency--NMC Portsmouth
  --Birth Product Line Expansion at 2 sites
  --Virtual Colonoscopy
  --Carido-thoracic Surgery at NMC Portsmouth
  --Sleep Lab Expansion at 3 Sites
  --Nurse Triage/Nurse Advise Line at 2 sites
  --Chile Health Center--NMC San Diego
  --Case Management Project
    The Optimization Fund projects are at various points in the 
approval, funding and implementation process. Implementation plans and 
outcome metrics will be monitored closely.
    Although many commands report numerous efforts to optimize or 
improve their facility, I am concerned that frequently these efforts 
are not tied to specific goals or objectives. This is where performance 
measurement comes in. Performance measurement provides focus and 
direction, ensures strategic alignment and serves as a progress report.
    In the Navy, we are making available comparative performance data 
on all facilities--so MTF commanders can see where they stand and learn 
from each others' successes. Ultimately, it allows us to raise the bar 
for the whole organization.
    We have already made adjustments to our measures and have found 
that many of the measures have data that only changes once a year. This 
may be fine to measure how well we are doing in moving towards some of 
our strategic goals, but they are not adequate by themselves to manage 
the complexity of the Navy Medical department. This year we've added 
more ``levels'' to our metrics. One is a group of Annual Plan measures. 
After reviewing our strategic plan in light of the current environment, 
understanding the strengths, weaknesses, opportunities, and threats to 
our organization, we identified several priorities for the year. We 
then identified measures to track progress on these items--and this 
data has to be measurable at least quarterly. Finally, we have added 
more measures for our ``Dashboard of Leading Indicators'' that our 
leadership will be looking at on a monthly basis. Once we look at the 
historical data for these dashboard indicators, we will be setting not 
only targets for where we want to be but also action triggers in case 
we are going the wrong direction in some area. We will agree on a level 
below which, we will no longer just watch and see if it improves, but 
we will take action to change the processes. We in the Navy have web 
based our Optimization Report Card and the satisfaction survey data is 
provided to MTF commanders in a more user friendly display on a 
quarterly basis. As we continue to improve our performance 
measurements, we will begin to identify targets for our system and for 
each MTF. Holding MTF CO's accountable for meeting those targets will 
be the next step in this evolution.

                   NAVY MEDICINE/DVA RESOURCE SHARING

    As I mentioned, VA resource sharing is part of our optimization 
program. Collaboration between the Veterans Affairs and Navy Medicine 
is an important way to enhance service to our beneficiaries and 
veterans. Navy Medicine is an active participant in the DOD/VA 
Executive Council working to establish a high-level program of DOD/VA 
cooperation and coordination in a joint effort to reduce cost and 
improve health care for veterans, active duty military personnel, 
retirees and family members. The Executive Council is made up of senior 
DOD and VA healthcare executives and has established seven workgroups 
to focus on specific policy areas. Navy Medicine participates on three 
of the workgroups (Benefit Coordination, Financial Management and Joint 
Facility Utilization/Resource Sharing). The Presidential Task Force to 
Improve Health Care Delivery to our Nation's Veteran's meets monthly 
and representatives from BUMED attend every meeting as well as members 
from the VA and other Services. To date, BUMED currently manages 193 
sharing agreements with the VA and provides resource sharing with the 
VA on over 2,800 individual healthcare line items. We have also 
established a new BUMED/VA web site, which will provide our commands an 
overview of joint sharing ventures and updates on local command 
initiatives. It's essential that our Commanding Officers pursue VA 
sharing initiatives in their daily business activities. Specific Navy/
VA Joint Ventures and other MTF agreements initiatives include:
  --NH Great Lakes and the North Chicago VAMC have reached agreement on 
        forming a joint North Chicago Ambulatory Healthcare system 
        which will support the mission at Naval Training Center (NTC), 
        Great Lakes with modern and efficient healthcare services.
  --The NMC Key West, Florida and VA Medical Center, Miami, Florida are 
        sharing a new joint medical clinic that is staffed by VA and 
        Navy providers.
  --NH Corpus Christi and the VA have also signed an agreement to share 
        surgical services and various ambulatory care services.
  --In Guam, the VA Outpatient Clinic is collocated at USNH GUAM; Navy 
        is considered the primary inpatient facility for veterans.
  --NH Pensacola has several VA/DOD agreements in place and is working 
        to establish additional agreements: Current agreements include: 
        Emergency Room Services, Inpatient services, OB services and 
        Orthopedic services, Lab and Radiology Services, Active Duty 
        physicals and Mental Health Services. Options are also under 
        review for new shared ambulatory healthcare settings.
  --NMC San Diego and NH Cherry Point are working with the VA to 
        establish a Joint Community Based Outpatient Clinic (CBOC).
  --NH Lemoore is negotiating a new sharing agreement with the VA in 
        Fresno, California to replace a recently expired agreement.
  --Agreements under development include: Corry Station--a combined 
        DOD/VA Outpatient Clinic. A project workbook has been started 
        and discussions continue. A site location has not been 
        determined at this time.
    The Consolidated Mail Outpatient Pharmacy (CMOP) Pilot Program is 
also providing promising results. The purpose of the CMOP pilot is to 
evaluate the impact and feasibility of shifting some of the DOD 
prescription refill workload from MTF pharmacies to VA CMOPs while 
maintaining quality service to DOD beneficiaries. VA and DOD have made 
important progress in their efforts to conduct a DOD/VA CMOP pilot for 
evaluating the merits of using CMOPs MHS wide. Timelines and metrics 
have been established, pilot sites have been selected, and the 
interfaces are developed and are being tested. A Navy pilot site is at 
the Naval Medical Center San Diego.

                          E-HEALTH TECHNOLOGY

    The Internet has dramatically changed the way we live and do our 
business in ways totally unforeseen even as recently as ten years ago. 
This is especially true in Medicine where the Internet offers the 
opportunity to extend healthcare access, services, and education to 
improve the care we provide our patients. Online services and 
information offer patients the ability to take control of their 
healthcare and partner with their healthcare provider to stay healthy.
    In Navy Medicine, we have recognized the enormous potential of the 
Internet, both in healthcare services and in accomplishing our mission. 
We want to move from reactive interventional healthcare, waiting for 
people to get sick before we intervene, to more proactive Force Health 
Protection where we identify the most common causes of illness and 
injury in our patients and then aggressively act to prevent those 
things through good preventive services and education. We realize we 
cannot achieve this vision if our patients have to come to the hospital 
for those services. As a result, we look to the internet to help us 
extend healthcare services, access, and education outside the hospital 
in a convenient, easily accessed manner.
    We also realize that the internet can help us extend healthcare 
services to remote areas where specialty care has historically required 
medically evacuating patients. Finally, we also realize that the 
internet can be a valuable tool to help us support our operational 
commanders while concurrently improving our internal efficiency and 
effectiveness.
    These four goals, (1) extending healthcare services outside our 
hospital to help move us to proactive Force Health Protection, (2) 
extend healthcare services to the patient, regardless of location, (3) 
improve support to operational commanders, and (4) improve our internal 
efficiency and effectiveness comprise the four main goals of Navy 
Medicine's e-health initiatives.
    There are three initiatives I would like to highlight to 
demonstrate our progress in this area:
  --TRICARE OnLine.--This is the MHS new healthcare portal. A 
        revolutionary concept, it allows our patients to go online, 
        create an account, and access customizeable personalized 
        healthcare information for their specific needs. They can also 
        create an online healthcare journal for their healthcare 
        providers to use and to help them track their health. There are 
        no comparable services in the civilian sector and it represents 
        the very hard work of a dedicated staff who took this from 
        concept to widespread deployment in less than two years. Navy 
        Medicine is partnering with TRICARE OnLine to share 
        applications, jointly develop new applications, and ensure 
        interoperability for new innovations in the future.
  --RADWORKS.--Radiology is increasingly important in the rapid 
        diagnosis and treatment of patients. Rapid access to radiology 
        expertise is critical to getting the best and quickest care for 
        our patients. Since we cannot have radiologists everywhere, we 
        are leveraging digital radiography over the web to provide this 
        service. We recently completed installation of this technology 
        onboard USNS COMFORT for use in supporting optimal care and 
        disposition of any casualties. Our patients will have immediate 
        access to the best radiologic support quickly regardless of 
        their location anywhere in the world.
  --Smallpox Tracking System.--With the threat of smallpox, it is 
        critical for us to both immunize the force and provide our 
        commanders with as near a real time view of their immunization 
        status as possible. Previous reporting used to be paper-based, 
        was very labor-intensive, and was almost always out of date 
        when received. We did smallpox immunization tracking 
        differently. Within two weeks of program start, a dedicated 
        Navy Medicine web team developed and implemented a real time 
        web-based tracking system that allowed us to provide, on a 
        daily basis, real time immunization reports to line commanders 
        for their use. This was subsequently upgraded to a more robust 
        system in use today. Navy Medicine responded quickly and 
        effectively to the needs of our commanders and the support we 
        needed to give to keep our Sailors and Marines healthy and 
        ready to go.
    The bottom line is that Navy Medicine is at the vanguard of 
leveraging the net and emerging web-based technologies to improve our 
healthcare services, better support our operational commanders, and 
ensure our Sailors, Marines, family members, and retirees receive the 
very best care possible anywhere, at any time.

                            MEDICAL RESEARCH

    Navy Medicine also has a proud history of incredible medical 
research successes from our CONUS and OCONUS laboratories. Our research 
achievements have been published in professional journals, received 
patents and have been sought out by industry as partnering 
opportunities.
    The quality and dedication of the Navy's biomedical R&D community 
was exemplified this year as Navy researchers were selected to receive 
prestigious awards for their work. CAPT Daniel Carucci, MC, USN 
received the American Medical Association's Award for Excellence in 
Medical Research for his work on cutting edge DNA vaccines. His work 
could lead to the development of other DNA-based vaccines to battle a 
host of infectious diseases such as dengue, tuberculosis, and 
biological warfare threats. Considering the treat of Biological 
terrorism, DNA vaccine-based technologies have been at the forefront of 
``agile'' and non-traditional vaccine development efforts and have been 
termed ``revolutionary''. Instead of delivering the foreign material, 
DNA vaccines deliver the genetic code for that material directly to 
host cells. The host cells then take up the DNA and using host cellular 
machinery produce the foreign material. The host immune system then 
produces an immune response directed against that foreign material.
    In the last year, Navy human clinical trials involving well over 
300 volunteers have demonstrated that DNA vaccines are safe, well-
tolerated and are capable of generating humoral and cellular immune 
responses. DNA vaccines have been shown to protect rodents, rabbits, 
chickens, cattle and monkeys against a variety of pathogens including 
viruses, bacteria, parasites and toxins (tetantus toxin). Moreover 
recent studies have demonstrated that the potential of DNA vaccines can 
be further enhanced by improved vaccine formulations and delivery 
strategies such as non-DNA boosts (recombinant viruses, replicons, or, 
importantly, exposure to the targeted pathogen itself).
    A multi-agency Agile Vaccine Task Force (AVTF) comprised of 
government (DOD, FDA, NIH), academic and industry representatives is 
being established to expedite research of the Navy Agile Vaccine.
    As other examples of scientific achievement, Navy Medicine is 
developing new strategies for the treatment of radiation illness. Navy 
Adult Stem Cell Research is making great strides in addressing the 
medical needs of patients with radiation illness. The terrorist attacks 
of 2001 identified the threat of weapons of mass destruction, to 
potentially expose large numbers of people to ionizing radiation. 
Radiation exposure results in immune system suppression and bone marrow 
loss. Currently, a bone marrow transplant is the only life saving 
procedure available. Unfortunately, harvesting bone marrow is an 
expensive and limited process, requiring an available pool of donors.
    In the past year, NMRC researchers have developed and published a 
reproducible method to generate bone marrow stem cells in vitro after 
exposure to high dose radiation, such that these stem cells could be 
transplanted back into the individual, thereby providing life-saving 
bone marrow and immune system recovery. This is the type of technology 
that will be needed to save the lives of a large number of victims.
    In this same line of research, Navy Medicine is developing new 
strategies for the treatment of combat injuries. We are developing new 
therapies to ``educate'' the immune system to accept a transplanted 
organ--even mismatched organs. This field of research has demonstrated 
that new immune therapies can be applied to ``programming stem cells'' 
and growing bone marrow stem cells in the laboratory. The therapies 
under development have obvious multiple use potential for combat 
casualties and for cancer and genetic disease.
    Other achievements during this last year include further 
development of hand-held assays to identify biological warfare agents. 
During the anthrax attacks, the U.S. Navy analyzed over 15,000 samples 
for the presence of biological warfare (BW) agents. These hand-held 
detection devices were used in late 2001 to clear Senate, House and 
Supreme Court Office Buildings during the anthrax attacks and 
contributed significantly to maintaining the functions of our 
government. Some of the most important tools that are used to analyze 
samples for the presence of BW agents in the field are hand-held 
assays. The hand-held assays that are used by the DOD were all 
developed at Naval Medical Research Center (NMRC). Currently NMRC 
produces hand-held assays for the detection of 20 different BW agents. 
These hand-held assays are supplied to the U.S. Secret Service, FBI, 
Navy Environmental Preventive Medicine Units, U.S. Marine Corps, as 
well as various other clients. Since September 2001, NMRC has produced 
over 120,000 assays and has fielded approximately 23,000 assays. In 
addition to the in-house production, NMRC has also provided emergency 
production capacity of antibodies needed for DOD fielded bio-detection 
systems, including the hand-held assays produced by JPO/BD for DOD use. 
The hand-held Assays have recently been upgraded with Platinum 
detection systems which will be 10 to 100 times more sensitive than the 
current systems, depending on what agent is being identified.
    The Navy's OCONUS research laboratories are studying diseases at 
the very forefront of where our troops could be deployed during future 
contingencies. These laboratories are staffed with researchers who are 
developing new diagnostic tests, evaluating prevention and treatment 
strategies, and monitoring disease threats. One of the many successes 
from our three overseas labs is the use of new technology, which 
includes a Medical Data Surveillance System (MDSS).
    The goal of the MDSS is to provide enhanced medical threat 
detection through advanced analysis of routinely collected outpatient 
data in deployed situations. Originally designed to enable efficient 
reporting of DNBI statistics and rapid response of preventative 
medicine personnel, MDSS may also enable supply utilization tracking 
and serve as a method of detecting the presence of chemical and 
biological agents. MDSS is part of the Joint Medical Operations-
Telemedicine Advanced Concept Technology Demonstration (JMOT-ACTD) 
program. Interfacing with the shipboard SAMS database system, MDSS 
employs signal detection and reconstruction methods to provide early 
detection of changes, trends, shifts, outliers, and bursts in syndrome 
and disease groups (via ICD-9 parsing) thereby signaling an event and 
allowing for early medical/tactical intervention. MDSS also interfaces 
with CHCS and is operational at the 121st Evacuation Hospital in South 
Korea, and is being deployed at the hospital and clinics at Camp 
Pendleton. Currently, MDSS may have an opportunity to collaborate with 
other industry and service-related efforts for the purpose of 
developing homeland defense-capable systems. Homeland defense 
initiatives are currently being coordinated through the Defense Threat 
Reduction Agency.

                               CONCLUSION

    Navy Medicine has covered a lot of ground over the last year and we 
face the future with great enthusiasm and hope. The business 
initiatives, along with new technical advances join to make our Navy 
Medical Department a progressive organization. I thank you for your 
continued support and in making the military health care benefit the 
envy of other medical plans. You have provided our service members, 
retirees and family members a health benefit that they can be proud of.
    I think we have been extraordinarily successful over the years, and 
we have opportunities for continued success, both in the business of 
providing healthcare, and the mission to supporting deployed forces and 
protecting our citizens throughout the United States.
    We are one team, with one fight, and we are now in the middle of 
that fight. I am certain that we will prevail.

    Senator Stevens. Thank you very much. I apologize for being 
late. I had another meeting. John Taylor.

STATEMENT OF LIEUTENANT GENERAL DR. GEORGE PEACH 
            TAYLOR, JR., AIR FORCE SURGEON GENERAL

    General Taylor. Mr. Chairman, Senator, it is a pleasure to 
be here today for the first time. It is also my very great 
privilege to represent the Air Force Medical Service. They are 
dedicated to providing outstanding force protection to our 
Armed Services as they have so ably demonstrated over the last 
year and a half.
    The Air Force Medical Service brings important capabilities 
to support any operation or contingency as a key component of 
agile combat support to the Nation's Aerospace Expeditionary 
Forces (AEFs), our sister services and allied forces both 
abroad and at home.
    We have been transforming for many years. Since the first 
Gulf War, we have achieved improvement in every step of the 
deployment process from improving predeployment health to post 
deployment screening and counseling. We believe in a lifecycle 
approach to health care. It starts with accession and lasts as 
long as the member is in uniform, and beyond through the 
Department of Veterans Affairs.
    As we deploy, we are now seeing a more fit and healthy 
fighting force for which we have the best fitness and health 
data ever. And we know how to take care of them. Our medical 
personnel are more prepared than ever. Training such as our 
advanced trauma training and readiness skills verification 
program assure that our wartime skills are current.
    Expeditionary medicine has enabled us to move our medical 
forces forward very rapidly, as in the initial deployments 
during Operation Iraqi Freedom. The capabilities we bring to 
the fight today provide troops a level of care that was 
unimaginable just 10 years ago, capabilities that make us a 
lighter, smarter and a much faster medical service.
    Our preventive medicine teams go in on the very first 
planes into the theatre of operations. This small team of 
experts gives us vital food and water safety capabilities. They 
begin collecting vital water hazard data and provide basic 
primary care. In fact, during Iraqi Freedom, one of our 
environmental medicine flight personnel actually parachuted 
with the Army's 173rd Airborne Brigade as part of the Air 
Force's 86th contingency response group and the initial 
contingent deployed in a Northern Iraqi air base. This 
independent duty medical tech was later joined by five 
remaining members of the flight to provide on-scene 
environmental security and force protection at that location.

                  EXPEDITIONARY MEDICAL SUPPORT UNITS

    Our surgical units, lightweight, highly mobile 
Expeditionary Medical Support units, or EMEDs, can be on the 
ground within 3 to 5 hours. EMEDs are comprised of highly 
deployable medical teams that can range from large tented 
facilities to five-person teams with backpacks. These five 
person mobile field surgical teams or MFSTs, travel far forward 
with 70 pound backpacks. In them is enough medical equipment to 
perform 10 lifesaving surgeries anywhere, at any time, under 
any conditions.

                       OPERATION ENDURING FREEDOM

    During a 6-month rotation for Operation Enduring Freedom 
one of these mobile surgical teams performed 100 infield 
surgeries, 39 of those were for combat surgeries. And when our 
sick and injured must be removed from the theater and 
transported to definitive care, we have the state of the art 
medical air evacuation system.
    In fact, another major advance since the Gulf War is our 
ability to move large numbers of more critically injured 
patients. Our Critical Care Air Transport Teams tend to these 
very ill patients throughout the flight providing lifesaving 
intensive care in the air. Last year in support of Operation 
Enduring Freedom, we transported 1,352 patients through the air 
evac system of whom 128 were just such critically ill or 
injured patients. And for Iraqi Freedom, we performed over 
2,000 patient movements, 640 of those were people with combat 
injuries.
    And thanks to the Department of Defense (DOD) TRANSCOM 
Regulating and Command and Control Evacuation System 
(TRAC\2\ES), we were able to track each patient from the point 
of pickup to the point of delivery in real time.
    It is important to note that each of these new programs 
have been woven seamlessly into a joint medical capability. 
This joint service interoperability was demonstrated during the 
crash of an Apache helicopter last April in Afghanistan. The 
two pilots had massive facial and extremity fractures. The 
injured pilots were initially treated and moved by an Air Force 
pararescue member who had been delivered onsite by an Army 
Special Forces helicopter crew. The two were then stabilized by 
an Army surgical team, transferred to a C-130 and then air 
evacuated out on a C-17.
    In flight they were restabilized by one of our Air Force 
Critical Care Air Transport Teams and landed safely at a 
military base in the European theater to be cared for by a 
jointly staffed military regional medical center, and all this 
was done within 17 hours of the time they hit the mountain in 
Afghanistan. This is just one seemingly unbelievable but in 
fact increasingly routine example of our integrated medical 
operations.
    Together, the three medical services have built an 
interlocking system for care for every airman, soldier, sailor, 
Marine or Coast Guardsman in harm's way. We have fielded data-
capture mechanisms to extend and enhance our force protection 
efforts. Using automated systems, we have documented and 
centrally stored almost 37,000 deployed medical patient medical 
records since 9-11, capturing almost 71,000 patient encounters. 
This is an update to what I told the House Armed Services 
Committee last week because it includes Operation Iraqi 
Freedom.
    We have tools in place to collect relevant environmental 
health data and are forwarding them for centralized analysis. 
This linkage between individual patient encounters and 
environmental data is absolutely critical to ongoing and future 
epidemiological studies. We are working hard with health 
affairs to ensure we maintain a solid, finely tuned deployment 
health surveillance system.
    In fact, the Air Force inspection agency assesses the 
deployment health surveillance program in each of our bases, 
active duty and Air Reserve Component, to ensure the quality of 
this vital program. And in the last 2 years, largely through 
their efforts and crosstalk, we have reduced significant 
discrepancies fourfold.

                                TRICARE

    Another crucial element of protecting our troops is 
ensuring peace of mind of their families. We continue to work 
hard to optimize the care we provide in our facilities for more 
than 1 million TRICARE patients and 1.5 million TRICARE for 
Life patients.
    We are doing this in many ways by ensuring providers have 
support staff, that their processes are efficient, and that 
their buildings and equipment are adequate. We look forward to 
the next generation TRICARE contracts and are stepping forward 
in optimization for these. Both are structured to give more 
resources and more flexibility to our local commanders.

                        RECRUITING AND RETENTION

    After all, politics and health care ``is local''. The 
challenge we continue to face is medical professional 
recruiting and retention. I personally believe the solution is 
twofold. First, incentives such as loan repayment, accession 
bonuses, increased specialty care, and increased specialty pay 
are beginning to make a difference. And again, we appreciate 
your critical support.
    Secondly, I believe that optimization and facility 
improvement projects, those that I mentioned above, will create 
a first-class environment of care for our outstanding, well-
trained and highly talented staffs.

                           PREPARED STATEMENT

    In conclusion, as we face the many challenges of our 
missions at home and abroad, your Air Force Medical Service 
remains committed to offering families quality, compassionate 
care and to supporting our troops as they protect and defend 
our great country. I thank you for your vital support, the 
support that you provide to your Air Force and to our families, 
and I look forward to your questions.
    [The statement follows:]

 Prepared Statement of Lieutenant General Dr. George Peach Taylor, Jr.

    Mr. Chairman and members of the committee, thank you for the 
opportunity to discuss with you some of the challenges and successes of 
the Air Force Medical Service, or the AFMS.
    As with all other aspects of the military, the AFMS is transforming 
itself.
    Transformation is a word that is being regularly used around 
Washington these days. To the Air Force, transformation is not just new 
technology, such as uninhabited combat aerial vehicles or space-based 
radars. Transformation is merging new technologies with new concepts of 
operations and new organizational structures.
    Think about the Air Force combat controllers on the ground in 
Afghanistan directing B-52s to drop directed-munitions within 500 
meters from their positions. This was accomplished by using global 
positioning satellites, laser range-finding devices, and new state-of-
the-art munitions to provide a new kind of effect: enhanced close-air 
support, which proved to be pivotal in the fight with the Taliban. This 
success serves as an example of one of many progressive steps the Air 
Force is taking in its march toward Transformation.
    The Air Force Medical Service is no stranger to transformational 
changes. In many ways we lead the Air Force and like to say ``that we 
were transforming before transformation was cool.'' Our modular, 
lightweight medical and preventive medicine teams, same-day 
laparoscopic surgery, advanced imaging--among many other components--
have changed the face of military medicine, from home base to 
battlefield.
    Our five Air Force Medical Service core competencies provide 
compelling lenses through which we view the transformational 
activities.
    I would like to briefly describe each core competency and share 
some of the exciting accomplishments we have achieved under each.
    Our first Air Force Medical Service's core competency is 
population-based health care. As the name indicates, population-based 
health care strives to keep our entire beneficiary population healthy 
by preventing disease and injury. But, if any do become sick or 
injured, our system will provide exceptional care.
    Our next core competency is human performance enhancement and 
sustainment. These include methods and equipment that protect our 
forces from harm and permit our troops to perform their missions 
better.
    Fixed wing aeromedical evacuation, our third core competency, 
addresses the innovative and life-saving ways we use aircraft to 
transport patients from the theater of operations to the nearest 
capable medical treatment facility.
    Our fourth core competency, medical care in contingencies, entails 
all the training, equipment, and logistics needed to provide care 
during humanitarian or combat operations.
    World health interface, our final core competency, recognizes the 
importance of interaction with other nations. Air Force medics are 
called to serve from Atlanta to Afghanistan, and from San Antonio to 
Sierra Leone. Therefore, we have institutionalized training programs 
that teach medics the language and customs of those countries in which 
they might be called to serve.
    These five core competencies are the heart and soul of the Air 
Force Medical Service. I would like to describe each in a bit more 
detail to better demonstrate to you the innovative ways in which the 
Air Force Medical Service is transforming itself.
Population-Based Health Care
    The U.S. military health care system cares for 8.3 million people 
and costs $26 billion. This huge system is in every state and in 
numerous countries. Yet, as immense as this system is, I adhere to the 
philosophy that all health care is local.
    What matters most in medicine and dentistry is the care our 
patients receive from their provider. It is my mission--my passion--to 
ensure that every provider has the leadership, training, people, 
facility space, and medical equipment he or she requires to give those 
patients the care they need, the care they deserve. Our first core 
competency, population-based health care, is critical to ensuring this 
becomes a reality.
    We have transitioned from the old medical paradigm--treating sick 
people--to the new paradigm of preventing people from getting sick in 
the first place. The old way makes for better TV drama, but the new way 
makes for better medicine. This new paradigm is called population-based 
health care. The programs I will discuss support population-based 
health, especially how it applies to our active duty forces.
    Because of the global war on terrorism, there has never been 
greater imperative to have a military force that is fully ready to 
``fly the mission.'' Our comprehensive Individual Medical Readiness 
program, ensures our military members are ``medically ready'' to 
perform.
    To help illustrate the Individual Medical Readiness program, I ask 
you to think of an aircraft--a new F/A-22 fighter, for instance. From 
the moment each aircraft enters our arsenal, it undergoes continuous 
monitoring, routine inspections, preventive maintenance, and if needed, 
repairs. These activities happen before, during, and after this weapon 
system is employed.
    A far more valuable resource--our airmen, the ``human weapons 
system''--receive that same level, if not more, of devoted care. 
Through our Individual Medical Readiness program, we constantly monitor 
the health of our airmen through inspections and preventative 
maintenance--called Preventive Health Assessments--and, if needed, 
repairs.
    The Individual Medical Readiness program has four main components, 
the first of which is the Preventive Health Assessment. At least once a 
year, we review the total health care needs and medical readiness 
status for every airman. During this appointment we make sure they have 
received all recommended and required preventive care, screenings, 
immunizations, and assessments. Preventive Health Assessments are the 
equivalent of the routine inspections and preventive maintenance 
provided to aircraft.
    Second, at each visit, whether in garrison or deployed, we take 
care of our troop's complaints, look for other preventive 
interventions, and ensure their fitness for duty.
    Third, we perform medical evaluations before and after troops 
deploy so that we can monitor the effect--if any--the deployments have 
on their health.
    Finally, we have created innovative new information systems 
designed to track all individual medical readiness and preventive 
health care requirements. It is called the Preventive Health Assessment 
Individual Medical Readiness program (PIMR).
    At the local level, PIMR can tell the medics which troops need 
blood tests, evaluations, or vaccines, who is healthy enough to be sent 
to the field, and who should remain behind until they are healthy. At 
the global level, PIMR provides leaders near real-time statistics that 
tell them what percent of their troops are medically fit to deploy. 
PIMR's metrics are also used to provide feedback and shape policies and 
programs so we can continually improve the readiness of our force.
    Population-Based Health Care is more than just the method to keep 
the active duty members healthy. It benefits all beneficiaries--active 
duty, their families, retirees and their families, and is our 
overarching model for healthcare. Our AFMS must accomplish three 
critical processes to ensure full-fledged Population-Base Health Care.
    First, care team optimization. An optimized primary care team, for 
example, has as its members a provider, nurse, two medical technicians, 
and one administrative technician. The team is provided the optimal 
number of exam rooms, medical equipment, and support staff needed to 
ensure that such things as facility constraints and administrative 
responsibilities do not hinder their ability to provide care to our 
airmen and their families. In such teams, our medical staff flourish.
    Where we have optimized our primary care clinics, we have enjoyed 
success. Based upon this success, the AFMS has embarked upon expanding 
this strategy. Soon, every clinical and non-clinical product line will 
undergo an expeditionary capability analysis, clinical currency 
analysis, and business case analysis to determine how best to optimize 
the use of our resources.
    In short, we have seen that optimization has great potential in the 
primary care setting, so now we hope to spread that success by 
optimizing specialty care. This year we will launch pilot programs for 
the optimization of orthopedics, general surgery, otolaryngology, OB/
GYN, and ophthalmology.
    The result of optimization is clear: Our people are receiving 
outstanding healthcare delivered by highly trained teams.
    A second critical process of Population-Based Health is ``PCM by 
name.'' PCM stands for ``primary care manager.'' A PCM is a provider 
who takes active oversight in every aspect of a patient's care. 
Beneficiaries are assigned a ``PCM by name,'' meaning they will 
routinely see that same provider. Previously, beneficiaries would 
arrive at the clinic and frequently did not know who their provider 
would be that day. Now, through PCM by name, they are assigned to a PCM 
who will see the patient for all routine medical care. The PCM becomes 
much like a trusted, small-town family doctor who becomes intimately 
involved in the care of the patient and his or her family.
    We have over 1.2 million customers enrolled to our 74 medical 
locations--and 100 percent of those beneficiaries are enrolled to a PCM 
by name.
    The tandem success of the Optimization and Primary Care Manager by 
Name efforts are serving our TRICARE beneficiaries well. The Health 
Employee Data Information Set Standards--or HEDIS--are the civilian 
national standards by which most Managed Care Organizations are 
measured. Here is how HEDIS ranks some of our efforts compared to 
civilian commercial health care plans:
  --For providing timely cervical cancer screenings, the Air Force is 
        in the top 10 percent of all health care plans in the United 
        States.
  --For breast cancer screenings the Air Force surpasses 66 percent of 
        commercial plans.
  --Our diabetic care program is in the top 9 percent of all similar 
        plans nationwide.
    And, recently, the Air Force Medical Service was recognized by 
civilian experts at the Kilo Foundation as one of two U.S. health care 
organizations on the cutting edge of optimizing health care delivery--
the other organization being Kaiser-Permanente.
    We optimized our care teams to deliver the best care, now we must 
also optimize the buildings in which our patients receive that care. 
Facility recapitalization is the third critical process that must be 
accomplished to support population-based health.
    Whether we are talking about the human body, aircraft, or 
buildings, the more each ages, the more they wear out, break down, 
creak and leak. They become more expensive to maintain. For that 
reason, the Defense Health Program currently supports the goal of 
medical facility recapitalization at a 50-year rate rather than the 67-
year rate provided to other, non-health-care facilities.
    We use the funds we are provided annually to pay for necessary 
renovations, modernization, and replacement needs.
    Before I discuss our remaining AFMS core competencies, I will 
mention a few population-based health care items I find worthy of 
mention, one of which is our success in suicide prevention.
    Suicide is the most preventable cause of death, yet is the 11th 
leading cause of death in the United States. Among people of military 
age, it is the fourth leading cause of death behind accidents, cancer, 
and heart attacks.
    Fortunately, suicide among our Air Force members and their families 
is nearly the lowest it has been in 20 years.
    We teach our leadership, airmen, and family members how to 
recognize, assist, and intervene when they identify members who might 
be contemplating suicide. Our efforts are succeeding. Throughout the 
mid 1990s, there were over 14 Air Force suicides for every 100,000 
members. That number is now just 8.3 for every 100,000. We are striving 
hard--very hard--to lower it yet more. We recognize that we can never 
completely eradicate suicide, but every life saved is crucial to the 
Air Force. And the quality of life for all those who seek and receive 
care is immeasurably enhanced.
    Another important quality of life initiative is our focus on 
enhancing obstetrical care in our military treatment facilities for our 
patients. We are working very hard across the Air Force, and indeed 
DOD, to optimize our OB programs. We are increasing routine prenatal 
ultrasound capability, improving continuity of care with patients and 
OB providers, and enhancing OB facilities to provide more comfortable 
labor and delivery rooms.
    Preliminary findings from the specialty care optimization pilot at 
Nellis AFB, show increases in access to care, in patient-provider 
continuity, and an increase in mothers desiring to deliver their babies 
at Nellis. In the last year alone nearly 11,000 mothers-to-be visited 
our OB clinics for a total of 193,000 visits. Carrying through on these 
optimization efforts, we feel confident that when it is time for our OB 
patients to choose their provider, they will choose their local 
military treatment facility. They will choose us.
    Our optimization efforts throughout the Air Force Medical Service 
are complemented by partnerships with Department of Veterans Affairs 
clinics and hospitals. The DOD has seven joint venture programs with 
the VA; the Air Force oversees four of them at Travis, Elmendorf, 
Kirtland, and Nellis Air Force Base Hospitals.
    One of our most successful joint ventures is our first--Nellis Air 
Force Base's VA/DOD hospital. This joint venture replaced the outdated 
Nellis hospital and offered VA beneficiaries a local federal inpatient 
facility for the first time in the area's history. The facility enjoys 
a fully integrated Intensive Care Unit, operating suite, emergency 
room, post anesthesia care unit, and shared ancillary services.
    Kirtland's joint venture is also impressive. There, the joint 
venture has gone beyond the sharing of staff and facilities. At 
Kirtland, the Air Force and VA have created Joint Decontamination and 
Weapons of Mass Destruction Response Teams. Their teamwork will permit 
a homeland defense capability that is superior to either organization 
could provide separately.
    Our four joint venture opportunities saved $2.5 million and avoided 
over $16 million in the just the last two fiscal years. Not all DOD 
hospitals are candidates for joint ventures, but we are excited about 
finding those that are and investing in the opportunity.
    Partnerships with the VA where they make good sense not only save 
money; they enhance care to both of our beneficiary populations. The 
new contracts promise enhanced pharmacy support and health care to 
beneficiaries.
    An additional enhancement to the DOD's health care benefit is that 
of Tricare For Life--the extension of Tricare benefits to our retirees. 
This program has dramatically improved the quality of life for our 
Medicare-eligible retirees and their families. In the first year, 
Tricare for Life produced 30 million claims. The program also 
significantly improved access to pharmaceuticals to our retiree 
population. Retirees appreciate both the quality of care and the 
knowledge that the country they proudly served is now there to serve 
them.
    I have described many activities the AFMS performs to ensure that 
the airmen we send into the field are healthy. But, once they are 
there, we must also work to ensure they stay that way--that they are 
protected from injury, disease, and biological and chemical weapons. We 
must provide an operations environment that is safe. This leads me to 
our second core competency, Human Performance Enhancement and 
Sustainment.

Human Performance Enhancement and Sustainment
    Airmen are our most valuable assets. Their readiness directly 
impacts the combat effectiveness of the United States Air Force. 
Therefore, it is not good enough to just have disease-free troops, they 
need to be working at their optimal performance level during strenuous 
military operations. To that end, the Air Force Medical Service has 
developed a Deployment Health Surveillance program that ensures and 
protects the health of its members from the day they enter service and 
don their first uniform, during deployments, and throughout their 
entire career.
    Deployment Health Surveillance is more than just the application of 
exams immediately before and after a deployment; it is a Life Cycle 
approach to health care that lasts as long as the member is in uniform 
and beyond. Some of the most recent developments in Deployment Health 
Surveillance are the most exciting. These include technologies that 
rapidly detect and identify the presence of weapons of mass 
destruction, technologies such as genomics, bio-informatics, and 
proteomic clinical tools.
    Each of these state-of-the-art efforts promises speedy 
revolutionary diagnostics, enabling near real-time bio-surveillance. 
And, whereas, most bio-chemical detectors take hours or days to detect 
and warn us that agents have been released into the environment, the 
sensors we are now developing will have near real-time capability to 
warn us of an attack.
    The AFMS was the first to transition polymerase chain reaction 
technologies into a fielded biological diagnostic detection system. 
This technology keeps watch over troops in the field and our homeland. 
It provides better protection for our entire nation while 
simultaneously revolutionizing daily medical practice.
    Whether these detection units stand sentinel over military men and 
women overseas or guard major population centers here at home, their 
presence translates into markedly decreased mortality and morbidity. 
Additionally, because it can quickly detect and identify pathogens, it 
decreases wasted time and resources in laboratory and therapeutic 
interventions.
    The AFMS is working to overcome another threat to our troops and 
citizenry--a threat more often associated with science fiction than 
with current events: directed energy weapons--lasers. Directed energy 
devices are now commonplace. Hundreds of thousands of lasers are 
employed by many countries around the world . . . mostly for peace, 
many for war. Militaries, including our own, use lasers in weapons 
guidance systems to help them drop bombs with pinpoint accuracy.
    In response to this threat from our enemies, we developed--and 
continue to improve upon--protective eyewear and helmet faceplates. 
These devices are designed to absorb and deflect harmful laser energy, 
thus protecting pilots from the damaging and perhaps permanent eye 
injuries these weapons inflict.
    We are also investigating commercial off-the-shelf, portable 
medical equipment that can quickly scan retinas and automatically 
determine if a person's eye has suffered damage from lasers.
    The AFMS is teaming with other Air Force organizations to 
transition several protecting and surveillance technologies to allow 
our forces to enter, operate and safely prevail within the laser-
dominated battle space.
    Lasers are not the only threat to our forces. There is also the 
familiar threat of biological and chemical weaponry. Congressional 
members and their staff, journalists, post office workers, and average 
citizens fell victim to anthrax attacks in the fall of 2001. As 
sobering as these attacks were, we were fortunate they were committed 
with a biological weapon for which we had a ready defense--an 
antibiotic--and that the anthrax was delivered in small amounts.
    Our nation and its medical community learned much from the 
incident; so did our enemies. They will know better how to strike us 
next time, and we must be prepared.
    To detect and combat such a threat, the AFMS is developing 
detection, surveillance, and documentation systems to help us recognize 
and respond to future biological and chemical warfare attacks. The 
Global Expeditionary Medical System--or GEMS--is one such system.
    GEMS was first developed and deployed during Operation DESERT 
SHIELD/DESERT STORM as a means to monitor and help protect the health 
of deployed forces. During that initial deployment, it captured over 
11,000 patient encounters in the field and relayed this valuable 
information to what is now the Brooks City Base in Texas for analysis.
    GEMS is now a mature, fully functioning asset. It establishes a 
record of every medical encounter in the field. It then rapidly 
identifies clinical events such as a potential epidemic. Whether the 
outbreak is accidental such as food poisoning, or intentional such as 
the release of a weapon of mass destruction like Anthrax at an airbase, 
GEMS can quickly alert medics about the presence of the weapon and 
allows our medics to attack and defeat the biological or chemical agent 
before its effect can become catastrophic.
    GEMS does not look like much . . . it is a ruggedized laptop 
computer with a few small attachments, but its toughness and small size 
make it ideal for troops in the field. GEMS will soon be incorporated 
into the Epidemic Outlook Surveillance system, or EOS. EOS is an 
initiative to network--to link together--all systems that detect and 
identify biological and chemical warfare agents. It also incorporates 
all data produced from provider-patient encounters. From this, medics 
and leadership can monitor the possible presence of weapons of mass 
destruction, determine their current and predicted impact on troops, 
and respond with precision to defeat their effect. This is all 
accomplished to protect not just a base, nor theater of operations; 
rather EOS will provide overarching, worldwide oversight of the health 
of our troops.
    What is fascinating about this system is its speed. The current 
standard to detect and identify a biological or chemical agent--and 
contain the epidemic it could create--is five to nine days. Aboard 
ship, or in a military base, the resources needed to care for the 
infected and the high casualty rate would overwhelm the mission. Even 
if the agent were detected in the first three days, we expect that up 
to 30 percent of our troops would fall ill or worse.
    When it comes to identifying chemical and biological weapons 
attacks, lost time means lost lives. We are fast now. We strive to be 
faster. Our goal is to recognize and combat a potential epidemic within 
the first three hours of its introduction into the population. We are 
working with the other services to create sensors with this capability. 
These technologies are just over the horizon, but we are developing 
man-portable sensors capable of detecting chemicals and pathogens 
almost instantly. When fully developed, these sensors will have the 
capability to read the genetic structure of a biological agent to tell 
us exactly what it is and what antibiotics would best defeat the 
attack.
    Obviously, such programs have both military and civilian 
application, so we are working with many other military, federal, 
university, and civilian organizations to develop, deploy, and share 
this amazing technology.
    The enemy is not the only threat our troops face. During extended 
operations, our airmen find themselves combating fatigue. Physical and 
mental exhaustion lead to judgment errors, errors that in combat can 
cost lives. With its ``Global Reach, Power and Vigilance'' mission, the 
Air Force continues to strain the physiologic limits of its aircrews. 
It must develop methods of protecting its troops from the dangers of 
fatigue, for fatigue is a killer in the battlefield.
    We have been working hard with the Air Force Research Laboratory, 
Air Combat Command and our aircrews to develop advanced techniques to 
maximize performance and safety on long-duration missions. These 
techniques include planning missions around the body's natural sleep 
cycles--the circadian rhythm--diet manipulation, and pharmacological 
and environmental assistance.
    Such activities greatly aid our force-protection measures in an 
ever-changing battle space. But, during operations, the AFMS' ``bread 
and butter'' is the level to which we can properly treat and move 
wounded battle participants.
    This leads me to our third core competency: Fixed Wing Aeromedical 
Evacuation.

Fixed Wing Aeromedical Evacuation
    We have invested many resources and much time into keeping troops 
healthy and enhancing their performance. But in the operational 
environment, people do become sick. They do get injured. For such cases 
we developed an aeromedical evacuation system that can move patients 
from the field to definitive care, often within hours of their 
acquiring the illness or injury.
    The Aeromedical Evacuation System is a unique and critical part of 
our nation's mobility resources. The need to move critically injured, 
stabilized patients from forward areas to increasing levels of 
definitive care has driven significant changes in the fixed-wing 
environment.
    In the past, Aeromedical missions were limited to certain airframes 
such as the C-141 cargo aircraft or our special C-9 Nightingale AE 
aircraft. However, aeromedical evacuation is a mission and not a 
particular aircraft platform; and it is a mission recognized as a core 
competency within the larger airlift mission. As we retire our aging AE 
platforms and transition from dedicated to designated aircraft in the 
mainstream of airlift flow, we are developing new tools such as the 
Patient Support Pallet, or PSP.
    The PSP is a collection of medical equipment compactly assembled so 
that it can easily fit into most any cargo or transport aircraft. When 
needed, it is brought aboard, unpacked, and within a short time is 
transformed into a small patient care area. This means that patients no 
longer have to wait hours or even days for an aeromedical evacuation 
flight. Just give our medics a PSP and an hour, and they will take the 
C-5 that just unloaded troops and tanks, and will convert a small 
corner of that plane into an air ambulance.
    Our 41 PSPs strategically positioned around the globe permit any 
suitable airframe in the airlift flow to be used. This awesome 
capability minimizes delay of movement, maximizes available airlift, 
and most importantly, saves lives. We plan to buy more.
    Insertion of critical care skills early in this process is provided 
in the form of specially trained Critical Care Air Transport Teams, or 
CCAT teams. These teams--comprised of a physician, nurse and 
cardiopulmonary technician--receive special training that enables them 
to augment our air evacuation crews and deliver intensive care support 
in the airborne environment. Our Active Duty medics have 42 CCAT teams, 
but our ARC forces are full partners in this new capability. The Air 
Force Reserve contributes 25 CCAT teams, and the Air National Guard 32 
teams to our AE mission. Each is ready for rotation into the AEF along 
with their Active Duty counterparts.
    Another valuable tool is the TRANSCOM Regulating and Command & 
Control Evacuation System, otherwise known as TRAC\2\ES. TRAC\2\ES is a 
DOD/Joint enterprise that allows us to plan which patients should fly 
out on what aircraft, what equipment is needed to support each patient, 
and what hospital they should fly to; and it provides us in-transit 
visibility of all patients all the time. TRAC\2\ES provides command and 
control of global patient movement in peacetime, contingencies and war.
    TRAC\2\ES is an overwhelming success. It has accomplished all of 
the goals specified in the re-engineering process and has produced 
benefits that no one anticipated. To date:
  --There have been more than 1,700 patients/soldiers moved as a result 
        of activities during OEF, and nearly 17,000 such moves 
        worldwide last year.
  --Every patient was directed to the appropriate treatment facility 
        for the needed care.
  --And an amazing 100 percent in-transit visibility has been 
        maintained on all patients moved through the TRAC\2\ES system.
    TRAC\2\ES is also de-linked to specific aircraft. This is critical 
to its success, especially during the activation of our Civil Reserve 
Air Fleet or CRAF. The CRAF is comprised of up to 78 commercial 
aircraft--both cargo and passenger--that are provided to the Department 
of Defense by civilian airline companies. We use them to transport 
material and people into the theater of operations. We could also use 
them to potentially evacuate sick or injured troops out of the theater. 
If so, TRAC\2\ES will still function, regardless of the service, 
regardless of the aircraft.
    Patient movement during current operations has incorporated all 
aspects of this continuum: maintenance of health in the field, use of 
organic airlift, versatile equipment support packages, early-on 
critical care intervention, and information systems that track and 
inform leadership of the health and location of their troops.
    From battlefield injury to home station, there is seamless patient 
movement under the umbrella of qualified, capable aircrew members and 
trained critical care professionals.
    I must mention here, that 87 percent of the aeromedical evacuation 
capability I have described resides within the Air Force Reserve 
Command and Air National Guard. These dedicated men and women of these 
organizations are truly our Total Force partners.

Medical Care in Contingencies
    Medical Care in Contingencies, is our fourth core competency and 
one in which we have also seen significant transformation.
    The Air Force Medical Service provides the full spectrum of ground-
based medical care during contingencies. Described as a ``Red Wedge'' 
capability, expeditionary medical care begins with a rapid ramp-up of 
medical capability. First into the field is our small Prevention and 
Aerospace Medicine--or PAM--Team. PAM teams are 2- to 4-person teams 
who are our first-in-and-last-out medics. They are inserted with the 
very first troops and are capable of providing health care, on 
location, before the first tent stake is in the ground.
    Team members include an aerospace medicine physician, 
bioenvironmental engineer, public health officer and an independent 
duty medical technician. They provide initial health threat assessment 
and the surveillance, control, and mitigation of the effects of the 
threat. Additionally, the aerospace medicine physician and independent 
duty medical technician provide primary and emergency medical care and 
limited flight medicine.
    As forces start to build in theater, so does the size of the 
medical contingency. The PAM team is quickly followed by a small but 
exceptionally skilled Mobile Field Surgical Team [MFST].
    This highly trained surgical team includes a general surgeon, an 
orthopedic surgeon, an emergency medical physician and operating room 
staff, including an anesthesia provider and an operating room nurse or 
technician. The 5 team members each carry a 70-pound, specially 
equipped backpack of medical and surgical equipment. Within these few 
backpacks is enough medical equipment to perform 10 emergency, life-or-
limb-saving surgeries without resupply.
    By putting backpack providers deep into the theater or operations 
we save time and we save lives. No longer do we wait for the wounded to 
come to us, we take the surgery to the soldier.
    The MFST's capability has been proven in Operation Enduring 
Freedom. For example, less than one month after Sept. 11, Air Force 
medics assigned to Air Force Special Operations in OEF saved the life 
of an Army sergeant who lost nearly two-thirds of his blood volume when 
he fell and severely damaged his internal pelvic region. Within 
minutes, an Air Force MFST reached him and worked more than four hours 
to stabilize him enough for transportation to a U.S. military medical 
facility.
    A Canadian journalist at Bagram Air Base--not far from Kabul, 
Afghanistan--was horribly injured when a grenade ripped open her side. 
Our medics were there instantly to provide initial stabilization, 
treatment, and her first surgery. Our Aeromedical and CCATT teams 
arranged rapid aeromedical evacuation and provided care in the air. The 
TRAC\2\ES system tracked her movement from Southwest Asia to Europe. It 
provided early warning to the receiving facility of her condition and 
extent of her wounds. When she landed she was met by our medics and 
taken to a military hospital for definitive care.
    Both patients survived. Just a few years ago, before we created 
this capability, both would have died.
    We can provide full spectrum care--anytime--anywhere.
    Expeditionary Medical Support--EMEDS--is the name we give our 
deployed inpatient capability. The small PAM and MFST teams I described 
are the first two building blocks of an EMEDS. To them, we add 17 more 
medical, surgical, and dental personnel. These medics bring with them 
enough tents and supplies to support four inpatient beds. We can keep 
adding people and equipment in increments as needed until we have 
erected a 125-bed field hospital. A unique capability of EMEDS is that 
they are equipped with special liners, ventilation and accessories to 
protect against biological and chemical warfare attacks.
    As an additional measure to defend against these weapons, we field 
Biological Augmentation Teams. They provide advanced diagnostic 
identification to analyze clinical and environmental samples centered 
around RAPIDS, our Rapid Pathogen Identification System. Each team has 
two laboratory personnel who can deploy as a stand-alone team or in 
conjunction with an EMEDS package.
    After our successful deployment of Biological Augmentation Teams to 
New York City in response to the October 2001 anthrax attack, we 
realized just how invaluable these teams were to local public health 
and Centers for Disease Control officials. Since then, we have reached 
a total of 30 fully staffed and equipped teams, and additional 14 
manpower teams designed to backfill or augment the other teams. They 
have been--and continue to be--deployed throughout OPERATION Enduring 
Freedom.
    A common attribute of each medical team I have described is that 
they are small. The Air Force expeditionary medical footprint is 
shrinking. These smaller units can be assembled in increments; 
therefore, are flexible to the base commander's requirements.
    Their small size makes them cheaper, easier, and faster to 
transport. A few years ago we used to talk about how many aircraft we 
needed to move our huge Air Transportable Hospitals into a theater. Now 
we talk about how many pallets we need on an aircraft.
    In just a little over a decade, we have become far more capable 
with fewer people, less size, less weight, less space--and less time.
    This is important. Speed counts. CNN claims it can have a 
journalist anywhere in the world reporting within seven minutes of an 
incident. We may not beat CNN to the scene, but our light, highly-
mobile expeditionary medical support teams will be on the ground 
shortly thereafter--perhaps within as little as three to five hours. 
For any humanitarian or combat contingency, our EMEDS concept is a true 
force multiplier. It gives the combatant commander state-of-the-art, 
worldwide medical care for his deployed forces.
    Our transformation has accelerated the speed with which Air Force 
medics get to where they are needed. Our training programs ensure that 
once they get there, they are fully capable of providing life-saving 
care.
    Two medical training programs are especially crucial to this 
capability; one is our Readiness Skills Verification Program (RSVP).
    Each member of a deploying health care team, whether a physician, 
logistician, administrator or nurse, will be called upon to perform 
numerous tasks in the field, tasks they would never encounter in their 
home-base medical facility. The RSVP ensures these troops train on, and 
master, each of these must-know tasks.
    Our medics practice them routinely. The list is varied: treating 
tropical diseases, linking our computer to foreign networks, using 
ruggedized surgical equipment in field tents--troops must master these 
tasks before their boots touch the ground in a deployed location.
    The other medical training program vital to our expeditionary 
medicine mission is the Center for the Sustainment of Trauma and 
Readiness Skills, or C-STARS.
    Because our military physicians care for arguably the healthiest 
population in the world, the medical problems they see during the 
normal duty day are different from the traumatic and life-threatening 
injuries the providers will encounter in the battlefield.
    To prepare our medics to care for these injuries, we train them in 
one of three C-STARS locations: civilian hospitals in Cincinnati--where 
our Reserve personnel train; St. Louis--where Air National Guard medics 
train; and Baltimore where active duty personnel train. Our staff work 
side-by-side with civilians in these facilities to care for patients 
suffering from knife and gunshot wounds, crushing injuries, and other 
traumatic wounds; the kind of injuries our medics can expect to 
encounter while deployed.
    Hundreds of our medics have trained at C-STARS over the last 2 
years. At one time, more than 75 percent of the Air Force special 
operations medics in Afghanistan received their first ``battle-field 
medicine'' experience at C-STARS, as have all of the CCAT care-in-the-
air teams I mentioned earlier.

Interfacing with World Health
    Our allies and coalition partners around the world are paying close 
attention to these initiatives. They are eager to work with us in 
improving their military medicine programs. This leads me to discuss 
our final core competency, Interfacing with World Health.
    The Department of Defense's Joint Vision 2020 states that today's 
U.S. forces must be prepared to operate with multinational forces, 
government agencies, and international organizations. The Air Force 
International Health Specialist Program fulfills this mission. The 
International Health Specialist program identifies medics with 
specialized language and/or cultural skills, trains these airmen to 
enhance their skills, and provides a database of medics tailor-made for 
specific international missions.
    Active Duty, Air National Guard, and Air Force Reserve 
International Health Specialists regularly interact with the U.S. 
Unified Command Staff, non-governmental agencies, members of foreign 
military units, and interagency personnel. They provide insightful 
recommendations on a variety of issues and situations.
    Whether assisting with blast resuscitation and victim assistance 
missions in Cambodia, conducting on-site capability surveys in Sierra 
Leone and Senegal, or by participating in discussions on international 
humanitarian law, our International Health Specialists are at the 
forefront of global health engagement. Their involvement in host-nation 
exercises and civic assistance activities ensures we are ready to 
deploy assets wherever and whenever needed, and that the Air Force 
Medical Service can effectively engage in multi-national environments.
    Through our Professional Exchange Program, foreign military 
physicians provide care shoulder-to-shoulder with our staff in Air 
Force medical facilities. In addition, our Expanded International 
Military Education and Training Program uses Air Force medics to 
``train the trainers'' of foreign military and civilian medical 
facilities. In the last couple of years we have trained 1,700 
healthcare providers in 18 countries. We share our expertise on how to 
train and prepare for, and react to, medical contingencies. Often, our 
foreign students are receiving such instruction for the very first 
time.
    Ultimately, if a regional contingency does occur, our medics will 
be able to respond to it as one of many partners in a carefully 
orchestrated international coalition of medics.
    To summarize, those are our five core competencies: Population-
based Health Care, Human Performance Enhancement and Sustainment, Fixed 
Wing Aeromedical Evacuation, Medical Care in Contingencies, and 
Interfacing with World Health.

Human Resources
    Our successes in these core competencies could not be accomplished 
were it not for the phenomenal people whom we recruit and maintain 
among our ranks. We know our medics are among the best in their fields. 
For example, the internal medicine program at Wilford Hall Medical 
Center at Lackland AFB, Texas, recently scored third out of 398 
programs nationwide during the Medical Resident in Training 
examinations, placing them in the top 1 percent in the nation. This is 
extremely impressive when one considers we're being compared to medical 
programs such as Harvard's. This is but one example of the caliber of 
our nearly 45,500 Active Duty and Reserve Component medical personnel. 
This number includes more nearly 1,400 dentists, 5,000 physicians, and 
7,000 nurses. However, attracting and keeping these troops is 
difficult. We seek only the most educated and dedicated nurses, 
physicians, and dentists. Obviously, those attributes are also highly 
sought by civilian health care organizations.
    The Air Force offers these young professionals a career of great 
self-fulfillment, awesome responsibility, and excitement. The civilian 
market offers these incentives, too, but in many cases--in most cases--
provides a far more attractive financial compensation. Furthermore, the 
life and family of a civilian provider is not interrupted by 
deployments--something our troops are experiencing at a frequency not 
seen since World War II.
    These deployments are a burden to our active and reserve forces. I 
am keenly aware of the elevated use of our Air Reserve Component over 
the last decade, and the difficulties deployments create for their 
family and work lives. My staff does their utmost to only use ARC 
forces on voluntary status, to activate them for the shortest time 
possible, and to call upon their services only when other options are 
not available.
    However, it is for these reasons--the lure of more attractive 
civilian compensation and the frequent deployments--that we find it 
difficult to attract the kind of medical professionals we badly need.
    For instance, our fiscal year 2002 recruiting goal was to acquire 
over 300 fully trained physicians--we recruited 41. We required 150 new 
dentists--we recruited 39. Nurses, we needed nearly 400--we recruited 
228.
    Fortunately, last year's National Defense Authorization Act permits 
increased compensation for these skills. It allows for loan repayment, 
increased accession bonuses and specialty pay. I thank you for 
providing these incentives. They are very useful tools and a good start 
toward obtaining the quality and quantity of medical professionals we 
so urgently need.

Conclusion
    In conclusion, I am incredibly proud of our Air Force medics and 
honored to lead them. Each of these five core competencies demonstrates 
how far the Air Force Medical Service has transformed since the fall of 
the Berlin Wall, especially in the last five years. We will continue to 
anticipate the challenges of tomorrow to meet them effectively.
    We are very proud to have a leading role in support of our 
expeditionary Air Force. As the U.S. Air Force focuses more and more on 
improved effects, we are in lockstep with the line in our ability to 
provide the right care at the right time with the right capability. We 
remain at the right shoulder of war fighters, at home base to provide 
for a healthy workplace and home, and in the field to keep war fighters 
protected and at the peak of their mental and physical capabilities.
    We thank you for the critical support you provide that makes this 
possible.

    Senator Stevens. Senator Inouye, you heard most of the 
testimony. Would you like to ask questions first?
    Senator Inouye. I thank you very much, Mr. Chairman. Before 
I proceed with my questions, I'd like to make four 
observations. Whenever a military person is wounded on the 
field or on a ship or in the air, I believe the first person he 
calls for is a medic or corpsman. That was my experience. No 
one called for his wife, but they called for a medic.
    Secondly, whenever the chairman and I have visited bases 
and camps, met with enlisted personnel and officers, the first 
question or the bulk of the questions asked refer to health 
care for dependents. In fact, very few have ever touched upon 
pay raises. It is always on health care for my kids or my wife.
    Third, it is obvious that morale depends upon the level of 
care that the personnel, their spouses, and their children 
receive.
    And fourth, this is a personal matter, but I say it in 
looking over the citations of medals for high bravery, 
especially for medals of honor. This is a common phrase, he 
killed 25, captured 18. Medics do not kill or capture. As a 
result, medals of courage for medics are very, very rare, and I 
think something should be done with that because if you ask any 
infantrymen or any Marine who will tell you that the bravest of 
them all are the medics or the corpsmen. And somehow, our award 
giving system does not cover that.

                        INCREASED MEDICAL COSTS

    And so with my question, I have a general question for all 
three of you. Since 9-11 the military has been taxed with 
additional missions both here and abroad. You have cited all of 
them. Each additional requirement results in increased medical 
costs, which are not always accounted for in the budget or 
fully covered in the supplemental request. The monitoring of 
our personnel before, during and after they are deployed is a 
result of the lessons learned after the Gulf War.
    Additionally, costs increased to backfill deployed medical 
personnel, handle casualties of war, and treat personnel in 
theater and at home. With our continued involvement in these 
missions in the upcoming fiscal year, I'd like to hear from the 
services on how they are executing fiscal year 2003 and what 
they anticipate for the next fiscal year 2004.

                        MEDICAL BUDGET SHORTFALL

    And my question will be for the services, will your 
services have sufficient funds to execute fiscal year 2003 and 
do you anticipate any budget shortfalls in fiscal year 2004? 
Are there ways to address the potential shortfall in fiscal 
year 2004?
    Because I'm certain all of us realize that we will be 
involved in the continuous global war on terrorism, not for the 
next 6 months, not for the next 6 years but much more than 
that. So with that in mind, General Peake?
    General Peake. Well, sir, first I would like to thank the 
committee for the help with the supplement that is working its 
way to us now and the $501 million that was designated for the 
Defense health program with the comments that need to get 
focused down to the direct care system.
    We haven't seen yet the amounts that will come down to us. 
It is clearly needed because we have been forward funding the 
effort that you have described, sir, from opening places like 
Fort McCoy and Fort Dix, where we do not necessarily have a 
presence yet, mobilizing soldiers, purchasing their 
prescriptions, providing them their glasses, all of those 
things to make them ready medically to go with the force.
    We have deployed in the Army now about 3,471 professional 
fillers out of the day-to-day health care environment into the 
hospitals that are in Iraq and into the brigades and battalions 
of our Army to provide them with medical support. And those 
people we have backfilled partially with reservists. They are 
terribly important to us. But others we have had to reach out 
and contract.
    Those numbers we are trying to do good accounting for and 
we look forward to the moneys coming out of the supplement to 
help us to defray those costs so that we, because what we had 
borrowed from is the day-to-day health care operations that go 
on in our large organization, that deliver health care to 
families and soldiers and so forth. We also have family members 
coming in from the Reserves who now are TRICARE eligible and we 
have an obligation to provide them quality care as well.
    So from the, from the global war on terrorism, aspects of 
it, sir, we are looking to see the money that gets to us from 
the supplement and there may or may not be more required to 
cover just that particular aspect for fiscal year 2003.
    Regarding fiscal year 2003, I am leveraging potential money 
in our maintenance accounts to be able to ensure that we are 
covering the health care that we are, should be doing at the 
quality we should be doing it for our full regular mission. I 
would tell you, sir, we are busier than just Iraq. We have 
Afghanistan going. We have people in Colombia, the Philippines, 
Honduras and Bosnia and a Kosovo mission as well. So it is a 
very, very busy military and therefore very busy medical 
structure as well.
    With all of that activity, it creates a bit of a unsettling 
of our business process so we really do have additional 
expenses that come up. This is a new expense that will have to 
be accounted for that is not yet accounted for.
    As we look to 2004, we will be redeploying our forces. As 
you say, sir, we will still have people deployed doing the 
variety of missions that go along with the post-Iraq business 
as well as the other areas that I have spoken about.
    We will have to face what potentially happens with the 
retention of our soldiers and so forth, which always creates a 
bit of a turmoil when folks start to return and readjust their 
lives and so forth. Right now, we are, we use the civilian care 
and we hire other professionals and nurses, as an example, to 
come and work in our hospitals to make up that delta, so we can 
continue the missions in our military hospitals. So those 
become the kind of bills that we will be facing in fiscal year 
2004 as well.
    In addition, we are doing the next contracts. There are a 
variety of things like appointing and utilization management 
that come back to the military treatment facilities instead of 
at the contractor level, and we will have to figure out how 
much that is going to cost us to get those things restarted 
within our own organizations.
    In the long run, we think it is absolutely the right thing 
to do, but there may be some startup costs that will have to be 
identified, and we are looking at that as well for 2004.
    Admiral Cowan. Sir, I will try to answer your question with 
a little different approach. Both fiscal year 2002 and fiscal 
year 2003, Navy medicine has been funded adequately. We are 
often asked are you fully funded and we say we are adequately 
funded. We have enough money to get properly through the year 
to execute our mission and to not require either supplementals 
or reprogramming.
    At an adequate funding level, we are sustainable for a long 
period of time, but we do not get at our backlog of military 
construction, repair, investment, capital investment, new 
equipment and so on. In fact, we may at this level be getting 
slightly behind. The newest building in which health care is 
delivered in Guam was built in 1952.
    The budget that we submitted for fiscal year 2004 will also 
be adequately funding. We are comfortable operating in the 
fiscal year 2004 time frame. This part of my answer is for the 
known mission of the health care to our beneficiaries.
    The second part of your question is the unknown missions, 
the ones that we have been involved with, both Iraq and 
Afghanistan, as well as the others that General Peake 
mentioned, and others that may come in the future.
    That is a harder question for us to answer. For example, 
right now, I would not be able to tell you the cost of the 
medical care caused by the Iraq war because much of that has 
been moved into our TRICARE networks and purchased care and we 
won't even see those bills for another 120 days.
    So, we are working with the TRICARE partners to normalize 
and make as much of the health care delivery as routine as we 
possibly can, as we go through these iterations of deployments. 
But to say that we are, can predict a budget for operational 
issues is not something I would be comfortable with right now.
    Senator Inouye. General Taylor?
    General Taylor. Senator, I wanted to say first of all, I 
would be glad to mount up with you on that charge for 
recognizing the medics who are in harm's way and are doing a 
great job for our Nation. I think all three of us would be more 
than happy to get on our steeds and mount that charge with you.
    In terms of fiscal year 2003, due to your great efforts 
through the supplemental, the Air Force is very comfortable 
that we are going to get through this year in good stead.
    In terms of next year for what we budgeted and what Health 
Affairs submitted for us through the President's budget, we are 
pretty comfortable. As Admiral Cowan said we are adequately 
funded. There is no provision in there for additional costs for 
the global war on terrorism. If we have Reservists and National 
Guard who remain activated into the next fiscal year, we have 
to account for their costs.
    We have done a very good job I think over the last few 
months of capturing all of the additional costs that go with a 
forward deployed force, and we are pretty comfortable we have 
been able to identify those costs to the Department. There is 
great uncertainty as the next generation TRICARE contracts come 
in, for instance, what kind of immediate resources we will have 
to use within the services to help bridge any gaps that occur 
as we move from one contract to the other.
    And finally, I believe that the optimization funds that are 
provided have been a Godsend in terms of giving us venture 
capital to allow each of us to increase the amount of care we 
deliver in the direct care system, generating dollars for the 
pennies invested and giving us that capability.
    So in summary, I think the Air Force Medical Service is in 
a solid state for the rest of this year and as budgeted for 
fiscal year 2004.

                        RECRUITING AND RETENTION

    Senator Inouye. A bit more specifically, do you have any 
problems in recruiting and retention, and if so, what areas of 
concerns do you have on specialties?
    General Peake. Sir, I think it is a concern for us, and we 
had good success with critical skills retention bonuses that 
we, each of our services funded for us this last year that we 
do not have. It is not a programmed payment. But we have, in 
terms of a net loss of physicians last year between 2002 and 
2003 was 43 and you say that is not that many, but when you 
start looking at them, 17 of them were anesthesiologists, 17 
radiologists. That becomes very expensive.
    We are looking to get a change in our benefit in terms of 
the bonus packages for physicians to be able to recruit better. 
We are, and I think that that is going to be an important thing 
for us to follow through on over the course of this year.
    Nursing is also a shortage for us, and I think we will hear 
about that on the next panel more expansively, that they are 
absolutely critical for our ability for us to do our business. 
We have had the direct hire authority to be able to hire 
civilian nurses and that's been really a big plus for us to be 
able to go out and quickly hire folks and we would, we need to 
have that authority continued.
    Admiral Cowan. Sir, we have shortages in each of the corps. 
In the medical corps we have traditional shortages, and those 
specialties that you would expect to have shortages because of 
pay discrepancies between the civilian and military world.
    Unfortunately, many of those tend to be wartime 
specialties, trauma surgeons, anesthesiologists and the like, 
and they frequently run in the 80 percent range. We are right 
in the process of undertaking some initiatives to get at that. 
We think there are two ways to improve those numbers.
    One is through changing the bonus structure for those 
particular specialties, and the other is providing other 
nonmonetary incentives for people to come in and serve in 
various roles, both active duty and Reserves, providing a 
variety of incentives that we do not have now, particularly in 
Reserves.
    We have a particular problem in the dental corps among 
young dental officers who accrue large personal debts because 
of the equipment that they have to buy to get through dental 
school and the pay differences between civilian practices and 
the military makes it uncomfortable for them to be financially 
stable in the military. And we have similar problems with 
health care providers in the medical service corps such as 
podiatrists who have large debts and find military service 
financially unattractive.
    We are understaffed in some areas in the hospital corps, 
and again looking to new programs and incentives that will move 
corpsmen into those critical specialties.
    Senator Inouye. Are those shortfalls occurring right now?
    Admiral Cowan. Sir, the shortfalls in the medical field 
have been chronic for many years.
    Senator Inouye. And the anesthesiologists?
    Admiral Cowan. Yes, sir.
    Senator Inouye. You do not have enough?
    Admiral Cowan. No, sir. We do have enough, but we do not 
have everybody back home. So if we went to two full wars at the 
same time, it would be very difficult for us to populate all 
those billets that we need.
    General Taylor. Very similar in the Air Force. One story is 
that last summer we had 39 internal medicine physicians who 
were eligible to leave the service and 38 of them did. There 
are pay issues in terms of improving pay. We have great 
authorities to increase pay. We are working diligently to get 
the funds to match that capability and flexibility.
    But it is not only specialty pay and loan repayment plans, 
it is the environment of work, and all three of us are working 
very hard to enhance the capabilities of our direct care system 
facilities, equipment, and staffing to enable all specialties 
from dental care to nursing corps to podiatrists to 
anesthesiologists to be able to practice the full spectrum of 
their capability.
    The money has been important to the Air Force as we try to 
bridge the gap that exists between the staffing we should have 
and the staffing that we actually have.
    We are going to have some terrible shortages in radiology 
coming up in the next 2 or 3 years. We have a terrible problem 
with anesthesia, and a 50 or 60 percent staffing range in 
internal medicine. Those are difficulties that we can contract 
in for if we can get the funds freed up. That's why the 
TRICARE-Nex program will lift those funds in the local group, 
and that optimization money gives us that venture capital to 
cover.
    So those are two important parts. It is not just specialty 
pay and loan repayment. It is the environment of care that will 
help greatly in recruiting and retaining wonderful people.
    Senator Inouye. I have a few other questions, Mr. Chairman.

                         STUDENT LOAN REPAYMENT

    Senator Stevens. Thank you very much. I will submit some 
questions for the record in view of the time frames. I am 
interested, though, in that line of questions Senator Inouye 
asked.
    In terms of the debts that your professionals have as they 
come into the service, do you have the system that we have here 
that we can pay a portion of the debts for each year that they 
serve, the debts they come to Government with from school, 
student loans? Are you paying off student loans for those who 
went to school when they joined the services?
    Admiral Cowan. Yes, sir. The way the Navy accesses 
physicians, we get about 300 a year through either scholarships 
or paying back, helping them pay their medical school debts. We 
get about another 50 through the Uniformed Service University 
and we get a handful through direct accession.
    We have similar programs for the dental corps and nurse 
corps, and in the nurse corps we have a very good incentive 
program that sends them along pending successful careers into 
master's and even Ph.D. programs as a part of their 
professional development.
    Our abilities, for example, to pay for the dentist's debt 
is, however, limited and because of changes in the way dental 
education has occurred, we now find ourselves at a competitive 
disadvantage.
    Senator Stevens. We will be glad to hear some of the 
problems you have encountered and see if funding is any part of 
the problem.
    Admiral Cowan. Sir, that would be very kind of you.
    Senator Stevens. Particularly where we have a situation 
where people who are called up, for instance, we ought to find 
some way to take on that, those debt repayments while they are 
on the service. I'm talking reservists. They have substantial 
burdens that we have discovered in this last call-up period.
    I'm sure Senator Inouye and I would like to pursue that, 
but we would be pleased to have you help us with some 
suggestions that you might have about how we can have a call up 
bonus, termination, a bonus on return to civilian life, but 
somehow reflect the costs that they have incurred by coming 
back in. The Reserve is a very important part of our medical 
services now.

                      MEDICAL COMBAT TECHNOLOGIES

    Secondly, I would like to ask, we spend a lot of time 
trying to help finance development of new systems of care for 
those who are critically wounded, right at the point nearest to 
the point of injury, so that during the period of 
transportation to a permanent care facility, they could receive 
the best care possible. Were any of those new technologies 
utilized in this recent Iraqi conflict?
    General Peake. Yes, sir. There were three different types 
of hemostatic dressings that were quickly pulled off the shelf, 
some out of the research base to be applied. Admiral Cowan 
talked about Quick Clot. Chitosan dressing was also purchased 
and investigational new drug fibrin dressing was provided to 
the special operations units as well.
    Senator Stevens. We had a description once of a possibility 
of developing a chair with diagnostic capability within 90 
seconds of determining the extent of critical harm to that 
person, in order that they might be instantly treated. Were any 
of those facilities, were any of those type of facilities 
utilized in this recent conflict?
    General Peake. Sir, this was some life support trauma and 
transport system forward with a mini intensive care unit with a 
stretcher with the built-ins, which I think you are referring 
to. There were folks treated on it. We are getting ready to 
send a team in for clinical after action lessons learned 
findings, and those are the kinds of things that are going to 
be looked at.
    We had the UH60 Lima helicopters were deployed for the 
first time in the theater with the forward looking infrared 
radar with the patient care capacity in the back that really 
allows you to work on a patient, and that's the first time we 
have had that asset. We are really looking forward to hearing 
the after action reviews on how well all of that worked, and 
the glass cockpit for aviation.
    Senator Stevens. Well, I do hope if you will convene sort 
of a symposium of medics who were there and try to get from 
them, what didn't you have? What could you have used? What type 
of procedures or particularly support concepts did you feel you 
needed, but did not have?
    We have to really investigate support right now for 
military and Defense appropriations. If history repeats itself, 
it is going to go away fairly soon, and we will be back to 
battling to get just the moneys that are necessary to continue 
basic support of the military.
    This is the time to fund the innovations that we proffered 
from the lessons we learned in Iraq, so I hope that you will 
move quickly, move very quickly to determine that. I have heard 
my good friend's comments about his four points, and he is 
absolutely right about the medics. That the difference is right 
now, with embedded journalism and cell phones, I think the 
world and families and everyone were contacted quicker, and 
this was more real exposure to what was going on in Iraq than 
any war in history. And that will only continue to expand.
    So I think that the comments that we have heard, at least 
that I have heard, at least from those people who were embedded 
journalists, was nothing but praise for your people and for the 
medics of this period. I certainly will join Senator Inouye, 
and I thank you all in trying to see to it that there is more 
recognition and valor for those people who were right there 
with the combat forces.
    I think we have to do something more than that, in terms of 
recognition for the future, and again, I think we would like to 
sit down with you all and talk about that. In terms of not only 
recognition for exceptional service and valor, but recognition 
for commitment. I think it takes a special person to be a 
combat medic. We both had experience on that. In our days, 
things were a lot simpler than they are now, and I think the 
stress on these medics must be extreme. Very much extreme.
    I would like us to consider spatial periods of readjustment 
for those medics and have some concept of rest and relaxation 
(R&R) that are built in to give people incentive to want to be 
medics in combat periods. But I commend you for what you are 
doing and hope you will follow through. I do not want to get 
too--our period up here is not going to be that much longer.
    I'm not sure how many wars we are going to sit through. We 
have sat through, in the last past 35 years, all of them. But 
we had eight wars so far. That ought to be a record for people 
on this committee. We want to make sure that we, on our watch, 
do everything we possibly can to make certain that the next one 
is handled even better than this one. This one has been handled 
exceptionally well.
    I agree with you about the comment you made about the young 
soldier who lost his foot. The difference between this 
generation and ours is a majority of ours was drafted. This was 
a volunteer.
    Admiral Cowan. Sir, one of the most inspiring things I have 
seen ever is listening to the Marines and corpsmen at the 
hospital. The corpsmen will only talk about the Marines that 
they feel responsible for and the Marines will only talk about 
the corpsmen who they think saved their lives.
    Senator Stevens. Any other questions, sir?

                             MENTAL HEALTH

    Senator Inouye. Just one question. A few days ago, I was 
watching the networks as most Americans do. And this network 
spent about half an hour covering an activity with the Marines, 
and I suppose he said that it covers all services. All of the 
men who were scheduled for deployment back to the United States 
were undergoing some psychiatric exercise. Is that the usual 
practice?
    General Peake. Sir, I think maybe it was referring to the 
combat stress debriefing business which we, I think, we all 
have sort of embraced the notion that you want to get folks 
able to talk about in a structured environment, the kind of 
trauma that they may have experienced or seen or been involved 
with.
    As we do the post deployment screening, we expanded the 
format, as some questions that apply to mental health to try to 
get at somebody who is having a particular problem.
    We will be doing an extensive post deployment screening 
process as every one of our soldiers, sailors, airmen come 
back. We will then score that centrally, be able to compare it 
against their predeployment screening, so what we want to do is 
identify those that might need additional help or need 
additional follow up, and so I think we are all planning on 
being a part of that kind of thing, but there is really two 
different pieces to it.
    Admiral Cowan. Sir, exactly the same way we have found over 
the years that people subjected to psychological trauma who sit 
with the others who they went through that with and talk 
through their feelings have good health outcomes, and the 
number of people who end up with post traumatic stress syndrome 
and these sorts of things goes way down, so all three services 
do that extensively.
    General Taylor. That's exactly right. The lessons we have 
learned over the last 100 years in mental health is to treat as 
far forward as you can with your peers. That's exactly what 
each of the services does. We feel, as the other services do, 
that these stress teams are a necessity in all major locations 
and must interact with troops on a daily basis. This is an 
ongoing process for all of us.
    General Peake. If I could add a follow-on, sir, in terms of 
this notion being an ongoing process. That's something 
important and something we in the Army are wrestling with now.
    The Coast Guard has had an employee assistance program 
independent of the medical that offers counseling and family 
counseling and those kinds of things without a ``medical 
statement'' or ``medical record.'' I think that's something we 
do not have in our budget that is something we really need to 
take on and be able to expand and get support for.
    As part of the larger holistic approach was, as you point 
out, sir, this global war on terrorism doesn't stop with Iraq. 
This is going to be an ongoing level of activity for us, and a 
level of stress for our families and our service members, and 
that kind of support will be important for us in the future, 
sir.
    Senator Inouye. I'm glad you are doing that because in war, 
mental illness or mental health is considered a stigma and 
Section 8, so no one talked about it. We just assumed that 
everything was fine. But reality tells us that there are 
psychiatric problems, and I'm glad you are doing that. Mr. 
Chairman, I have many other questions I would like to submit 
for the record.
    Senator Stevens. Yes, sir. We will submit some questions 
for each of you, if you will, and what Senator Inouye said, 
again, I really think if we look back over the years, the 
people who were not really compelled to talk about the problems 
right from the start were the ones that had the greatest 
problems.
    I urge you to think about that, along with we ought to have 
a psychological advisor right there. It will work much better 
in the long run. Thank you all very much. We appreciate what 
you are doing. I hope you'll on behalf of all of us here 
congratulate all of the people for the wonderful job they have 
done under our flag. Thank you very much.
    We are now going to hear from the chiefs of the service 
nursing corps. This committee's views on this is critical to 
our future. We will here from the Army, General William T. 
Bester, Chief of the Army Nurse Corps. We thank you very much 
for the service to the Army and our country. We welcome Admiral 
Nancy Lescavage, Director of the Navy Nurse Corps, and it is 
really a great pleasure to have you with us again, Admiral. We 
will proceed with General Bester, since this is his last 
appearance on our watch.
STATEMENT OF BRIGADIER GENERAL WILLIAM T. BESTER, 
            CHIEF, ARMY NURSE CORPS
    General Bester. Thank you, Mr. Chairman. Senator. Thank you 
for this opportunity to provide you an update on this state of 
the Army Nurse Corps. During the past year the Army Nurse Corps 
has again demonstrated our flexibility and determination to 
remain ready to serve this great Nation during a very 
challenging time in our history.
    Senator Stevens. Let me first, if I may, rearrange your 
testimony. Welcome, General Barbara Brannon, Assistant Surgeon 
General for Air Force Nursing Services. We welcome you back and 
apologize to you for not turning the page. General.
    General Bester. Mr. Chairman, what we ask of and receive 
from our nurses in today's uncertain world is nothing short of 
amazing. I'd like to begin by telling you what Army nurses are 
doing at this very minute in places and under conditions as 
austere as soldiers in this country have ever experienced.
    In Iraq and Kuwait, Army nurses have been moving forward 
with the operational flow, saving lives and treating the 
wounded as they do so. Army nurses are integral to the success 
of each and every forward surgical team, Mobile Army Surgical 
Hospital (MASH) and combat support hospital in the theater.
    And as we sit here today, nearly 2,500 active and Reserve 
component Army nurses have or are currently deployed, with time 
away from home exceeding last year's level by sixfold. These 
are selfless dedicated Army nurses who are proud to serve this 
country of ours and to care for our most precious resource, the 
American soldier.
    I'd like to highlight some of the units currently on the 
ground supporting Operation Iraqi Freedom, the fine soldiers of 
the 86th Combat Support Hospital from Fort Campbell, Kentucky 
are providing far forward medical care. We have watched them 
perform their expert skills on the television, and we have read 
about them in the newspapers. Hundreds of patients have 
benefited from their presence, although the full impact of 
their support will not be fully appreciated until the conflict 
ends.
    The 212th MASH from Miesau, Germany initially deployed to 
Kuwait is now providing the highly mobile surgical care needed 
for Operation Iraqi Freedom. This is the last MASH unit left in 
the Army inventory and is again demonstrating the needs for 
flexible, rapid and mobile medical surgical assets.
    Our Reserve component colleagues have stepped to the plate 
to support current operations. The 396th Combat Support 
Hospital out of Vancouver and Spokane, Washington activated on 
January 25 and moved to Fort Lewis, Washington in a matter of 3 
days. Scheduled to be part of the contingent that was to go 
into Turkey, this unit has remained stateside and is now 
integral to the manning requirements of Madigan Army Medical 
Center.
    The personnel of the 396th that performed over 400 surgical 
cases and are providing expert care in in-patient and 
outpatient critical care units, thereby allowing Madigan to 
maintain a high level of operation, in spite of significant 
personnel losses to deployment. The men and women of the 396th 
are just another example of extreme importance of active and 
Reserve integration.
    Army Nurse Corps officers are providing care for our combat 
casualties throughout the entire continuum of care. As I 
pointed out earlier, nurses are far forward in order to quickly 
receive an ill or injured soldier. Our nurses at the higher 
level care facilities in Europe and in the United States are 
ready and waiting to provide the care needed once a combat 
casualty is stabilized for movement.
    At Landstuhl Army Medical Center in Germany, nurses are 
providing critical care for soldiers such as PFC Jessica Lynch. 
Nurse case managers have been manning the Deployed Warrior 
Management Control Center since Afghanistan and are now in full 
operation during Operation Iraqi Freedom. This center was 
established to enhance case management of any casualty from 
their initial injury in theater through his or her return to 
the United States and has facilitated the coordination of care 
amongst all three services.
    Army nurses are also proud to be an integral part of the 
transformation of the new 91 Whiskey health care specialist, 
our combat medic.
    We are embedded in the training unit as leaders and 
educators and positively impact on sustainment training of this 
critical military occupational specialty at every medical 
treatment facility. I'd also like to commend one of our 
outstanding young Army nurses, Captain Timothy Hudson, the 
recipient of the 2002 White House Military Office Outstanding 
Member of the Year award for a company of great officers.
    Clearly, Senators, Army nurses are at the forefront of 
caring and are responding with excellence to the needs of those 
all the way from the President of the United States to our 
great soldiers and their families and our very deserving 
retirees around the world.
    On the recruiting front, we continue to struggle with our 
recruitment of nurses to support today's health care needs and 
the needs of the Army in the years to come. The affect of the 
national nursing shortage continues to affect our ability to 
attract and maintain quality nurses.
    We are still below our budgeted end strength of 3,381, but 
are actively pursuing incentives to counteract this shortfall 
and promote the force in our years to come. As a direct result 
of the 2003 National Defense Authorization Act, we are actively 
pursuing an increase in the accession bonus beginning in fiscal 
year 2005.
    This spring we plan to implement the health professional's 
loan repayment program for both newly recruited nurses as well 
as our cornerstone company grade officers who are serving in 
their first 8 years of commissioned service.
    Understanding the great potential of our enlisted soldiers 
to serve as commissioned officers, we continue to sponsor 
dozens each year to complete their nursing education to become 
Registered Nurses (RN) and subsequently Army Nurse Corps 
officers via the Army Enlisted Commissioning Program.
    We are very proud of these successes, yet we will continue 
to pursue all recruiting and retention avenues in order to 
secure more long-term stability in our manning posture.
    Sir, the general referred earlier this afternoon to our 
civilian nurses and they now comprise about 60 percent of our 
total nurse work force and are clearly key to our nursing care 
delivery in the medical treatment facilities. I'm pleased to 
tell you, Senator, in fiscal year 2002, we achieved an 89 
percent fill rate of documented civilian Licensed Practical 
Nurse (LPN) positions. This is an increase of 7 percent and 13 
percent, respectively, from last year.
    In the direct hire authority that the Surgeon General 
talked about earlier, granted to us by Congress, has 
dramatically reduced the length of time it takes from 
recruitment to first day of work from 111 days to a remarkable 
23 days for Registered Nurses. This has resulted in a 50 
percent reduction of unfilled RN positions in our facilities.
    Clearly, we need to continue this approach to civilian RN 
recruitment and we will continue to seek expansion of this 
authority to include LPNs and legislative approval that makes 
direct hire authority permanent.
    Although many of our nurses are deployed or dedicating the 
majority of their time to the support of the global war on 
terrorism, nurses are still actively engaged in other nursing 
activities such as research and education.
    I want to offer my thanks and appreciation to this 
committee for the continued steadfast support of the TriService 
Nursing Research Program (TSNRP). Since 1992, TSNRP has funded 
230 research proposals that have resulted in continued advances 
in nursing practice for the benefit of our soldiers and for 
their family members and for our great retirees.
    I would also like to extend my appreciation to the 
Uniformed Services University of the Health Sciences for their 
continued flexibility and support of the Advanced Practice 
nurses. Adeptly responding to the needs of Federal nursing, 
they have established perioperative nursing as well as a 
doctoral program in nursing, with the first candidates for 
study in each of these programs to begin this summer.
    Our continued partnership is key to maintaining sufficient 
numbers of professional practitioners necessary to support our 
mission. Finally, Senators, the Army Nurse Corps once again 
reaffirms its commitment to recognizing the Bachelor of Science 
degree in nursing as the minimum educational requirement and 
basic entry level for professional nursing practice.

                           PREPARED STATEMENT

    In closing, I assure you that the Army Nurse Corps is 
comprised of professional leaders who are totally committed to 
providing expert nursing care. It has been my honor and it has 
truly been my privilege to lead such a tremendous organization. 
Thank you for this opportunity to present the extraordinary 
contribution made by today's Army nurses.
    [The statement follows:]

       Prepared Statement of Brigadier General William T. Bester

    Mr. Chairman and distinguished members of the committee, I am 
Brigadier General William T. Bester, Commanding General, United States 
Army Center for Health Promotion and Preventive Medicine and Chief, 
Army Nurse Corps. Thank you for this opportunity to update you on the 
state of the Army Nurse Corps. In the past year, the Army Nurse Corps 
has again demonstrated our flexibility and determination to remain 
ready to serve our great Nation during challenging and difficult times.
    The effects of the National nursing shortage continue to impact the 
ability of the Army Nurse Corps to attract and retain nurses. The 
decline in nursing school enrollments over the past several years, 
coupled with the increasing average age of a registered nurse, clearly 
dictate the need to focus recruitment and retention efforts towards 
enhancing the image of nursing as a worthwhile and rewarding long-term 
career choice. We are encouraged by the fact that for the first time in 
over six years, enrollment in baccalaureate nursing programs in 2001 
increased. However, since education resources are limited, there is 
still a need for such initiatives as the Nurse Reinvestment Act and we 
applaud the support that you have provided towards this effort. It will 
be critical that we continue to develop programs of this magnitude.
    We are well aware of the impact that the decreased nursing 
personnel pool has had on our civilian nurse recruitment and retention. 
Civilian nurses now comprise over 60 percent of our total nurse 
workforce and we have worked diligently to streamline hiring practices, 
improve compensation packages and enhance professional growth and 
development in order to attract the types of nurses who will commit to 
the military healthcare system. I am pleased to report to you that we 
have experienced some success in our civilian recruitment actions over 
the past year. In fiscal year 2002, we achieved an 89 percent fill rate 
of documented civilian Registered Nurse positions and an 83 percent 
fill rate of documented civilian Licensed Practical Nurse positions. 
This is an increase of 7 percent and 13 percent, respectively, from the 
previous year. The Direct Hire Authority granted to us has dramatically 
reduced the length of time it takes from recruitment to first day of 
work from 111 days to a remarkable 23 days for Registered Nurses. This 
initiative has resulted in a 50 percent reduction of unfilled RN 
positions in our Medical Treatment Facilities. Clearly, we need to 
continue this type of long-term approach to civilian RN recruitment.
    The Army Nurse Corps is actively engaged in a DOD effort to 
simplify and streamline civilian personnel requirements. The intent is 
to recruit, compensate, and promote civilian nursing personnel with the 
flexibility necessary to respond to the rapidly changing civilian 
market. We have clearly identified our needs related to the payment of 
these greatly needed premium, on-call, overtime and Baylor Plan pay 
strategies and are very ready to implement these strategies when the 
Defense Finance Accounting Service (DFAS) support is available. In 
addition, we are progressing with the clinical education template 
currently required in the legislation in order to ensure consistency of 
hiring practices. We strongly value continuing professional development 
of our civilian nurse workforce and are reenergizing our already 
established Civilian Nurse Tuition Assistance Program to enhance 
retention and symbolize our trust in the civilian nurse workforce 
abilities and commitment to taking care of soldiers. We firmly believe 
that enhancing job opportunities for our military family members is 
consistent with the Army's overall goal to support the well being of 
our soldiers and families.
    We are also well aware of the impact of the decreased nursing pool 
on our military nurse recruiting efforts. The Army Nurse Corps is still 
below our budgeted end-strength of 3,381. We ended fiscal year 2002 at 
a strength of 3,152, a deficit of 229. We have taken aggressive 
measures to strengthen our position in both the Army Reserve Officer 
Training Corps (AROTC) and U.S. Army Recruiting Command (USAREC) 
recruiting markets. We have re-established targets in the AROTC program 
and expanded school participation in our AROTC scholarship program by 
four-fold. As a direct result of the 2003 National Defense 
Authorization Act, we are actively pursuing an increase in the 
accession bonus beginning in fiscal year 2005. This year, we were 
successful in offering a Critical Skills Retention Bonus (CSRB) to 54 
percent of our Nurse Anesthetists and 76 percent of our Operating Room 
nurses. This spring, we are implementing the Health Professions Loan 
Repayment Program (HPLRP) for newly recruited nurses as well as to our 
cornerstone company grade Army Nurse Corps officers who are serving in 
their first eight years of commissioned service. The HPLRP and 
accession programs, in conjunction with our already established and 
robust professional and clinical education programs, will allow us to 
consistently reinforce the value of our Army Nurses through the 
critical early career timeframe. Finally, we have been extremely 
successful in providing a solid progression program for our enlisted 
personnel to obtain their baccalaureate nursing degree through the Army 
Enlisted Commissioning Program. This year alone, we will sponsor 85 
enlisted soldiers to complete their nursing education to become 
Registered Nurses and subsequently, Army Nurse Corps officers. Since 
last year, we have increased the number of available slots for soldiers 
qualified for this program by 30, a 55 percent increase. I want to 
emphasize that this program provides us with nurses who already possess 
the strong soldiering and leadership skills that we foster and desire 
in Army Nurses.
    Retention of our junior nurses is extremely important to us. We 
continue to closely monitor the primary reasons that our company grade 
officers leave the Service and have determined that the reasons are 
primarily related to quality of life, work schedules and compensation. 
We have taken this feedback and used it as the basis to address the 
focus of our senior leadership efforts at the local level. Compensation 
strategies such as the Critical Skills Retention Bonus (CSRB) and the 
Health Professions Loan Repayment Program (HPLRP) have been paramount 
in our effort to recognize individuals for their tremendous efforts and 
sacrifices. The Army Nurse Corps continues to sponsor significant 
numbers of nurses each year to pursue advanced nursing education in a 
variety of specialty courses as well as in masters and doctoral 
programs. We are all working to improve the practice environment, 
foster mentoring relationships, and ensure equitable distribution of 
the workload among our nurses. We intend to aggressively capitalize on 
all financial, educational and benefit packages available to recruit 
and retain dedicated officers.
    The Army Nurse Corps continues to answer the call to support the 
Nation's War on Terrorism as well as other contingency missions. In 
fiscal year 2002, 1,001 Army Nurses deployed to over 20 countries 
totaling 25,133 man-days. Since October 2002, the deployment pace is 
swifter than ever, with 1,162 Army Nurses deployed totaling 80,083 man-
days. Our nurses continue to provide expert nursing care on Forward 
Surgical Teams (FSTs), which provide far forward immediate surgery 
capability that enables patients to withstand further evacuation to 
more definitive care. Currently, nurses are deployed in multiple FSTs 
in support of Operation Enduring Freedom, Operation Iraqi Freedom, and 
other missions worldwide. The 250th FST was the first to deploy to 
Kandahar, Afghanistan in direct support of the Combined Special 
Operations Task Force South-Forward and executed medical operations 
under the most austere combat conditions. The 274th FST provided 
surgical coverage of northern Afghanistan and provided care to more 
than 500 patients to include over 200 combat casualties. In March 2002, 
the 274th FST received and treated all combat casualties sustained 
during Operation Anaconda and provided extensive orthopedic and 
surgical care for the detainees held at the Bagram Airbase. Each of 
these outstanding forward surgical elements contains a substantial 
nurse element that is critical to the team's success.
    The 86th Combat Support Hospital (CSH) is now supporting Operation 
Iraqi Freedom and is providing far forward medical care in the most 
austere conditions for both coalition forces and local nationals. The 
full impact of their support on the numbers of casualties cared for by 
these fine soldiers is not known at this time. Always ready, this same 
Combat Support Hospital was also the most forwardly deployed Level III 
Combat Support Hospital in Central Asia to support Operation Enduring 
Freedom. At that time, the personnel in the 86th included Army Nurses 
from Fort Campbell, Kentucky with augmentation by Army Nurses from Fort 
Bragg, North Carolina, Fort Belvoir, Virginia, Fort Rucker, Alabama and 
West Point, New York. This hospital, consisting of a 2-bed operating 
room, 7-bed emergency medical treatment section, and 24-bed inpatient 
area, provided care for 63 combat related casualties as well as the 
care for the acute health care needs of the deployed forces.
    In the past year, we provided expert nursing care with the 28th 
Combat Support Hospital from Fort Bragg, North Carolina in support of 
Task Force Med Eagle (TFME) in Bosnia-Herzegovina. In the same theater, 
the 249th General Hospital conducted Medical Civil Action Programs 
(MEDCAPs) to improve relations by providing basic medical screenings 
and care to 130 local national personnel within the Multinational 
Division-North Area of Operations in Bosnia. In addition, nursing 
personnel provide support to an ongoing multidisciplinary health 
promotion program for soldiers and civilian employees in the Task 
Force. Flexible and ready, some of these same units are now providing 
the needed support to the soldiers currently in Southwest Asia.
    The Army Nurse Corps continues to strengthen our commitment to 
integrating our Active and Reserve Components. Last year, the 212th 
Mobile Army Surgical Hospital from Miesau, Germany teamed with the 
5501st United States Army Hospital from San Antonio, Texas to conduct 
maneuvers at the Combat Maneuver Training Center (CMTC) in Hohenfels, 
Germany. This was the first time that level III health care support was 
incorporated directly into a CMTC rotation. This is just one example of 
many where Active and Reserve Army Nurses join forces to provide expert 
patient care and superb clinical leadership.
    In light of current world events, we have imbedded training on the 
personal and medical response to the chemical, biological, radiation, 
nuclear and high explosive threat into all our professional nursing and 
military education courses and deployment preparations. I can assure 
you that all Army Nurse Corps Officers will continue to be ready to 
meet any deployment challenge in any environment that they may 
encounter.
    It is a pleasure to be able to highlight good news stories about 
nurses at the many medical treatment facilities around the world. As a 
result of a productive collaboration among the Department of Defense, 
the Army Medical Department's Outcomes Management Section, and the 
Veteran's Health Affairs Quality Assurance and Performance Improvement 
Office, we implemented an additional nine Clinical Practice Guidelines 
(CPGs) in 2002. The practice guidelines relate to the care of Low Back 
Pain, Asthma, Diabetes, Tobacco Use Cessation, Post Deployment Health, 
Post-operative Pain, Major Depressive Disorder, Substance Abuse 
Disorder & Uncomplicated Pregnancy. These compliment the seven other 
Practice Guidelines already in place and demonstrate the unprecedented 
collaboration between clinicians and researchers working at Army, Air 
Force, Navy and Veteran's Affairs facilities. Clinical nurse 
specialists, nurse practitioners, nurse midwives, nurse educators, 
community health nurses, and staff nurses are intimately involved in 
both the development and the implementation of the guidelines. These 
guidelines may be applied to patient care in both the peacetime and 
combat hospital settings and aim to decrease variation in the 
management of specific conditions, thereby improving quality of care. A 
notable success associated with the implementation of the CPGs includes 
the fact that none of the 28 Army Medical Treatment Facilities surveyed 
by the Joint Commission on Accreditation of Healthcare Organizations 
(JCAHO) have had any findings related to the new JCAHO CPG 
implementation mandates.
    Nurses have embraced new technology in support of patient care. The 
Great Plains Regional Medical Command and Brooke Army Medical Center 
nurse practitioners are currently testing a new composite computer 
software program called MEDBASE that will allow Commanders at all 
levels to have visibility of the data necessary to ensure soldier 
medical readiness. This database will also facilitate electronic 
medical record documentation, soldier profiling and tracking, worldwide 
immunization tracking, electronic health and wellness documentation, 
procedure and diagnostic coding, and numerous practical medical 
readiness reports for all levels of the military system. This tool, 
designed to interface with current and programmed DOD information 
technology systems, has incredible potential to conserve personnel and 
fiscal resources and will directly impact our performance improvement 
initiatives.
    MAJ Laura Favand and MAJ Lisa Lehning, Army Nurse Corps Officers 
from William Beaumont Army Medical Center in El Paso, Texas and Brooke 
Army Medical Center in San Antonio, Texas, respectively, assisted in 
the development of another valuable data management tool. The Combat 
Trauma Registry was employed at Landstuhl, Germany and contains data 
entered on soldiers injured in Afghanistan in support of Operation 
Enduring Freedom. The purpose of the Combat Trauma Registry is to 
examine the feasibility of identifying, collecting, and reporting 
combat trauma care information from the point of injury to return to 
duty, discharge from active duty, or death from combat casualties. The 
data collected in this registry will be used as input into the planning 
factors used to develop combat health support models such as casualty 
estimates, personnel at risk, and injury types for future military 
operations. This is the first attempt to collect this type of data 
since the Vietnam conflict.
    Army Nurses at Walter Reed Army Medical Center are supporting 
disaster and bioterrorism preparedness with the implementation of Phase 
I of the DOD plan for smallpox vaccinations. Phase I includes the 
vaccination of the military's smallpox response teams and hospital and 
clinic teams located in military hospitals. Walter Reed personnel 
prepared and conducted a two-day conference for their staff and 
personnel, providing smallpox education and training for people who are 
to be vaccinated and for those administering the vaccine. As Federal 
agencies reorganize and lines of authority are adjusted in the newly 
formed Department of Homeland Security, it is clear that nurses across 
all specialties will play a significant role in the overall medical 
disaster response strategy.
    Army Nurses are proud to be an integral part of the transformation 
of the new 91W Healthcare Specialist Military Occupational Specialty. 
We are imbedded in the training units as leaders and educators. In 
fact, there are thirteen Army Nurse Corps officers directly assigned to 
the training battalion at Fort Sam Houston, TX in which each new 91W 
soldier is initially trained. In addition, Army Nurse Corps officers 
were directly responsible for developing and implementing the hospital 
based clinical training experience that is part of the sixteen-week 91W 
initial entry training. Army Nurse Corps officers also serve as 
preceptors and mentors for these soldiers throughout their initial 
entry training as well as the sustainment training programs in place 
across the Army. I want to share with you my impression of these 
soldiers. Simply put, they are the best-trained combat medics in our 
history and we are proud to serve side by side with these exceptional 
soldiers. We will continue to steadfastly support all aspects of this 
transformation until it is completed.
    Army nurses continue to be at the forefront of nursing research. We 
aggressively pursue evidence-based research focusing on critical 
military healthcare problems that nurses can positively impact. Last 
year, I shared with you our five primary research focus areas: the 
identification of specialized clinical skill competency training and 
sustainment requirements; issues related to pre-, intra-, and post-
deployment; issues related to the nursing care of our beneficiaries in 
garrison; nurse staffing requirements and their relationship to patient 
outcomes; and finally, issues related to civilian and military nurse 
retention. Today I will share with you our progress and accomplishments 
in these five priority areas.
    To insure that our combat medics are trained in critical life-
saving skills and ever ready for battle, they are required to become 
nationally certified as Emergency Medical Technicians. The nurse 
researchers at Madigan Army Medical Center are assessing the impact of 
a computer-based three-dimensional virtual Emergency Medical Technician 
training simulator on overall educational outcomes of students and the 
resulting national certification pass rates. To date, one hundred 
thirteen 91W students are enrolled in this study. This adjunct to our 
educational design could result in improved pass rates and related cost 
savings as soldiers will be better prepared to pass the national 
certification examination the first time taken.
    The recent increase in our deployment tempo has kept all our 
medical personnel busy. Nurse researchers at Walter Reed Army Medical 
Center are engaged in a study to identify the physiologic, 
psychosocial, work and lifestyle factors of Army Medical Department 
soldiers who have experienced musculoskeletal injuries. They will 
examine how these factors may be associated with the occurrence of 
these injuries. The results of this study will help us devise 
strategies targeted at reducing the frequency of these injuries in 
these soldiers. In addition, students in our Nursing Anesthesia 
graduate program have studied the safety and efficacy regarding the use 
of an oxygen concentrator in the field environment. Use of this device 
will allow for the delivery of required oxygen to patients in the field 
and eliminate the need to transport heavy oxygen bottles. Army Nurse 
researchers are also conducting a large-scale study to identify the 
ethical issues nurses encounter in caring for patients in deployed and 
garrison-based military hospitals. Early results from this study 
indicate that our military and civilian nurses most often encounter the 
challenges of staffing patterns that limit quality of nursing care, 
protecting patient rights to quality nursing care and staffing patterns 
that limit patient access to nursing care. The intent of this study is 
to develop pre-emptive educational programs that will prepare nurses in 
a variety of military settings to best manage the ethical challenges 
presented to them. All of the studies mentioned are truly targeted at 
improving nursing care for soldiers in all our practice environments.
    Nursing research consistently examines the potential of new 
technology on practice. Nurse researchers at Walter Reed Army Medical 
Center are examining the use of telenursing for our remote, home-based 
patients who are in need of cardiac rehabilitation following coronary 
artery bypass graft surgery. This program will allow nurses to 
``virtually'' visit patients up to three times per week to follow both 
the physiological progress of the patient such as vital signs, surgical 
incision assessment, and electrocardiograph analysis as well as provide 
educational interventions that the home-bound patient might otherwise 
not receive. The nurse researchers at Brooke Army Medical Center have 
designed a study to decrease ventilator-associated pneumonia in 
patients at Brooke Army Medical Center and at Wilford Hall Air Force 
Medical Center. This study has dramatic potential in both human 
outcomes as well as cost outcomes by determining care criteria that 
could decrease the number of days that a person is on a ventilator.
    Nurse researchers at Madigan and Walter Reed Army Medical Centers 
completed the Army Nursing Outcomes Database study initiated in 2001 
and have extended the concept to include medical treatment facilities 
from both the Air Force and Navy. This Tri-Service project is dedicated 
to the collection of standardized and high quality data related to the 
effects of nurse staffing and patient outcomes. The expanded Military 
Nursing Outcomes Database will assess data integrity, examine new 
indicators of quality nursing care and will add a dimension of the 
rapidity of patient movement into and out of the hospital. The Army 
Nurse Corps also continues to collect data from nurses who have chosen 
to leave the military in order to identify those issues that we can 
positively impact upon with the goal of retaining as many quality Nurse 
Corps officers as possible. This ongoing assessment indicates that 
nurses leave the military in order to pursue life goals such as having 
a family and stabilizing their location. We have taken this feedback 
seriously and are striving to address the retention needs of our nurses 
through the initiatives and incentives outlined earlier in this 
testimony.
    In conclusion, Army nurse researchers continue to seek the 
solutions to the important challenges facing military healthcare. The 
Army Nurse Corps continues to identify areas for collaboration with 
researchers in the Navy and the Air Force. Since 1992, the TriService 
Nursing Research Program has funded 230 research proposals and during 
fiscal year 2002, seventeen military nurse researchers received funding 
in areas that include nursing practice during operations other than 
war, air evacuation, fitness among National Guard personnel, sexually 
transmitted disease and pregnancy prevention during deployment, and 
educational strategies for chemical warfare. The Tri-Service Nursing 
Research Program continues to offer a breadth of supportive activities 
such as workshops and symposiums to promote, encourage and develop both 
our novice and seasoned researchers. It is clearly evident by the types 
of proposals submitted that nursing research is, and will continue to 
be, focused on relevant and timely research problems that necessitate 
solid outcome data. Your continued support of the TriService Nursing 
Research Program is truly appreciated and has resulted in continued 
advances in nursing practice for the benefit of our soldiers, their 
family members, and our deserving retiree population.
    I would like to extend my appreciation to the leadership and 
faculty of the Uniformed Services University of the Health Sciences 
(USUHS) for their continued support in the training of our Certified 
Registered Nurse Anesthetists and Family Nurse Practitioners. USUHS 
continues to provide us with professional nursing graduates who have a 
near perfect pass rate for national certification, easily exceeding the 
national standard. Adeptly responding to the needs of Federal nursing, 
USUHS established this past year the Clinical Nurse Specialist Program 
in Perioperative Nursing as well as the foundation for the Doctoral 
Program in Nursing, with the first candidates for study in each program 
to begin this summer. USUHS continues to refine and evolve strong 
curricula that have three focused research and practice areas including 
Operational Readiness in Changing Environments, Population Health and 
Outcomes, and Clinical Decision-Making in the Federal Health Care 
System. In addition, they have placed cross cutting emphasis on patient 
safety, ethics, force protection, and international health and 
leadership. The curricula are interwoven with the necessary military 
applications essential for the response to any global challenge, such 
as scenarios involving deployment of weapons of mass destruction, 
disaster or humanitarian assistance, and contingencies other than war. 
USUHS continues to be flexible and responsive to our Federal Nursing 
needs and our continued partnership is key to maintaining sufficient 
numbers of professional practitioners necessary to support our mission.
    Finally Senators, the Army Nurse Corps once again reaffirms its 
commitment to recognizing the Bachelor of Science degree in Nursing 
(BSN) as the minimum educational requirement and basic entry level for 
professional nursing practice. We appreciate your continued support of 
this endeavor and your commitment to the educational advancement of all 
military nurses. We continue to be resolute in meeting the challenges 
we face today and are ready and determined to meet the uncertain 
challenges of tomorrow. We will continue with a sustained focus on 
readiness, expert clinical practice, professionalism, leadership and 
the unfailing commitment to our Nation that has been the hallmark of 
our organization for over 102 years. Thank you for the opportunity to 
present the extraordinary contributions made by Army Nurses.

    Senator Stevens. Thank you, General. Admiral Lescavage.

STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, NURSE 
            CORPS, UNITED STATES NAVY, DIRECTOR, NAVY 
            NURSE CORPS

    Admiral Lescavage. Good afternoon, Chairman Stevens, 
Senator Inouye. I am Rear Admiral Nancy Lescavage, the 20th 
Director of the Navy Nurse Corps and Commander of the recently 
established Naval Medical Education and Training Command. It is 
indeed an honor and a privilege to represent a total of 5,000 
active duty and Reserve Nurse Corps officers. I welcome this 
opportunity to testify regarding the status of the Navy Nurse 
Corps.
    The Navy Nurse Corps is ``living'' the mission of Navy 
medicine today providing preeminent health care in worldwide 
missions. When called to duty recently, our Navy nurses readily 
packed their seabags and moved forward. Meanwhile, our 
remaining military and civilian nurses back home continued to 
be the backbone in promoting, protecting and restoring the 
health of all entrusted to our care, including those heroes who 
have gone before us in harm's way.
    Not a beat was missed in our mission. This year, to chart 
the course, we have revised our strategic plan which now 
parallels Navy medicine's goals of being ready, caring about 
our people, delivering that health care benefit to all, and 
promoting best practices.
    Through our collective leadership, I'm happy to tell you we 
are also united with our Federal nursing partners to advance 
professional nursing practice. What a thrill that is to be one 
team with my fellow colleagues.
    I will now speak to each of our goals and address the 
status of professional nursing in Navy medicine relative to the 
national nursing shortage. First of all, to stand ready. Our 
mission is exemplified in our continuous commitment to 
readiness in peacetime, wartime, humanitarian and other 
contingency missions.
    Augmenting our 70 Navy nurses who are routinely assigned to 
operational billets, we have deployed a total of approximately 
600 Navy nurses in support of Operation Iraqi Freedom on a 
variety of platforms. They have been and remain assigned to 
forward resuscitative surgical support teams, fleet surgical 
teams, Marine Corps medical battalions, Marine Corps force 
service support groups, our fleet hospitals, our casualty 
receiving and treatment ships, and our hospital ships such as 
the U.S.N.S. Comfort currently deployed. Part of that crew will 
be returning today.
    And they also serve aboard our aircraft carriers. Eighty-
nine out of 140 nurse anesthetists have been deployed and are 
serving us well. We have also recalled approximately 400 
Reserve Navy nurses to support our operational missions and the 
continuum of care in our military treatment facilities. You 
see, we really do truly work as a team, both active duty and 
Reserve.
    During this past year, there have been an additional 43 
Navy nurses involved in other missions, such as at Camp X-Ray 
in Guantanamo Bay, Cuba, Operation Provide Hope and Operation 
Enduring Freedom. Almost 400 Nurse Corps officers have also 
been involved in various training exercises in the past year, 
such as in our fleet hospital training, fleet hospital 
operational readiness evaluation, and Exercise Battle Griffin.
    Strengthening our emergency preparedness posture, Navy 
nurses now serve in vital leadership roles in Navy medicine's 
Office of Homeland Security, the Department of Defense smallpox 
response team, the Marine Corps chem/bio incident response 
team, and in command emergency preparedness offices. In meeting 
our readiness mission in all operational environments, training 
opportunities occur across Federal, as well as civilian 
agencies. As an example, this past fall, the Navy medicine's 
trauma training program rotated its first class through the Los 
Angeles County University of Southern California Medical 
Center, one of the Nation's top level one trauma centers. We 
successfully trained many Nurse Corps officers by enhancing 
their combat trauma skills and medical readiness, and they do 
that along with their respective platform teams, so they truly 
are ready for trauma cases.
    In addition, five of our Navy medical treatment facilities 
have established agreements with local trauma centers, training 
numerous emergency and critical care nurses, as well as our 
operating room nurses. Collaborating with the Army and the Air 
Force, we have also shared instructors and training 
opportunities to enhance these critical skills.
    Secondly, in caring about our people, we continually strive 
to be recognized as an employer of choice in recruiting, 
training and retaining the right professional nurses. We 
closely monitor the national nursing shortage projections and 
civilian compensation packages and determine the best course 
for us to take in the competitive market.
    The Navy Nurse Corps amazingly continues to meet active 
duty military and civilian recruiting goals and professional 
nursing requirements. We do that through diversified accession 
sources. Those are our pipeline programs, for example, in our 
Reserve Officer Training Corps (ROTC).
    We also do that through pay incentives, graduate education 
and other retention initiatives that address quality of life 
issues, to meet our special needs, such as critical care. And I 
really believe we need more Navy nurses in the mental health 
arena, in midwifery and neonatal nursing. We too are exploring 
the health professional's loan repayment program in those 
areas.
    For our Civil Service nurses who make up a huge part of our 
backbone, recruitment, retention and relocation bonuses are 
used, along with special salary rates and that wonderful 
special hire authority which we can thank you so much for.
    We also had our certified registered nurse anesthetists and 
operating room nurses this year participate in the critical 
skills retention bonus. Ninety percent of our operating room 
nurses who were eligible took that, as well as 70 percent of 
our nurse anesthetists.
    I'd like to highlight our Navy Reserve component. We have 
processed 63 percent of our accession goal of 261 nurses to 
enter the Reserves, maintaining the same pace as we did last 
year. Beneficial incentives in procuring our Reservists in 
critical wartime specialties include an accession bonus for the 
Reserves, as well as loan repayment and stipend programs for 
graduate education. I have noticed through the years that the 
one thing nurses most want is to be greater educated. We are 
now proposing to expand bonus eligibility to new nursing 
graduates. In addition, we are in the initial stages of 
exploring the feasibility of instituting a pipeline scholarship 
program for our Reserve enlisted component, those corpsmen who 
desire to go on to become Navy nurses. And that's similar to 
the pipeline program for our active duty colleagues.
    Through several surveys, graduate education opportunities 
have been cited as one of our most important retention 
initiatives. We now are able to focus all of our scholarship 
training, as Admiral Cowan stated, on master's degrees and 
doctorate degrees based on our operational specialty 
requirements, specific health population needs and staffing 
projections.
    We are sending several of our nurses to the recently 
established perioperative clinical nurse specialist program at 
the Uniform Services University of Health Sciences (USUHS). We 
greatly look forward to the new doctoral program at USUHS, and 
are additionally considering nurse fellowship opportunities in 
such arenas as gerontology, business management and mental 
health.
    This year, we also instituted nursing internship programs 
at our three major medical centers and other naval hospitals 
for all new nursing graduates. The news is good on this as 
well. There have been several hundred military and civilian 
nurses who have completed these programs. These new nurses 
attest to increased self-confidence with clinical practice and 
are eager to assume greater responsibilities.
    Thirdly, delivering that health care benefit. Population 
health management is at the forefront and our Navy nurses are 
actively engaged in various clinical settings through health 
promotion, disease management and case management programs. 
These innovations do four things for us. They expedite a much 
quicker return to full duty for our sailors and Marines. They 
decrease lost work hours, increase productivity, and enhance 
our customer satisfaction. You see the benefits are endless and 
the line really appreciates the return to duty.
    Embracing force health protection, numerous programs have 
been developed to ensure a healthy and fit force such as a 
command preventive health assessment program, nurse managed 
hyperlipidemia clinic at our naval hospital in Rota, Spain, the 
in-garrison rehab platoon program at Camp Pendleton and 
clinical care services, which we call drive-by health care. 
They pull up to the pier in a van and are able to render basic 
primary care to our sailors who have just returned.
    Just as the health and fitness of our military members is 
critical to force readiness, so is the health of our extended 
military family and other eligible beneficiaries. In at least 
four medical treatment facilities, our nurses are leading the 
way in the assessment and management of our patients. Diabetes 
case management has significantly enhanced patient compliance 
with their recommended plan of care. In support of the unique 
needs of seriously ill and terminally ill patients, our first 
Navy palliative care clinic was established at our medical 
center in Portsmouth. Our mother baby clinic provides follow-up 
for high-risk mothers and babies for early detection and 
prevention of complications. Pediatric nurses at our naval 
hospital in Naples liaisoned with the Department of Defense 
school nurses and teachers to collaborate on taking care of 
asthmatic children to prevent asthmatic attacks. This sampling 
of programs demonstrates that Navy nurses indeed are innovative 
and have specialized knowledge that can be applied in any form 
in a military setting.
    Lastly, promoting best health care business practices. 
Nurse Corps officers continue to be strategically placed in 
pivotal roles where they can influence legislation, health care 
policy and delivery systems. We have active duty and Reserve 
Nurse Corps officers in executive roles, including our current 
Navy's Deputy Surgeon General and many others such as 
commanding officers, executive officers and officers in charge. 
Personally, I am honored to have been chosen to lead the charge 
in revolutionizing Navy medicine's education and training.
    Always striving for nursing excellence, many commands have 
aligned their performance metrics with the American Nurse's 
Association magnet recognition program and Malcolm Baldrige 
criteria for excellence. These standards provide the framework 
for sustained quality patient care. Our goal is to complete our 
first application which is at our medical center in Portsmouth, 
Virginia, and have that completed by next year.
    Nursing research has become our cornerstone for excellence 
in all settings, from military treatment facilities to the 
operational environment. Our revised Navy Nurse Corps research 
plan provides the foundation and scope of military nursing 
research ranging from the utilization of doctorally prepared 
Nurse Corps officers in key leadership positions to their 
responsibilities in leading evidence-based practice studies.
    With authority and influence, our Navy nurse researchers 
now create health policies and delivery systems and are right 
at the tip of the spear in leading the way in our major medical 
treatment facilities. We were honored to have one of our nurse 
anesthetists named researcher of the year by the American 
Association of Nurse Anesthetists.
    We do as well appreciate your support of the TriService 
nursing research program funding. I would like to highlight 
just a little bit of our research programs out there. A program 
involving the studies examined Navy recruits at risk for 
depression, after undergoing the bootstrap intervention 
program. This is at Great Lakes. Preliminary results indicate a 
potential for decreased attrition, improved recruit 
performance, and an identified cost-effective method of recruit 
retention.
    On the cutting edge of molecular research, a team led by a 
Navy nurse is investigating the potential use of a readily 
accessible medication to be used in the field to treat 
respiratory problems. We also have a multidisciplinary team 
with nurses in it working on diabetic care and that has 
enhanced the patient's ability to achieve the mastery of self-
care and live independently with potential savings of $7,000 to 
$42,000 per patient a year.
    In closing, I appreciate your tremendous support of 
legislative initiatives and the opportunity to share our 
accomplishments. In our 95th year of the Corps, our Navy nurses 
are very proud of our heritage and professional practice as 
innovators, change agents and leaders.
    In my other role as Commander, Navy Medical Education and 
Training Command, I fully support the philosophy that 
continuous learning and guidance for all health care 
professionals is integral to what we do in meeting our 
peacetime and wartime missions.
    Regarding lessons learned, Chairman Stevens, my command 
with education and training has a command under it called the 
Naval Operational Medical Institute. Several years ago, we did 
come up with the lessons learned program and we are very 
excited about that. That has already been launched, which 
really has value in learning from what has just occurred.

                           PREPARED STATEMENT

    I look forward to continuing to work with you and my 
colleagues during my tenure as the Director of the Navy Nurse 
Corps. Thank you for this great honor and privilege. In my 
view, there is no better job.
    [The statement follows:]

         Prepared Statement of Rear Admiral Nancy J. Lescavage

    Good morning, Chairman Stevens, Senator Inouye and distinguished 
members of the Committee. I am Rear Admiral Nancy Lescavage, Director 
of the Navy Nurse Corps and Commander of the recently established Naval 
Medical Education and Training Command. It is an honor and a privilege 
to represent a total of 5,000 Active Duty and Reserve Navy Nurse Corps 
officers. I welcome this opportunity to testify regarding our 
achievements and issues.
    The Navy Nurse Corps is ``living'' the mission of Navy Medicine 
today and fulfilling the vision of the Navy Nurse Corps of preeminent 
health care in executing worldwide missions. When called to duty, Navy 
Nurses readily ``packed their seabags'' and moved forward, with dynamic 
leadership, clinical expertise, teamwork, perseverance and patience. 
Meanwhile, military and civilian nurses who remained at the homefront 
continue to be the backbone and structure in promoting, protecting and 
restoring the health of all entrusted to our care.
    This year, to ``chart the course,'' we have revised our Strategic 
Plan, which parallels Navy Medicine's goals of Readiness, People, the 
Health Benefit, and Best Health Care Business Practices. Through 
collective leadership, we have also united with our federal nursing 
partners to advance professional nursing practice.
    I will now speak to each of our goals in the Navy Nurse Corps 
Strategic Plan and address the status of professional nursing in Navy 
Medicine relative to the national nursing shortage.

                               READINESS

    Our mission to promote, protect and restore the health of all 
entrusted to our care is fully actualized through our continuous 
commitment to readiness in peacetime, wartime, humanitarian and other 
contingency missions. Both active duty and reserve components have 
exemplified unselfish devotion to duty, working side-by-side in the 
continental United States and abroad in a multitude of care delivery 
environments.

Readiness and Contingency Operations
    Augmenting our seventy Navy Nurses in operational billets, we have 
deployed a total of approximately six hundred nurses in support of 
Operation Iraqi Freedom on a variety of platforms, such as Marine Corps 
Force Service Support Groups, Fleet Hospitals, Casual Receiving 
Treatment Ships, Hospital Ships and with Command Headquarters staff to 
plan and operationalize our health care delivery system. Eighty-nine 
out of a total of one hundred and forty Certified Registered Nurse 
Anesthetists (CRNA) alone have been deployed. We have also recalled 
approximately four hundred reserve nurses to support our operational 
missions and the continuum of care in our military treatment 
facilities. During this past year, there have been an additional forty-
three nurses involved in other missions, including Camp X-Ray at 
Guantanamo Bay, Cuba, Operation Provide Hope and Operation Enduring 
Freedom. Almost four hundred Nurse Corps officers have also been 
involved in various exercises in the past year such as Fleet Hospital 
Field Training, Fleet Hospital Operational Readiness Evaluation, and 
Exercise Battle Griffin.

Homeland Security
    Strengthening our emergency preparedness posture, Navy Nurses serve 
in vital leadership roles in Navy Medicine's Office of Homeland 
Security, the Department of Defense Smallpox Epidemiological Emergency 
Response Team, the Marine Corps Chemical-Biological Incident Response 
Force and in command Emergency Preparedness Offices. Involvement in key 
initiatives to execute our Force Health Protection mission under any 
circumstance include: multiple training programs; military-civilian 
partnerships with U.S. hospitals; innovative site visits to identify 
vulnerabilities and exercise command emergency preparedness plans; and 
development of disaster response curriculum with other federal 
agencies.

Readiness Training
    In meeting our readiness mission in all operational environments, 
training opportunities are collectively optimized across federal and 
civilian agencies. Last summer, Navy Medicine's Trauma Training Program 
rotated its first class through the Los Angeles County/University of 
Southern California Medical Center, one of the nation's finest Level I 
Trauma Centers. We successfully trained many Nurse Corps officers by 
enhancing their combat trauma skills and medical readiness with their 
respective platform teams, the Forward Resuscitative Surgical Support 
or Fleet Surgical Teams. In light of recent events and the national 
focus on homeland security and terrorism, the curriculum has added 
treatment of casualties under these stressors, as well as conventional 
battle injuries.
    Seeking to expand training opportunities for nurses assigned to 
other operational platforms, five military treatment facilities have 
established agreements with local trauma centers, training over fifty 
emergency and critical care nurses through didactic and clinical 
experiences. Collaborating with the Army and Air Force, we have shared 
instructors and training opportunities in support of critical skills 
enhancement at the Army Medical Center in Landstuhl, Germany; Wilford 
Hall Medical Center in San Antonio, Texas; the Critical Care Air 
Transport Team Course at Brooks Air Force Base in San Antonio to name a 
few facilities. In addition, Navy Nurses at the Naval Hospital in Rota, 
Spain are involved in training Embassy, Department of State and foreign 
military physicians and nurses.

                                 PEOPLE

    We continually strive to be recognized as an employer of choice in 
recruiting, training, and retaining the right professionals. To attain 
our prestigious standing, we closely monitor national nursing shortage 
projections and civilian compensation packages and determine the best 
course for us to take in the competitive market.

National Nursing Shortage
    A 2002 study conducted by the Health Resources and Service 
Administration predicted that the national nursing shortage will 
experience a deficit of over 275,000 nurses by 2010, based on the 
dwindling supply of registered nurses and the increasing demand for 
their clinical expertise. A report by the American Association of 
Critical Care Nurses, cited factors impacting the nursing work force 
supply including the declining number of nursing school graduates, job 
dissatisfaction, and inadequate compensation. We continuously monitor 
each of these factors because the strength of our nursing work force 
can best be maintained through a blend of counter initiatives to these 
dissatisfiers.

Recruitment and Retention Initiatives

             FISCAL YEAR 2002 ACCESSION SOURCES: ACTIVE DUTY
------------------------------------------------------------------------

------------------------------------------------------------------------
Direct Procurement......................................              77
Reserve Recall..........................................              15
Nurse Candidate Program.................................              62
Naval Reserve Officer Training Program..................              52
Medical Enlisted Commissioning Program..................              42
Other...................................................               5
------------------------------------------------------------------------

    The Navy Nurse Corps amazingly continues to meet military and 
civilian recruiting goals and professional nursing requirements through 
diversified accession sources, pay incentives, graduate education and 
training programs, and other retention initiatives that address quality 
of life and practice satisfaction. The increase of the maximum 
allowable compensation amount for the Certified Registered Nurse 
Anesthetist Incentive Special Pay (CRNA ISP) and the Nurse Accession 
Bonus (NAB) in the Fiscal Year 2003 National Defense Authorization Act 
will further enhance our competitive edge in the nursing market. To 
meet specialty needs, such as critical care, mental health, midwifery 
and neonatal nursing, we are exploring the Health Professions Loan 
Repayment Program. Successful recruitment and retention tools have been 
the NAB, CRNA ISP, Board Certification Pay and the recent Critical 
Skills Retention Bonus for our uniformed members. For our civil service 
nurses, recruitment, retention and relocation bonuses; special salary 
rates; and Special Hire Authority have significantly decreased our 
vacancy rates in several of our facilities. All of these pay 
initiatives will become even more critical in the future years to meet 
our wartime and peacetime missions and maintain authorized endstrength.
    Now, I'd like to highlight our Navy Nurse Corps, Reserve Component. 
We have processed sixty-eight percent of our fiscal year 2003 accession 
goal of two hundred and sixty-one nurses, maintaining the same pace as 
last year. Beneficial incentives in procuring our reservists in 
critical wartime specialties include: the accession bonus, loan 
repayment and stipend programs for graduate education. To meet our 
contributory support mission, we are proposing to expand bonus 
eligibility to new nursing graduates. In addition, we are in the 
initial stages of exploring the feasibility of instituting a pipeline 
scholarship program for the reserve enlisted component similar to those 
given to our active duty colleagues.

Education and Training Initiatives
    Since graduate education opportunities have been cited as one of 
our most important retention initiatives, we constantly evaluate our 
patient care requirements to annually update our Duty Under Instruction 
Scholarship Plan. We now focus our training on Master's Degrees, 
Doctoral Programs, and fellowships based on operational and specialty 
requirements, specific health population needs and staffing 
projections. This year, we are sending several of our nurses to the 
recently established Perioperative Clinical Nurse Specialist Program at 
the Uniformed Services University of Health Sciences (USUHS). We look 
forward to the new Doctoral Program at USUHS and are currently 
exploring nursing post-graduate fellowship opportunities.
    Nursing internship programs have been initiated at the National 
Naval Medical Centers in Bethesda, Maryland; Portsmouth, Virginia; San 
Diego and the Naval Hospital in Jacksonville, Florida for all new 
nursing graduates. There have been a total of one hundred and forty 
military and civilian nurses who have completed their respective 
programs. Outcome measures for these new nurses attest to increased 
self-confidence with clinical practice and the ability to assume 
greater responsibilities which facilitates their integration into the 
Navy Nurse Corps.
    Navy Nursing supports national initiatives to increase the nursing 
work force numbers in several ways. Our robust scholarship pipeline 
programs help to support nursing school enrollment. Through agreements 
with schools of nursing, military treatment facilities provide varied 
clinical experiences and clinical experts, who may also serve as 
adjunct faculty. We also enhance the image of nursing in the community 
through numerous presentations and approved advertisement campaigns.

                             HEALTH BENEFIT

    Through an innovative framework of nursing practice, we deliver 
high quality, cost-effective and easily accessible primary and 
preventive health care services. Population health management has been 
at the forefront in various clinical settings through health promotion, 
disease management and case management programs. These innovations 
expedite a much quicker return to full-duty; decrease lost work hours; 
increase productivity and enhance customer satisfaction.

Healthy and Fit Force
    Embracing Force Health Protection, many programs have been 
developed to ensure a healthy and fit force. For instance, command 
Preventive Health Assessment Programs identify at-risk active duty 
members and promote therapeutic lifestyle changes, such as in the 
Nurse-Managed Hyperlipidemia Clinic at our Naval Hospital in Rota, 
Spain. The In-Garrison Rehabilitation Platoon Program at our Naval 
Hospital in Camp Pendleton, California has expedited the Marines' 
return to training through improved continuity and coordination of all 
aspects of patient care, saving 2,100 convalescent leave days over a 
two-month period. Health Promotion efforts instituted the Choices 
Program at our Naval Air Station in Sigonella, Sicily. This program 
focuses on pregnancy prevention through education, including the use of 
baby simulators to mimic seventy hours of parenthood. Based on a 
comparison study, female Sailors who successfully completed the course 
were three times less likely to get pregnant. Additionally, Family 
Nurse Practitioners continue to provide support to the Fleet through 
pierside clinical services, health promotion programs, and disaster 
training.

Family Centered Care
    Just as the health and fitness of our military members is critical 
to force readiness, the health of our extended military family and 
other eligible beneficiaries is equally important. Case Management 
targets prevention, early diagnosis, cost effective intervention and 
quality outcomes. In at least four medical treatment facilities, 
Diabetes Case Management has significantly enhanced patient compliance 
with their recommended plan of care. In support of the unique needs of 
seriously-ill and terminally-ill patients, the Palliative Care Project 
at our Naval Medical Center in Portsmouth is the first of its kind in 
Navy Medicine. This program embraces the philosophy of caring during 
the final phase of life. Our Mother Baby Clinics provide follow-up 
visits for high risk mothers and babies for early detection and 
prevention of complications. Pediatric nurses at Naval Hospital Naples 
liaison with Department of Defense school nurses and teachers to 
collaborate on the development of students' Asthma Action Plans based 
on the National Asthma Education & Prevention Guidelines. This 
initiative alone has decreased emergency room visits by seventy-five 
percent and inpatient admissions by eleven percent. Our Nurse-Run 
Primary Care Clinics use approved protocols to increase access and 
incorporate population health concepts. This sampling of the 
aforementioned programs demonstrates that Navy Nurses are innovative 
and have specialized knowledge that can be applied to many forums 
unique to military settings.

                  BEST HEALTH CARE BUSINESS PRACTICES

    Nurse Corps officers continue to be strategically placed in pivotal 
roles where they can influence legislation, health care policy and 
delivery systems. There are active duty and reserve Nurse Corps 
officers in executive roles, including the Deputy Surgeon General, 
Commanding Officers, Executive Officers, Officers in Charge, policy 
makers and many others.

Strategic Planning and E-technology
    Always striving for nursing excellence, many commands have aligned 
their performance metrics with the American Nurses Association Magnet 
Recognition Program and the Malcolm Baldridge Criteria for Excellence. 
These standards provide the framework for sustained quality patient 
care outcomes, visionary leadership, strategic planning, and 
exceptional staff performance.
    To enhance communication and conduct business, we have strategized 
and marketed clinical outcomes, research findings and business 
practices through video teleconferences, newsletters, conferences, and 
professional journals. Online clinical training sources, Navy e-
learning modules and nursing practice resources are tested for 
effectiveness and linked through our website or Navy Medicine's 
Telelibrary.
Research

    ----------------------------------------------------------------

Navy Nurse Corps Research Plan: Focus on
    Deployment Health
    Developing and Sustaining Competencies
    Recruitment and Retention of the Work Force
    Education and Training Outcomes
    Clinical Resource Management
    Military Clinical Practice

    ----------------------------------------------------------------

    Our revised Navy Nurse Corps Research Plan provides the foundation 
and scope of military nursing research ranging from the utilization of 
doctoral prepared Nurse Corps officers to their responsibilities in 
leading evidenced-based practice studies. Placed in positions of 
authority and influence, our nurse researchers create health policies 
and delivery systems, advance and disseminate scientific knowledge, 
foster nursing excellence, and improve clinical outcomes. In addition, 
our senior nurse executives have promoted a culture of scientific-based 
practice in all settings from military treatment facilities to the 
operational environment. Ongoing nursing research and evidence-based 
practice ultimately effects quality outcome, captures cost 
effectiveness and enhances patient satisfaction. Nursing Research has 
become our cornerstone for excellence. In fact, we have the honor of 
having one of our Navy Nurses named ``Researcher of the Year'' by the 
American Association of Nurse Anesthetists.
    Through your support of TriService Nursing Research Program 
funding, research has been conducted at our three major medical 
centers, our two Recruit Training Centers, several Naval Hospitals, on 
more than six aircraft carriers and collaboratively with our uniformed 
colleagues and more than thirteen universities across the country. Navy 
nursing TSNRP-funded research has been published in numerous 
professional journals.
    I would like to highlight some of the research that has been 
supported by TSNRP funds. A program of research involving three studies 
examined Navy recruits at-risk for depression. After undergoing the 
BOOT STRAP Intervention Program, preliminary results indicated 
potential for decreased attrition, improved recruit performance and an 
identified cost-effective method of recruit retention. On the ``cutting 
edge'' of molecular research, a team led by a Navy nurse is 
investigating the potential use of a readily accessible drug to be used 
in the field to treat military personnel with respiratory problems. 
Through a multidisciplinary team approach to diabetic care, a third 
study focuses on enabling the patient's ability to achieve mastery of 
self-care and live independently, with potential cost savings of 
$7,000-$42,000/patient/year. Participants report more independence and 
greater satisfaction with the disease management intervention.

                               CONCLUSION

    In closing, I appreciate your tremendous support of legislative 
initiatives and the opportunity to share our accomplishments and issues 
that face the Navy Nurse Corps. Our nurses are very proud of our 
heritage and professional practice as innovators, change agents and 
leaders at all levels from policymaking to program implementation, 
across federal agencies and in all clinical settings. In my other role 
as Commander, Navy Medicine Education and Training Command, I fully 
support the philosophy that continuous learning and guidance for health 
care professionals is integral to enabling uniformed services personnel 
to meet our peacetime and wartime missions. This foundation transcends 
across all levels of practice and the ``Five Rights'' of nursing, which 
involves placing the right person in the right assignment at the right 
time with the right education and the right specialized training. 
Herein lies the basis of our superior performance in promoting, 
protecting and restoring the health of all entrusted to our care.
    I look forward to continuing to work with you during my tenure as 
the Director of the Navy Nurse Corps. Thank you for this great honor 
and privilege.

    Senator Stevens. Thank you, Admiral. General Brannon.

STATEMENT OF BRIGADIER GENERAL BARBARA BRANNON, 
            ASSISTANT SURGEON GENERAL, AIR FORCE 
            NURSING SERVICES AND COMMANDER OF MALCOLM 
            GROW MEDICAL CENTER

    General Brannon. Chairman Stevens, Senator Inouye. It is 
once again an honor and my great pleasure to present the great 
accomplishments of Air Force nursing. As we vigorously execute 
our mission at home and abroad, Air Force nurses and enlisted 
nursing personnel are meeting the increasing challenges with 
great professionalism and distinction.
    Aeromedical evacuation is the critical link between 
casualties on the battlefield and definitive medical care. Our 
superb medical crews and the advances in medical technology 
make care in the air more sophisticated than ever before.

                   CRITICAL CARE AIR TRANSPORT TEAMS

    Our critical care air transport teams or CCATTs were 
instrumental in the lifesaving airlift of four Afghan children 
who were caught in the crossfire of war. They received 
emergency care from an Army forward surgical team and then were 
treated by our CCATT team during the 2-hour flight to a combat 
Army surgical hospital. The team worked in total darkness using 
night vision goggles until the aircraft was out of danger.
    Medical teams from all three services have worked together 
very smoothly in the operational environment and the patient 
handoffs were virtually seamless. The teamwork has been 
phenomenal. Embedded journalists and continuous network 
coverage have enabled the world to watch this war unfold.
    What the world hasn't seen is our Air Force independent 
duty medical technicians working with pararescue units at the 
battle's forward edge, their critical skills and training and 
special operations have made a lifesaving difference during 
evacuation of the wounded.
    They have employed leading edge technology, and the 
experiences of these brave airmen have set new standards for 
wartime emergency care. While much of our energy has been 
directed toward wartime support, there were also exciting 
initiatives continuing at the home station.

                       POPULATION HEALTH PROGRAMS

    Last year, I talked about our great progress in deploying 
population health programs. We are now engaged in comprehensive 
health care optimization to improve effectiveness and 
efficiency of services in every clinical area. Nurses and 
medical technicians are the backbone of successful 
optimization. Their expanded support to providers enable not 
only treatment of disease, but also stronger focus on 
preventive services and population health management.
    A great example comes from Charleston Air Force Base, South 
Carolina, where primary care teams launched an aggressive 
preventive screening campaign. Capitalizing on technology, they 
use an automated program to generate a letter to patients in 
their birth month inviting them to come for the recommended 
screening. This is very successful and the percent who complete 
screening exceeds national benchmarks by 6 percent.

                      NURSE CORPS GRADE STRUCTURE

    The key to success in nursing is a strong nursing force, a 
force with the right numbers and with the right experience and 
skills. Today, almost 79 percent of our authorizations are in 
the company grade ranks of lieutenant and captain, with only 21 
percent in field grade rank. Having a relatively junior Nurse 
Corps is a growing concern due to the higher acuity of our in-
patients, complexity of outpatient care and the robust role 
that we play in wartime support.
    To validate a rebalance in our Nurse Corps grade structure 
we initiated a top down grade review last year, that will 
identify by position the skill and experience required. Early 
data shows a significant need to increase our field grade 
authorizations. A by-product of this increase would be a 
greater promotion opportunity, bringing it more in line with 
other Air Force officer specialties. We expect to recommend 
that to our leadership in the very near future.

                               RECRUITING

    Recruiting continues to be a significant challenge. We 
ended last year with 104 nurses below our authorized end 
strength of 3,974. This was significantly better due to an 
unusually low rate of separations. We continue to implement new 
recruiting strategies both at headquarters and local levels. We 
are currently working with our sister services to fund an 
increased accession bonus for a 4-year commitment and exploring 
the feasibility of accession bonus for nurses who choose a 3-
year obligation.
    Our recruiting at the Air Force Academy has been extremely 
successful. Six academy seniors have selected nursing for their 
military profession, the largest group since it became an 
option in 1997. They will attend Vanderbilt University School 
of Nursing to earn a 2 year graduate degree.
    We are making great strides in enhancing the strength of 
our nursing care team by capitalizing on the talents of our 
enlisted personnel. We are partnering with the Army Nurse Corps 
to enable our medical technicians to attend a superb licensing 
program at Fort Sam Houston. We hope to increase the capacity 
of the current program to include 60 Air Force medics per year.
    We also recognize the needs to increase our enlisted in 
baccalaureate nursing programs and are exploring stipend 
initiatives similar to those used by the Navy Nurse Corps to 
make it easier for enlisted Nurse Corps to earn a BS, and be 
commissioned in our Nurse Corps. This year 300 nurses 
participated in a research program. Collective work expanded 
evidence-based nursing practices in several clinical and 
operational areas.

                         AIR MEDICAL EVACUATION

    A key study was on air medical evacuation. As we have 
increased the use of cargo aircraft for patient movement, the 
inability to control the temperature in patient areas has 
adversely affected the seriously ill and injured. Researchers 
have now identified patient location priorities and tested the 
effectiveness of improved monitoring and warming devices. Other 
researchers are using the lessons learned from our deployed 
nurses and technicians to validate war readiness training 
programs.
    One of the roles I enjoy most is being an advisor to the 
Uniformed Services University Graduate School of Nursing. They 
have made incredible progress in their first decade. Under 
energetic and visionary leadership, the school continues to 
grow in scope and build programs to meet the emerging needs of 
military nursing.
    Barely 2 years ago we began discussion on the feasibility 
of a master's program in perioperative nursing, and this fall 
the first class begins. The nursing Ph.D. program also went 
from concept to reality in just 1 year and the new curriculum 
will prepare nursing leaders in research and for key roles in 
health care strategy and policy.
    Mr. Chairman, Senator Inouye, thank you for allowing me to 
share just a few of the many activities of Air Force nursing 
with you today. On behalf of the men and women of the nursing 
services, I want to thank you for your tremendous advocacy, not 
only on behalf of military nursing, but also for the 
advancement of nursing across our Nation.

                           PREPARED STATEMENT

    You can trust that Air Force nursing will continue to serve 
in peace and war with the same professionalism, pride and 
patriotism that we have demonstrated for almost 54 years. There 
has never been a better time to be a member of the Air Force 
nursing team. Thank you.
    [The statement follows:]

        Prepared Statement of Brigadier General Barbara Brannon

    Mister Chairman and distinguished members of the committee, I am 
Brigadier General Barbara Brannon, Assistant Surgeon General, Air Force 
Nursing Services and Commander of Malcolm Grow Medical Center at 
Andrews Air Force Base. This is my fourth testimony before this 
esteemed committee and, once again, I am very proud to represent Air 
Force Nursing and delighted to share our accomplishments and challenges 
with you.
    First and foremost, as the Air Force aggressively executes its 
mission in support of our great nation, Air Force medics are keeping 
our people fit and providing outstanding healthcare wherever it is 
needed. Air Force nurses and enlisted nursing personnel are meeting 
increasing commitments and challenges with great professionalism and 
distinction. Today I'd like to review the following: deployments, 
training, force management, optimization and research, as examples of 
these commitments and challenges.
    Over the past year, hundreds of Nursing Service personnel have been 
deployed to every corner of the globe to support the ongoing war on 
terrorism and to provide humanitarian relief. There are more than 400 
nurses and technicians currently deployed in Expeditionary Medical 
Systems (EMEDS) facilities, and hundreds more prepared and awaiting 
orders to deploy. The Air Force continues to rely on an ambitious Air 
Expeditionary Force (AEF) rotation cycle to accomplish deployment 
missions and maintain home station health care services.
    In addition to supporting ongoing commitments to Operation ENDURING 
FREEDOM, IRAQI FREEDOM and other deployments, Air Force medical 
personnel have been called frequently to support humanitarian 
operations throughout the world. Four months ago, twelve nurses and 
technicians from Yokota AB Japan deployed to Guam to assist in federal 
medical support in the aftermath of the devastating Super Typhoon 
Pongsona. Arriving in the middle of the night, they established initial 
medical capability to triage and treat casualties within 24 hours.
    Nurses and technicians also provide humanitarian support through 
their active engagement in the International Health Specialist program. 
They are successfully forging and fostering positive relationships 
around the world. A great example is Major Doreen Smith, recognized as 
the Air Force International Health Specialist of the Year in Europe 
2002 for her outstanding work in Africa. She was instrumental in 
establishing the first Republic of Sierre Leone Armed Forces (RSLAF) 
HIV/AIDS Prevention Committee that developed treatment protocols used 
by field medical technicians to prevent transmission of HIV/AIDS. She 
later implemented training programs in both Ghana and Nigeria.
    Aeromedical evacuation remains a unique Air Force competency and 
our ability to respond to urgent transport requirements is second to 
none. Nurses and technicians were integral members of teams providing 
care during the evacuation of over 2,548 patients from forward areas in 
Operation ENDURING FREEDOM and IRAQI FREEDOM. Aeromedical evacuation is 
the critical link between casualties on the front lines and progressive 
levels of restorative healthcare abroad and in the continental United 
States.
    Captain Michael McCarthy was on a Critical Care Air Transport Team 
mission over hostile territory to rescue two CIA operatives critically 
injured during the prison uprising in Kandahar, Afghanistan. This was 
not a typical mission for our critical care team--the mission was flown 
in blackout conditions due to Special Operations requirements. Captain 
McCarthy's expert critical care saved the life of a casualty whose 
condition deteriorated in-flight. He received the prestigious Dolly 
Vinsant Flight Nurse Award from the Commemorative Air Force for his 
heroic actions on this mission.
    The tremendous accomplishments of our Air Force Flight Nurses have 
also been heralded by civilian flight nurse organizations. The Air and 
Surface Transport Nurses Association (ASTNA) presented the 2002 Matz-
Mason Award to Captain Greg Rupert, Critical Care Air Transport Team 
Program Coordinator, Lackland AFB, Texas, for exceptional leadership 
and positive impact on flight nursing on a global scale.
    Three years ago the Air Force identified that many medical 
personnel's peacetime healthcare responsibilities did not adequately 
sustain their proficiency in critical wartime skills. Medical career 
field managers and specialty consultants developed the specific 
readiness skills required for each specialty and established training 
intervals to ensure our people were prepared to meet deployment 
requirements. This year, we refined the program based on lessons 
learned in the deployed environment.
    As I briefed last year, the Air Force has entered into partnerships 
with civilian academic medical centers to provide intense training for 
nurses and technicians prior to deployment. The first ``Center for 
Sustainment of Trauma and Readiness Skills'' (CSTARS) was initiated in 
January 2002 at the Shock Trauma Center in Baltimore. This program 
provides our health care personnel with valuable hands-on clinical 
experience that covers the full spectrum of acute trauma management, 
from first response to the scene, during transport, to trauma unit 
care, to operating room intervention and finally to management in the 
intensive care unit. The three-week session also incorporates the 
Advanced Trauma Care Course for nurses and the Pre-Hospital Trauma Life 
Support Course for our medical technicians. To date, over 200 personnel 
have been trained in Baltimore.
    Building on the success of this first site, the Air Force has 
developed and opened two new CSTARS programs, one at St. Louis 
University primarily for the Air National Guard (ANG) team training, 
and the other at the University Hospital of Cincinnati for Reserve 
teams. The St. Louis program started in January 2003, and we expect to 
train over 270 personnel during their two-week annual tour. Early 
feedback is impressive as reflected by an end-of-course survey comment, 
``this is far and away the greatest training program I have been able 
to attend in the Air Force/ANG''.
    The CSTARS partnership between the University of Maryland Medical 
Center (UMMC) and the Air Force was key to the great success of the 
exercise ``Free State Response 2002'' conducted in Baltimore, Maryland 
in July of last year. The purpose of the exercise was to train as many 
people as possible in community disaster response and to foster 
effective coordination and collaboration between agencies involved in 
disaster management. The exercise received wide media coverage in the 
national capital area and was judged a huge success.
    Expeditionary Medical Systems (EMEDS) is a five-day course that 
provides hands-on field training for personnel assigned to EMEDS 
deployment packages to prepare them to work in the operational 
environment. There are currently three sites for EMEDS training: Brooks 
City Base, Texas primarily for active duty, Sheppard AFB, Texas for 
Reserves, and at Alpena, Michigan for ANG personnel. So far, 3,608 
personnel have been trained in this critical operational requirement.
    Overall trends in healthcare delivery and the National Defense 
Authorization Act of 2001, allowing care for beneficiaries over age 65, 
have resulted in an increase in the acuity and complexity of the 
patients we serve. This has increased the need for experienced nurse 
clinicians. Facility chief nurses have expressed growing concerns over 
the challenge of providing the most effective care with a relatively 
junior staff. In our military system, rank reflects the relative 
experience of the individual. When we look at our current Nurse Corps 
force structure, we note that more than 72 percent of our 
authorizations are for second lieutenants, first lieutenants and 
captains. These nurses range from ``novice to proficient'' in their 
nursing skills. Nurses at the major and lieutenant colonel level are 
``expert to master'' in their practice. The ratio of company grade to 
field grade nurses is significantly higher than for other medical 
career fields or the line of the Air Force.
    To correct the imbalance in our mix of novice and expert nurses, 
authorizations for field grade nurses would need to be increased. The 
Air Force Nurse Corps has initiated a Top Down Grade Review (TDGR) to 
identify, justify, and recommended needed adjustments. We are nearing 
the end of our data collection and research phase of the study and 
anticipate draft recommendations for our surgeon general in the next 
couple of months. If approved, and if additional field grade billets 
are indicated, the process to adjust authorizations among career fields 
can be initiated with the Chief of Staff of the Air Force's approval.
    In a separate but related issue, the Nurse Corps has the poorest 
promotion opportunity among Air Force officers. With only 28 percent of 
our authorizations in field grade ranks compared to 46 percent in the 
line of the Air Force, it is easy to understand why so many excellent 
officers are not getting selected for promotion. This lack of promotion 
opportunity is a major source of dissatisfaction in our Nurse Corps. 
The inequity in promotion opportunity has caught the eye of many line 
and medical commanders and garnered some support for our TDGR 
initiative. It is anticipated that a TDGR would validate increases in 
field grade Nurse Corps requirements. An increase in field 
authorizations would improve Nurse Corps promotion opportunity and 
bring it closer to that of other Air Force Officers.
    Although the programs instituted on a national level to address the 
nursing crisis are encouraging, recruiting enough nurses to fill 
positions is still a huge challenge across the United States and in 
many other nations. Last year was the fourth consecutive year the Air 
Force Nurse Corps has failed to meet our recruiting goal. We have 
recruited approximately 30 percent less than the goal each year since 
fiscal year 1999. At the end of fiscal year 2002, we had 104 fewer 
nurses than our authorized end strength of 3974. Early personnel 
projections forecasted we would end the year 400 nurses under end 
strength. Our final end strength reflects an abnormally low number of 
separations last year, 136 compared to our historical average of 330. 
Our fiscal year 2003 recruiting goal is 363 nurses, and, as of February 
2003, 100 have been selected for direct commission. This year 
recruiting service is able to offer an accession loan repayment of up 
to $26,000 as an incentive. With $6.2 million available to fund this 
initiative, we are hopeful that it will be as successful as last years 
retention loan repayment program and boost our accession numbers closer 
to the goal.
    Last year we revived an earlier policy that allowed Associate 
Degree (ADN) nurses who had a Baccalaureate degree in a health-related 
field to join the Nurse Corps. This was in response to Recruiting 
Service's belief that this would give access to a robust pool of 
recruits. But, in reality, only 13 ADN nurses were commissioned under 
this carefully monitored program. I rescinded the policy in October 
2002 since it did not produce the desired effect.
    We continue to recruit nurses up to the age of 47 because it proved 
very successful in fiscal year 2002. Thirty-four nurses over age 40 
were commissioned into the Air Force last year. Many of them have the 
critical care skills and leadership we need to meet our readiness 
mission and most have the years of experience to make them valuable 
mentors for our novice nurses.
    ``We are all recruiters'' is our battle cry as we tackle the 
daunting task of recruiting the nurses we need, and I continue to 
partner closely with recruiting groups to energize our recruiting 
strategies. Among other activities, I have written personal letters to 
nurses inviting them to consider Air Force Nursing careers and have 
manned recruiting booths at professional conferences. I look for 
opportunities to highlight and advertise the exciting opportunities Air 
Force Nurses enjoy, and have had nurses featured in print media 
coverage. I encourage each nurse wearing ``Air Force'' blue to visit 
their alma mater and nursing schools near their base of assignment to 
make presentations to prospective recruits. I have also assigned four 
nurses to work directly in recruiting groups to focus exclusively on 
nurse recruiting. Recruiters are using innovative marketing materials 
that my staff helped develop to champion Air Force Nursing at 
conferences, in their website, and in other publicity campaigns.
    Retention is another key factor in our end strength. In an effort 
to identify factors impacting separations, I directed the Chief Nurse 
of every facility to interview nurses who voluntarily separate. Exit 
interviews were standardized to facilitate identification of the 
factors that most influenced nurses to separate. Nurses indicated they 
might have elected to remain on active duty if staffing improved, if 
moves were less frequent, if they had an option to work part time, or 
if they could better balance work and family responsibilities. Most of 
these are requirements of military life that cannot be changed by the 
Nurse Corps. With regards to staffing, our nurse-patient ratios are 
fairly generous compared to civilian staffing models. The Air Force 
Medical Service has launched an aggressive initiative to develop 
standardized staffing models for functions across all medical 
facilities to optimize staffing effectiveness.
    We are developing a new survey for all nurses to identify 
workplace/environmental impediments so we can target opportunities to 
increase satisfaction. We continue to recommend Reserve, National 
Guard, and Public Health Service transfers for those who desire a more 
stable home environment but enjoy military service and can meet 
deployment requirements.
    We appreciate the continued support for the critical skills 
retention bonus authorized in the fiscal year 2001 NDAA. The Health 
Professional Loan Repayment Program, implemented in fiscal year 2002, 
was embraced by 241 active duty nurses saddled with educational debt. 
These nurses had between six months and eight years of total service 
and were willing to accept an additional 2-year active duty obligation 
in exchange for loan repayment of up to $25,000. This program improved 
our immediate retention of nurses and has great potential to boost 
long-term retention in critical year groups.
    The TriService Health Professions Special Pay Working Group 
identified Certified Registered Nurse Anesthesiologists (CRNAs) and 
Perioperative Nurses as critically manned and therefore eligible for a 
retention bonus. This program was enthusiastically welcomed with 66 
percent of eligible CRNAs and 98 percent of Perioperative Nurses 
applying for a critical skills retention bonus in exchange for a one-
year service commitment.
    We are looking at the benefits of increasing the number of civilian 
nurses in our workforce. We are grateful for the support of Congress in 
implementing U.S. Code Title 10 Direct Hire Authority to streamline the 
civilian nurse hiring process. During the period from August to 
December 2002, the Air Force was able to use direct hire to bring 14 
new civilian registered nurses on duty. With use of Direct Hire 
Authority, positions that had been vacant for as long as 18 months were 
filled within weeks. Our ability to hire civilian nurses would be 
greatly enhanced if we could hire at a competitive salary. We greatly 
appreciate your support and interest in Title 38-like pay authority for 
health professions.
    We are delighted to report that this year six Air Force Academy 
graduates selected the profession of nursing for their career field. 
This is the largest group to choose nursing since the option was 
instituted in 1997. Cadets selected for direct entry into the Nurse 
Corps attend Vanderbilt University School of Nursing via the Health 
Professions Scholarship Program. This accelerated degree program allows 
non-nurses with a bachelor's degree to obtain a master's degree in 
nursing after two years of study. To date, eight academy graduates have 
completed this program. Graduates of the Vanderbilt program have the 
leadership skills gained at the Academy coupled with a nursing degree 
from a prestigious university. They are prepared as advanced practice 
nurses and have the leadership base and potential to become top leaders 
in military healthcare.
    Air Force Nursing has been actively engaged in optimizing the 
contributions of our enlisted medical technicians by expanding their 
responsibilities and, in some cases, merging skill sets. In November 
2002, the Air Force consolidated three career fields, the aeromedical 
technician, medical service technician and public health technician. We 
now have two key career fields, the aerospace medical service 
technician and public health technician. This consolidation provides 
more robustly trained enlisted medics and increases manpower to support 
force health protection and emergency response. In this transition, 
every health care facility stood up a Force Health Management element 
responsible for ensuring designated personnel are medically cleared, 
prepared and ready to deploy at a moment's notice.
    Air Force Independent Duty Medical Technicians (IDMTs) have been 
tasked to support an expanding variety of missions and have become high 
demand, low-density assets. In Operation Enduring Freedom, they have 
been added to Special Forces teams for a variety of missions. IDMTs 
have provided medical care during prisoner transports, on an expedition 
into Tibet for recovery of remains, on drug interdiction operations, in 
austere, remote locations and on the front lines. This year, we are 
substituting IDMTs for the medical technicians assigned to our Squadron 
Medical Elements, teams deployed with flying squadrons to provide 
medical care in the operational environment. To support these 
additional taskings, we have increased our IDMT training program from 
108 to 168 per year.
    We continue our efforts to expand the scope of enlisted nursing 
practice through licensed practical nurse (LPN) training programs. This 
past year, we continued to send personnel to St. Phillip's College in 
San Antonio, Texas for a six-month program that prepares graduates to 
take the state board LPN licensure exam. To date, 48 medical 
technicians have completed the LPN program at St. Phillips College. 
This year, we are partnering with the Army Licensed Vocational Nurse 
Program to provide a more structured and comprehensive training program 
and increase our numbers of graduates to 60 students per year. As of 1 
November 2002, a special experience identifier was implemented to 
provide visibility in the personnel system for licensed practice nurses 
and enable appropriate assignment actions.
    We are successfully maintaining our medical enlisted end strength. 
The overall manning for technicians in the aerospace medical service 
career field remains above 90 percent, which can be construed as a 
positive reflection of satisfaction and the impact of quality of life 
initiatives. The neurology technician career field has been critically 
manned for some time, and I am pleased to report that the 
implementation of a selective reenlistment bonus has been very 
successful. The neurology career field manning has improved from 69.2 
percent in May 2001 to 88.5 percent in November 2002 and is projected 
to grow to over 90 percent with the graduation of the next training 
course.
    Nursing services is actively engaged in optimizing health care. 
This maintains a healthy, fit and ready force, improves the health 
status of our enrolled population and to provides health care more 
efficiently and effectively. The Air Force has seen continuing growth 
in the success of Primary Care Optimization (PCO) and we are now 
beginning the optimization of specialty services throughout our system, 
moving towards Health Care Optimization (HCO). Nurses and medical 
technicians continue to be the backbone of successful optimization, and 
we are refining the roles of the ambulatory care nurse, medical service 
technician, and Health Care Integrator (HCI) to ensure the patient 
receives the right care, at the right time, by the right provider.
    The PCO team is the epicenter for preventive services, management 
of population health and treatment of disease. We use civilian 
benchmarking to assess our healthcare outcomes and progress. The Health 
Plan Employer Data and Information Set (HEDIS) measures the health of 
our population and compares our outcomes to those of comparable 
civilian health plans. Using ideas generated from ``Best Practices'', 
we have seen impressive increases in the indicators of good diabetic 
management. In fact, 91 percent of Air Force facilities exceed the 
quality indicators for diabetic control measured through blood 
screening.
    Air Force facilities have been highlighted for other outstanding 
achievements in healthcare. Nurses and technicians at VA/DOD Joint 
Venture, 3rd Medical Group (MDG), Elmendorf AFB, AK were part of a 
project to increase the involvement of family and friends in patient 
care. This initiative's tremendous success led to the facility's 
selection by the Picker Institute as the #1 Benchmark Hospital in the 
United States for patient-centered surgical dimensions of care.
    In the 3rd MDG's ICU and multi-service unit (MSU), Air Force and 
Veteran Affairs (VA) nursing personnel are working side-by-side to 
deliver the highest quality care to DOD and VA beneficiaries. Air Force 
nurses train VA nurses in the MSU and VA nurses train Air Force nurses 
in the ICU. The robust and successful professional collaboration is the 
bedrock of this joint venture.
    Another great success in ambulatory care is the implementation of a 
population-based approach to case management. This program proactively 
targets at-risk populations and individuals along the health care 
continuum. One of our leading case managers, Lt. Col. Beth Register at 
Eglin AFB, FL has built an integrated approach that allows her six team 
members to each manage 50 cases, 200 percent above civilian industry 
caseload standards. Lt. Col. Register is preparing a TriService Nursing 
Research grant proposal to look at ``Efficacy of Case Management at an 
Air Force Facility'' and to test and validate the success of this case 
management program.
    Air Force nurse researchers continue to provide the answers to 
clinical questions that improve the science and the practice of 
nursing. Twenty-three Air Force nurses are actively engaged in 
TriService Nursing Research Program (TNSRP) funded research.
    The TNSRP-funded Nurse Triage Demonstration Project is in its 
second and final year of looking at the effective and efficient 
delivery of TeleHealth Nursing Practice. There have been some 
demonstrated positive outcomes. Clinical practice has been standardized 
through the use of medically approved telephone practice protocols; 
documentation has been improved through computer-based technologies and 
training programs have been developed and implemented.
    Another study conducted on in-flight invasive hemodynamic 
monitoring identified inaccuracies due to procedural variance. The 
recommendations resulted in significant process changes--and for the 
first time change was driven by scientific research. These process 
changes will be incorporated into the training programs for Critical 
Care Air Transport Teams (CCATT) and Aeromedical Evacuation (AE) 
nurses.
    The nurse researchers at Wilford Hall Medical Center in Texas are 
studying the care of critical patients in unique military environments. 
One of these studies looked at physiological responses to in-flight 
thermal stress in cargo aircraft used for aeromedical evacuation. The 
study identified areas in the aircraft where thermal stress was at a 
level that could be detrimental to critically ill patients. They also 
identified previously unrecognized limitations in accurate measurement 
of patient oxygenation during flight. These findings led to a study of 
warming devices to protect trauma victims from the deleterious effects 
of thermal stress following exposure in cold field environments or on 
cargo aircraft.
    It has been an exciting year for the Graduate School of Nursing at 
the Uniformed Services University and it is wonderful to be part of the 
planning for the development of a PhD nursing program. This program is 
crucial for Air Force Nursing to help us build leaders who are 
strategically prepared to lead in our unique military nursing 
environment.

                            CLOSING REMARKS

    Mister Chairman and distinguished members of the Committee, I have 
had the opportunity to lead the men and women of Air Force Nursing 
Services for three years and each has been full of new challenges, 
great opportunities and many rewards. Our nurses and aerospace medical 
technicians remain ready to support our Air Force by delivering best-
quality healthcare in peace, in humanitarian endeavors and in war. The 
escalation of world tensions in the last year has afforded a showcase 
for their enormous talent, stalwart patriotism and devotion to duty. On 
behalf of Air Force Nursing, I thank this committee for your tremendous 
support of military men and women, and in particular, for the special 
recognition and regard you have shown for our nurses. We are forever 
grateful for your advocacy and leadership. Thank you and may GOD BLESS 
AMERICA!

    Senator Stevens. Well, thank you very much, all of you and 
General, thank you very much for your appearances before our 
committee and wish you well in your further endeavors. I'm 
going to have to excuse myself now. I had an appointment at 
noon. This is one of the strangest days. Senator Inouye will 
complete the hearing. Thank you very much.

                             NURSE SHORTAGE

    Senator Inouye [presiding]. Thank you, Mr. Chairman. As I 
believe all of you are aware, the American Hospital Association 
just announced that there is a shortage at this moment in 
excess of 126,000 nurses in our Nation's hospitals, and the 
American Medical Association announced that by the year 2020, 
this shortage will exceed 400,000.
    Add to this the fact that all three services have had to 
send and deploy nurses to Operation Iraqi Freedom. My question 
to all of you is that during this period, were we able to 
provide appropriate, adequate, and effective nursing care to 
the patients at home here?
    General Bester. Senator, I can answer that question with an 
unequivocal yes. I think each one of our facilities has 
carefully looked at our nursing staffing situations with our 
Reserve backfill. Of course, as you had mentioned earlier not 
at the level that we would like to see it, but certainly with 
the Reserve backfill that we have got with hiring some 
additional contract nurses, and then with the support the 
continued support of our civilian nursing staff, we have looked 
at the staffing situation by hospital.
    In some cases, it means that we have had to divert some 
patients downtown and in some cases, on rare cases we have had 
to close or at least decrease the number of operational beds 
that we have, but I think we have always kept our focus on the 
quality of care to be sure that we are providing the same 
quality of care that we did prior to the war.
    Admiral Lescavage. Senator, I believe the answer all boils 
down to great attitude and team spirit. We watched very 
carefully as we deployed several hundred nurses and saw our 
wonderful Reservists step in who are used to working in our 
facility anyway during their Reserve time, as well as our 
civilian nurses, our backbone.
    We also are in line with the Institute on Health Care 
Improvement, with their big safety initiatives. We have safety 
programs that occur in our hospitals constantly looking for any 
discrepancies in care. We have seen zero, and I'm truly 
confident that our patients continue to receive the best and 
safest care that they possibly can, both in the war scenario, 
as well as back at our MTFs.

                      HOSPITAL SERVICES REDUCTION

    Senator Inouye. I have been told that in some facilities 
they had to curtail certain services like obstetrical surgery 
and such. Did we experience anything like that?
    Admiral Lescavage. Senator, we have curtailed slightly. We 
worked with the network to take care of those patients, but 
between what we expected compared to what truly did happen, 
there wasn't that big of a difference.
    Senator Inouye. So Bethesda is still a full-service 
hospital?
    Admiral Lescavage. Yes, sir.
    General Brannon. Yes. I would echo the comments from my 
colleagues with careful attention to staffing ratios and the 
acuity of the patients in our facilities. We have been able to 
ensure that the care we are rendering is just as safe as when 
we had those other nurses who were deployed.
    We did get some backfill after many of our nurses deployed, 
and that enabled us to keep full services at most 
installations. Occasionally we needed to close beds and divert 
patients downtown. At most facilities it was temporary until 
the acuity of the patients was lower, the same procedure we use 
in peacetime.

                          SPECIALIZED TRAINING

    Senator Inouye. Very few of our nurses have combat care 
experience. What sort of specialized training did you provide 
to prepare them for this? General?
    General Bester. Senator, our nurses are actively engaged in 
a number of programs. First of all, as was mentioned by General 
Peake of the Army Trauma Training Center down at Ryder Trauma 
Training Center in Miami is a place where we train all of our 
forward surgical teams. We have five full time Army Nurse Corps 
officers assigned to that facility and in just this last year, 
we have trained 290 Army Nurse Corps officers, both active and 
Reserve through that facility.
    We send our nurses to the combat casualty care course, a 9-
day course in San Antonio, that they experience taking care of 
patients under combatlike conditions. General Peake initiated a 
couple years back a superb type of program that is now 
mandatory to take before any of our courses, short courses that 
we take. And so many of our Nurse Corps officers are actively 
engaged in that training.
    We feel in addition to that, we have a lot of professional 
training that goes on. We have some facilities that actually 
have medical sites, and they do real wartime training in those 
facilities. We feel we have kept well ahead of that rolling 
ball as far as training our nurses on a continual basis, so we 
feel they were very well prepared when it came time for them to 
deploy.
    Admiral Lescavage. Senator, we saw this coming and in order 
to increase our comfort level, a while ago, we instituted 
training not only for our nurses but for the teams, the 
corpsmen, the physicians, as well as the nurses who would be 
dealing with combat casualties.
    As I stated in my testimony, we instituted trauma training 
courses with LA County. That's working very well. We also have 
joined our sister services in some of their training as General 
Bester just alluded to, such as the combat casualty care 
course. Across all of our joint service nurses, many of them go 
to that, as well as to our education and training command. We 
offer many courses and again I'm fully confident that they are 
trained very well.
    General Brannon. Well, I think training is one of the real 
strengths in our Air Force and in our air expeditionary 
platforms. We ensure that people go for the training they need 
prior to deployment.
    What we have done in the medical service is identify, by 
task, all of the skills needed by people who are in specific 
deployment modules and we make sure that they have current 
training in each of those tasks. We have set up a modular 
deploying medical force sized from very small units all the way 
up to our EMEDS unit, which provide more sustaining patient 
care.
    For those smaller, more acute critical teams, we use the 
Baltimore shock trauma system at the University of Maryland for 
training through a collaborative partnership. That program has 
been in existence for more than 1 year. We have trained more 
than a couple of hundred medics including 70-some nurses. We 
also have EMEDS training in San Antonio at Brooks City Base. 
All of our EMEDS people go through that training prior to 
deployment.
    Finally, for many years we have had the Top Start programs 
at different medical centers where medics, both enlisted and 
officers, get training for a variety of tasks and procedures. 
It is a great performance-based training.

                       PERCENTAGE OF MALE NURSES

    Senator Inouye. One last question, and I will submit the 
rest and Senator Stevens has requested that his questions be 
submitted also. What percentage of your nurses in the Army are 
male?
    General Bester. Senator, at the current time, 36 percent.
    Senator Inouye. Navy?
    Admiral Lescavage. One-third of our nurses or 3,200.
    General Brannon. A little over 30 percent, sir. Similar 
percentage.
    Senator Inouye. I'm glad to see it coming up. For too long, 
nursing has been looked upon as a secondary position filled 
with women only. And apparently, this is a man's world yet, and 
so the more men you get, the bigger pay you'll get. That's not 
a nice thing to say, but----
    General Brannon. It is very true.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Inouye. Those are the facts of life around here. 
Without objection, all of the statements of the witnesses will 
be made part of the record.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]

          Questions Submitted to Vice Admiral Michael L. Cowan

               Questions Submitted by Senator Ted Stevens

                    DEPLOYMENT OF MEDICAL PERSONNEL

    Question. The staff's discussions with the Surgeons General 
indicate that the Services have backfilled for deployed medical 
personnel at the Medical Treatment Facilities at varying levels.
    Some of the Services are relying more heavily on private sector 
care rather than backfilling for deployed medical personnel.
    To what extent has the recent deployment of military medical 
personnel affected access to care at military treatment facilities? 
What are you doing to ensure adequate access to care during this time?
    Answer. We have been able to maintain services required to address 
the needs of both patients coming in from the battlefields and those 
seeking regular care through significant deliberate planning. We 
implemented core doctrine and conducted intense scrutiny of Military 
Treatment Facilities (MTFs) services availability. We identified the 
appropriate reservists to support the Military Treatment Facilities 
(MTFs) in maintaining services, in some cases adding contract 
personnel. Each week we tracked the availability of services at each 
MTF. Our MTF personnel, along with activated reservists worked at 
unsustainable levels during the deployment and were able to ensure that 
access to care was maintained at all MTFs. A survey of activated 
reservists is now underway to fully assess the productivity and 
effectiveness of all of our personnel, including our reserve support in 
ensuring that access to care was maintained for all beneficiaries 
during Operation Iraqi Freedom.

              MOBILIZED RESERVISTS IN MEDICAL SPECIALTIES

    Question. What percentage of mobilized Reservists in medical 
specialties are being used to backfill positions in the United States?
    Answer. Backfilling of Military Treatment Facilities (MTFs) using 
Reservists in medical specialties is determined on a ``case-by-case'' 
basis, and approved by USD (P&R). During Operation Iraqi Freedom (OIF), 
the Navy was approved to backfill Navy MTFs (in a phased plan) at a 
rate of 53 percent of deployed active duty medical personnel. Due to 
the short course of OIF, Navy MTFs were actually backfilled at 43 
percent.
    Question. Are there shortages of personnel in some specialties? If 
so, which specialties are undermanned and by how much?
    Answer.
Dental Corps
    Due to a significant downward trend in retention of LT/LCDR General 
Dentists coupled with significant under execution of CNRC DC accessions 
the Dental Corps is undermanned; specifically Oral Surgeons, 
Endodontists, and General Dentists.
    Dental Corps overall manning has been trending downward for the 
last three years, ending fiscal year 2002 at 94.4 percent manning 
(1,294 INV/1,370 BA or -76). The EFY 2003 projection is estimated at 
<90 percent.
    In addition to General Dentists, the Oral Surgeon and Endodontist 
communities are significantly short due to reduced numbers of officers 
entering the training pipeline as direct impact from the shortfall in 
the General Dentist community, and an increase in the loss rates in 
these communities.

----------------------------------------------------------------------------------------------------------------
                                                                                                 Fiscal   Fiscal
                  Corps Specialty (PSUB)                      INV       BA      PCT      +/-      Year     Year
                                                                                                  2004     2005
----------------------------------------------------------------------------------------------------------------
DC--Dentist (1,700).......................................      486      594       82     -108       80       78
DC--Oral Surg(1,750J/K)...................................       66       82       80      -16       78       72
DC--Endodontist (1,710J/K)................................       44       52       85       -8       83       80
----------------------------------------------------------------------------------------------------------------

    The remaining Dental Corps specialties are stable at this time with 
sufficient gains to compensate for losses, but is anticipated to become 
a problem in the future if General Dentist retention and accessions is 
not significantly improved, as this is the applicant pool for specialty 
training.

Medical Corps
    The Medical Corps continues to have difficulty in retaining certain 
specialties. The Medical Corps has less than 80 percent manning in 
Anesthesia, Radiology, General Surgery, Pathology, and Radiation 
Oncology. Internal Medicine and subspecialties (84 percent) and 
Dermatology (83 percent) are near the critical point of under manning.
    Inability to access or retain specialties noted above can be 
attributed to significant military-civilian pay gaps and declining 
number of quality of work attributes that once made practicing in Navy 
Medicine enticing over the private sector (e.g., increased operational 
tempo). Additionally, the changing face of medicine in the civilian 
sector (e.g., fewer applicants for medical school and even fewer 
medical school graduates going into the above specialties) is affecting 
Navy Medicine as well.
    The primary pipeline for Navy physicians is the Health Professions 
Scholarship Program (HPSP), which brings in 300 of the 350 individuals 
entering as medical students. The HPSP recruiting goal for fiscal year 
2003 is 300. The Navy is behind in recruiting in that by May, there are 
usually about 150 recruited. Presently there are only 51. It should be 
noted that not only is the number of HPSP recruits diminishing, but the 
quality has also decreased when utilizing MCAT scores as an indicator 
of quality. In he past, HPSP recipients had MCAT scores of 26-30. 
Applicants with scores as low as 22 are being considered in order to 
fill quotas.

Medical Service Corps
    Retention in the Medical Service Corps is good overall. End of 
fiscal year 2002 manning was at 98.5 percent with projections for the 
next two years at or near 98 percent manning. However, difficulties 
remain in retaining highly skilled officers in a variety of clinical 
and scientific professions.
    The Medical Service Corps is comprised of 32 different health care 
specialties in administrative, clinical, and scientific fields. The 
education requirements are unique for each field; most require graduate 
level degrees, many at the doctoral level.
    Biochemistry, Entomology, and Podiatry are undermanned by more than 
10 percent. Average yearly loss rates are high in Biochemistry, 
Physiology, Environmental Health, Dietetics, Optometry, Pharmacy, and 
Psychology. Loss rates this year are very high for Microbiologists & 
Social Workers.
    The Medical Service Corps does not have available to them retention 
tools or special pays for scientists and very limited ones for 
clinicians such as Optometrists, Pharmacists, and Podiatrists.

Nurse Corps
    The Nurse Corps continues to be healthy considering the national 
nursing shortage. The affect of a decreasing number of students who 
choose nursing as a career and the ever-increasing demand for 
professional nursing services will need to be closely monitored to 
ensure Navy Nurse Corps is able to meet the requisite number and 
specialty skill mix.
    Ability to meet Navy Nurse Corps requirements are due to concerted 
efforts in diversifying accession sources and increased retention rates 
and as a direct result of pay incentives and graduate education 
opportunities.

Hospital Corps
    The Hospital Corps continues to have difficulty in retaining 
certain specialties. Currently there is less than 80 percent manning in 
11 Hospital Corps and one Dental Technician NEC. Inability to access or 
retain some of these specialties can be attributed to significant 
military-civilian pay gaps.
    Question. Are there other ways of structuring the staffing of 
military medical units that might help address shortages in a few 
specialties, such as making increased use of civilian contractors or 
DOD civilian personnel in MTFs stateside?
    Answer. MTF Commanders have been tasked with creating business 
plans for the optimal operation of medical treatment facilities within 
each market area. An integral part of the business planning process is 
the assessment of the supply of critical staffing as compared with the 
expected demand in a given market. MTF Commanders use this analysis in 
determining shortfalls of critical medical staff. Meeting these 
critical requirements can be accomplished using a variety of methods. 
MTF Commanders may shift existing DOD civilian personnel where 
feasible, hire additional contract personnel or request changes in the 
billet structure via Manpower at the Bureau of Medicine.
    Question. Is DOD considering any changes to the mix of active duty 
and reserve personnel in medical specialties?
    Answer. At this time, no changes are anticipated regarding the mix 
of active and reserve personnel within medical specialties from Navy 
Medicine's perspective. Various studies have been initiated but the 
current view of casualty causes for OEF and OIF do not suggest that any 
major changes in force structure mix or specialty will be necessary.

          MONITORING THE HEALTH OF GUARD AND RESERVE PERSONNEL

    Question. An April 2003 GAO report documents deficiencies by the 
Army in monitoring the health of the early-deploying reservists. Annual 
health screening is required to insure that reserve personnel are 
medically fit for deployment when call upon.
    Review found that 49 percent of early-deploying reservists lacked a 
current dental exam, and 68 percent of those over age 40 lacked a 
current biennial physical exam.
    What improvements have been made to the medical information systems 
to track the health care of reservists? Are they electronic, do they 
differ among services?
    Answer. The Naval Reserve is utilizing the Reserve Automated 
Medical Interim System (RAMIS), a web-based Oracle product, deployed in 
March 2002 to serve as an interim system until the Naval Reserve's full 
participation in the Theater Medical Information Program (TMIP). The 
system tracks medical and dental readiness requirements and provides 
roll up reporting capabilities to produce a ``readiness snapshot'' for 
unit commanders, activity commanding officers and headquarters. Plans 
are currently being drafted to begin development work in 2004 for an 
all Navy (Active/Reserve) web-based system using technology from RAMIS 
and a Navy active duty product, SAMS Population Health. This product 
will be part of TMIP and will provide interoperability between all DOD 
components and services.

               NUMBER OF RESERVISTS WITH MEDICAL PROBLEMS

    Question. During the mobilization for Operation Iraqi Freedom, how 
many reservists could not be deployed for medical reasons?
    Answer. 436 Naval Reservists were unable to be deployed due to 
disqualifying medical or dental reasons.

            NUMBER OF RESERVISTS NOT IN DENTAL CLASS 1 OR 2

    Question. How many deployments were delayed due to dental reasons, 
and how many reservists are not in Dental class 1 or 2?
    Answer. The Naval Reserve averages 90 percent of our personnel in 
dental categories 1 and 2. We estimate that less than 1,600 personnel 
out of more than 20,000 Naval Reservists mobilized (approximately 8 
percent) were delayed for any amount of time for dental reasons.
    Question. What is the current enrollment rate in the TRICARE Dental 
Program for reservists and what action has DOD taken to encourage 
reservists to enroll in TDP?
    Answer. The fiscal year 2003 end strength numbers for eligible Navy 
and Marine Corps Selected Reserve sponsors is estimated to be 127,358 
(Navy Reserve 87,800 and Marine Corps Reserve 39,558). TDP enrollments 
as of January 2003 for this eligible population were 8,599 (Navy 
Reserve 6,566 and Marine Corps Reserve 2,033). These figures represent 
a 6.8 percent enrollment rate. Marketing of the TRICARE Dental Program 
(TDP) to all eligible populations is conducted by the TDP contractor. 
The initial marketing effort by the contractor entailed sending TDP 
information to each reserve and guard unit. Quantities of information 
sent were based on unit end strengths. Health Affairs policy 98-021 
directed the services to ensure all members of the Selected Reserve 
undergo an annual dental examination. The documenting tool provided by 
HA is DD Form 2813; DOD Reserve Forces Dental Examination. A provision 
in the TDP contract requires network providers to complete the DD Form 
2813 for TDP enrolled reservists. It is the responsibility of the 
reservist to present the form to the dentist. The Defense Manpower Data 
Center (DMDC) provides the TDP contractor quarterly file listing newly 
eligible sponsors. This file is used for the ongoing marketing efforts 
under the TDP. The TDP contractor has also established a website for 
the TDP. The contractor has a staff of Dental Benefits Advisors (DBA) 
that travel to military installations to include reserve and guard 
facilities. TMA's Communications & Customer Service marketing office 
has worked with Reserve Affairs to developed and post TDP fact sheets 
on the TMA website that are linked to other reserve and guard websites 
and the TDP contractor.

               REMAINING MEDICAL AND DENTAL REQUIREMENTS

    Question. What needs to be done and what will it cost to ensure 
that reservists are medically and dentally fit for duty?
    Answer. The Reserve Components have little or no identified funding 
support for medical and dental readiness and, under Title 10 authority, 
are not eligible for Defense Health Program (DHP) funds. OSD(RA) is 
presently drafting a White Paper in support of a Reserve Health Program 
that will require a separate appropriation to support Medical/Dental 
Readiness for the seven Reserve/Guard Components. Cost estimates will 
be available when the White Paper is complete.

                  REPERCUSSIONS FOR UNFIT UNIT MEMBERS

    Question. Are there any repercussions for commanders who do not 
ensure that their troops are fit for duty?
    Answer. Unit commanders are responsible for ensuring personnel are 
trained and ready in all aspects, including medical and dental fitness, 
for mobilization. Unit commanders are evaluated and ranked, in part, in 
Fitness Reports based upon total unit readiness.

                COMBAT TREATMENT IN IRAQ AND AFGHANISTAN

    Question. All of the Services have undertaken transformation 
initiatives to improve how medical care is provided to our front line 
troops.
    The initiatives have resulted in more modular, deployable medical 
units which are scalable in size to meet the mission.
    How well have your forward deployed medical support units and the 
small modular units performed in Operation Enduring Freedom and 
Operation Iraqi Freedom?
    Answer. Most of the information provided is anecdotal. We will not 
have significant formal input until the ``lessons learned'' are 
provided by the deployed platforms and the receiving component 
commanders. The formal collection of feedback is still ongoing as units 
return from Iraq. Initial reports indicate that the 116 bed 
Expeditionary Medical Facilities forward-deployed into Iraq functioned 
as they were designed. The 250-bed Fleet Hospital staged in Rota, Spain 
also functioned well. The USNS Comfort was on station, on time to 
receive casualties. The casualties received were handled well. Use of 
the Comfort by the theater commands raised issues related to inter-
theater movement of patients. These issues are being reviewed as part 
of the overall assessment of CASEVAC/MEDEVAC. The Casualty Receiving 
and Treatment Ships were stationed and staffed as required. Due to the 
nature of the conflict, they saw limited action. The Forward 
Resuscitative Surgical Systems were deployed in pairings with the 
surgical companies. These locations were less far forward than 
initially planned and the optimal placement is under review. Reports 
from Level II and Level III facilities strongly support that 
interventions by the FRSS were critical in saving lives that might have 
been lost in previous conflicts. Three PM-MMART teams were deployed to 
Iraq and were highly successful in providing disease vector assessment/
control, epidemiology and epidemiological humanitarian support, 
industrial and environmental site assessment, sanitation assessment and 
public health education.
    Question. What are some of the lessons learned from our experience 
in Iraq?
    Answer. Smaller, lighter, more mobile works and works well. Task 
orienting enhances the likelihood of success. Communications in the 
field between Level I care and higher levels are not optimal. This is 
also true for inter-service communication. Component UIC's work and 
work well. Management of the component UIC's needs to remain centrally 
located. Arbitrary peripheral changes to platforms by individuals and 
units disrupted the ability to fully staff platforms with qualified 
personnel and hampered the ability to identify replacements and 
augments for future needs. Using Fort Benning to inprocess individual 
augmentees and equip them prior to deployment was highly successful and 
emphasized joint inter-operability. Personnel policies regarding stop-
loss or stop-move should be determined before deployments commence. The 
policies need to be tailored to the circumstances and not applied 
across the board unless this is indicated. Provision needs to be made 
for providing transportation for the PM-MMART units, either as part of 
COCOM support or as part of the intrinsic equipment package.
    Question. What tools/equipment is still required to improve the 
care provided to combat casualties?
    Answer. Dedicated, durable, mobile, state-of-the-art, easily up-
gradable communications, both between levels of care and between 
services is needed. Better CASEVAC capability is required under all 
circumstances. As we gather ``lessons learned'' through the formal 
process, more needs may be identified and further recommendations will 
be forthcoming.

              T-NEX--NEXT GENERATION OF TRICARE CONTRACTS

    Question. The award date for these contacts has slipped from the 
scheduled date in July of 2003. Since the timeline for awarding the 
contracts has slipped, what is the expected start date for the delivery 
of T-Nex?
    Answer. The overall schedule for the suite of T-Nex solicitations 
has not been changed although some award dates may be delayed if 
proposals require more extensive review. The TRICARE Mail Order 
Pharmacy Contract was awarded, and performance began on March 1, 2003. 
The TRICARE Retiree Dental Contract was also awarded and performance on 
this contract began on May 1, 2003. Proposals have been received for 
both the TRICARE Healthcare and Administration Managed Care Support and 
the TRICARE Dual-Eligible Fiscal Intermediary contracts, and the 
evaluation process for both of these is ongoing. Requests for Proposal 
have been issued for the TRICARE Retail Pharmacy and National Quality 
Monitoring contracts, and those proposals are due June 11 and June 3, 
respectively. Procurement sensitivity rules prohibit disclosure of any 
specific information or details about the ongoing evaluation of 
proposals. However, I can tell you that the evaluations are ongoing. No 
decision has been made to alter the implementation schedule for any of 
the contracts.
    Question. What planning is taking place to help ensure that when 
the contracts are entered into there will be a seamless transition for 
beneficiaries?
    Answer. No transition of this magnitude is easy. A customer focused 
perspective in execution is central to making this as seamless as 
possible. We have already transitioned the TRICARE Mail Order Pharmacy 
contract with success. The TRICARE Retiree Dental Plan contract was 
also awarded without protest and now is in its first month of operation 
without issues. With regard to our managed care contracts, going from 
seven contracts to three will simplify administration, but more 
importantly better serve our beneficiaries with incentivized 
performance standards, greater uniformity of service, alleviation of 
portability issues, and simplified business processes.
    I have instituted a solid oversight structure (see attachment), and 
appointed a senior executive to spearhead this transition and supervise 
all aspects of the procurement including the implementation of the new 
regional governance structure. This operational approach and structure 
requires my direct involvement through the Transition Leadership 
Council made up of the Surgeons General, the Principal Deputy Assistant 
Secretary of Defense for Health Affairs and the Health Affairs Deputy 
Assistant Secretaries of Defense. This body is supported by a TRICARE 
Transition Executive Management Team which is chaired by TMA's Chief 
Operating Officer.
    An area of detailed focus right now is access to care and all 
business processes that will impact access including: networks, 
provider satisfaction, appointing and scheduling, Military Treatment 
Facility (MTF) optimization, and local support for MTF commanders. We 
are optimistic that robust networks can be maintained. On all customer 
service fronts, my staff and other participants are poised to execute a 
smooth transition immediately following contract award. Regular 
meetings are underway to measure our progress and formulate sound 
decisions on any problematic issues. A contract transition orientation 
conference is planned for June 2003 to fully engage government 
participants in all aspects of the transition process.
    Question. Are beneficiaries experiencing any change in quality of 
care due to DOD's inability to enter into new long-term managed care 
agreements?
    Answer. The evaluation of contractor proposals is now underway and 
will culminate in the awarding of three new Health care and 
Administration regional contracts. A planned 10-month minimum 
transition period will precede start of health care delivery. 
Surveillance for the delivery of services of outgoing contractors 
during the transition period will remain focused to avoid any 
deterioration in customer service standards. Current contracts have 
been extended beyond original termination dates to ensure there is no 
adverse impact on the beneficiary or quality of care.
    Any signs of negative shifts in quality during this transition 
period will be quickly recognized and dealt with on a priority basis. 
Our proactive posture is expected to result in a near-seamless 
transition to next generation contracts. Additionally, in T-Nex 
contracts, industry best business practices are fully expected to 
emerge through the competitive process. Customer service protocols will 
be favorably impacted by outcome-based requirements and accompanying 
performance standards. Additionally, web-based service applications 
will also improve business processes and the way customers can access 
information. This is all very exciting and bodes well for our customers 
in the new contracts.
    Question. Under T-Nex, what services currently provided by the 
TRICARE contractors will shift to the direct care system and what are 
the costs associated with this shift in services?
    Answer. Appointing, Resource Sharing, Health Care Information Line, 
Health Evaluation & Assessment of Risk (HEAR), Utilization Management, 
and Transcription services will transition from the Managed Care 
Support Contracts to MTFs under T-Nex. The Services have been tasked to 
provide requirements in each of these areas, cost estimates, and 
transition timelines. We have worked with the Services to develop a 
joint approach to determine local support contract methodology. 
Transition of Local Support Contract services must be completed not 
later than the start of health care under T-Nex in each region. Based 
on known contract and staffing lag times, funding is required six 
months prior to the start of health care delivery to ensure smooth and 
timely stand up of new services. At this stage, cost estimates are 
varied and of limited value until the requirement is validated and 
fully known. Initial rough estimates are in the hundreds of millions of 
dollars. The funding source for Local Support will come from funds 
committed to the current Military Health System (MHS) Managed Care 
Support contracts. Those funds were programmed based on existing 
purchased care contracts that included these services. Because it is 
understood that these funds may not cover the entire spectrum of Local 
Support contracts, the Medical Services have prioritized these services 
across the MHS into three tiers based on impact and need. Initial costs 
may ultimately include some investment in telephone and appointing 
infrastructure, thus driving a significant increase in front end costs.

                        RECRUITING AND RETENTION

    Question. Personnel shortfalls still exist in a number of critical 
medical specialties throughout the Services. The Navy reports 
shortfalls in Anesthesiology, General Surgery, Radiology, and 
Pathology, and has stated the civilian-military pay gap is their 
greatest obstacle in filling these high demand specialties. Recruiting 
and retaining dentist appears to be a challenge for all the Services.
    To what extent have Critical Skills Retention Bonuses or other 
incentives been successful in helping to retain medical personnel?
    Answer.

Dental Corps
    When the CSRB was combined with the renegotiation of Dental Officer 
Multi-year Bonus (DOMRB) contracts, the effect was increased obligation 
for those that took DOMRB contracts. This in effect tied the one-year 
CSRB to a multi-year obligation, having some positive effect.

Medical Corps
    The CSRB helped retain some individuals in Anesthesia, Radiology, 
Orthopedics, and General Surgery who would have otherwise gotten out of 
the Navy. Because the CSRB was limited to a one year contract, the long 
term benefit is minimal.

Medical Service Corps
    The Critical Skills Retention Bonus was not offered to any of the 
Medical Service Corps specialties.

Nurse Corps
    The Critical Skills Retention Bonus was offered to qualified nurses 
resulting in acceptance rates of 87 percent for Certified Registered 
Nurse Anesthetists (CRNAs) and 98 percent for Perioperative Nurses. For 
the CRNAs, it has been a positive influence for staying beyond their 
obligated service period. We are presently at end-strength in both 
communities based on a combination of factors such as special pays, 
scope of practice satisfaction and a focus on quality of life issues.

Hospital Corps
    When incentive and special pays have been put in place for 
undermanned specialties, accessions have increased.
    Psychiatry Technician and Respiratory Therapy Technician 
communities manning increased, 36 percent and 28 percent respectively, 
after implementation of the Selective Training and Reenlistment (STAR) 
Program and increased Selective Reenlistment Bonus.
    Question. What else needs to be done to maximize retention of 
medical personnel?
    Answer.

Dental Corps
    The NDAA fiscal year 2003 raised the caps on the Dental Officer 
Multi-year Retention Bonus (DOMRB). It is hoped that the anticipated 
increase in pay while falling significantly short of comparable 
civilian pay, will demonstrate a commitment by Navy to increase 
compensation for dentists in the interim while a more comprehensive 
plan is developed.
    There was a slight enhancement in overall retention as a result of 
increases in dental ASP in 1997 and the initial offering of DOMRB in 
1998 compared to previous years, but that effect has since worn off. 
Despite the introduction of the DOMRB and increase in ASP rates, the 
overall loss rate continues to climb to the highest it has been at 12.2 
percent in fiscal year 2002, higher than the 11-year average of 10.8 
percent. The majority of losses are junior officers (LT-03) releasing 
from active duty at the completion of their first term of obligated 
service. These year groups are not eligible for the DOMRB at this point 
in their careers and the current ASP rates are too low to impact their 
decision to stay on active duty. Furthermore, under current 
legislation, if the junior officer were to enter residency training 
they would have to give up the ASP for up to 4 years depending on the 
program length. Again, reducing the incentive to remain on active duty 
and pursue training.
    There is no incentive special pay (ISP) for dental officers, 
although it may be helpful to target pay increases for dental 
specialties with the largest military-civilian pay gap. A comparison of 
representative civilian and military average pays is as follows 
(source--the American Association of Oral and Maxillofacial Surgeons):

----------------------------------------------------------------------------------------------------------------
                        Avg Mil LCDR Pay                           Military Pay    Civilian Pay    Differential
----------------------------------------------------------------------------------------------------------------
Specialist......................................................         $94,654        $202,360        $107,706
Oral Surgeon....................................................          94,654         297,360         202,706
General Dentist.................................................          68,871         154,741          85,870
----------------------------------------------------------------------------------------------------------------

Medical Corps
    In addition to closing the civilian to military pay gap, physicians 
look for similar qualities of life as their line counterparts. The 
ability to increase their level responsibility, take on clinical, 
operational and administrative challenges, practice their profession 
the way they feel they should, hone their skills, select for the next 
higher rank, maintain geographic stability for their families, and have 
time to spend with family and friends are all important in retaining 
physicians. Having support staff in adequate numbers, well maintained 
and current technical specialty equipment, and a professional 
environment which respects the physician is tantamount to maintaining 
our physician workforce.

Medical Service Corps
    Retention in the Medical Service Corps is good overall. However, 
difficulties remain in retaining highly skilled officers in a variety 
of clinical and scientific professions. Retention of these highly 
skilled officers is predominately affected by:
  --Civilian to military pay gap.--Economic influences as well as 
        civilian workforce shortages can have a profound effect on the 
        size of the pay gap. With the evolving Home Land Security 
        requirements, the demand for our scientific officers with 
        chemical, biological, radiological and nuclear training and 
        experience in the private sector is becoming a significant 
        factor in retention. Need to explore the implementation of U.S. 
        Code: 37, Section 315, Engineering and Scientific Career 
        Continuation Pay to improve the retention of our highly skilled 
        scientific officers.
  --Significant student debt load.--Many of our clinical and scientific 
        professions require a doctorate level degree to enter the Navy. 
        Frequently, there are a limited number of training programs 
        available in the United States and often only available at 
        private institutions. For example, there are approximately 
        seven institutions that train Podiatrists. All of the schools 
        are private institutions. Podiatry school is a four-year 
        academic program after completing their undergraduate pre-
        professional requirements,. The average student debt load for 
        our entering Podiatrists is $150,000. The use of HPLRP, AFHPSP 
        and HSCP alleviates much of the student debt load for a few of 
        these officers.
  --Personal issues.--Dual family careers, child care and frequent PCS 
        moves can impact retention. However, what may be considered a 
        strong reason to leave military service by one member may be 
        considered a strong reason to stay on active duty for another.

Nurse Corps
    Nurse Corps officers seek scope of practice satisfaction that 
includes continuing formal education opportunities, collegial 
relationships with physicians and other allied health personnel and 
current technical capability. Nurse Corps officers also vocalize the 
need to attend to quality of life issues such as affordable housing and 
childcare and geographic stability for their families.
                                 ______
                                 
            Questions Submitted by Senator Pete V. Domenici

               JESSE SPIRI MILITARY MEDICAL COVERAGE ACT

    Question. In 2001, a young Marine Corps 2nd Lieutenant from New 
Mexico lost his courageous battle with cancer. Jesse Spiri had just 
graduated from Western New Mexico University and was awaiting basic 
officer training when he learned of his illness.
    However, because his commission had triggered his military status 
to that of ``inactive reservist,'' Jesse was not fully covered by 
TRICARE. As a result, he was left unable to afford the kind special 
treatment he needed.
    I believe that it is time to close this dangerous loophole. That is 
why I intend to offer a bill entitled the ``Jesse Spiri Military 
Medical Coverage Act.''
    This bill will ensure that those military officers who have 
received a commission and are awaiting ``active duty'' status will have 
access to proper medical insurance.
    Would you agree that this type of loophole is extremely dangerous 
for those who, like Jesse, suffer with a dreaded disease?
    Answer. When an individual accepts an offer of a commission in the 
USN or USMC, there is a period of time prior to the beginning of Active 
Duty when they are in a ``inactive reservist'' status. During this 
time, the individual is not covered as a health care beneficiary in the 
TRICARE program. The individual remains responsible for obtaining their 
own health care insurance because they are not yet in ``active duty'' 
status.
    Question. And do you agree that our military health care system 
should close this loophole, and can do so very cost effectively (given 
the relatively low number of officers it would affect)?
    Answer. We would like the opportunity to more carefully study this 
situation. There are other categories of individuals who have agreed to 
serve in the Armed Forces and who need to maintain their own health 
insurance until they begin active duty or active training. These would 
include all officer candidates on some type of delayed entry program 
such as medical students in the Health Scholarship Program, ROTC 
students, as well as personnel who agree to join the military following 
college. In addition, there are many enlisted personnel who join the 
military on a delayed entry program and are required to maintain their 
health insurance until they begin active training. These individuals 
are also awaiting entry on ``inactive reservist'' status. Without 
studying each of these categories of individuals, estimating their 
numbers and their likelihood of developing illnesses, it is premature 
to estimate the financial burden to the Navy in implementing the 
proposed changes.

               MILITARY FAMILY ACCESS TO DENTAL CARE ACT

    Question. I think everyone here is familiar with the adage that we 
recruit the soldier, but we retain the family. That means taking care 
of our military families and giving them a good standard of living.
    I have introduced a bill that would provide a benefit to military 
families seeking dental care, but who must travel great distances to 
receive it.
    Specifically, my bill, the ``Military Family Access to Dental Care 
Act'' (S. 336) would provide a travel reimbursement to military 
families in need of certain specialized dental care but who are 
required to travel over 100 miles to see a specialist.
    Often, families at rural bases like Cannon Air Force Base in 
Clovis, NM meet with financial hardship if more than one extended trip 
is required. This bill reimburses them for that travel and is a small 
way of helping our military families.
    Given that current law provides a travel reimbursement for military 
families who must travel more than 100 miles for specialty medical 
care, do you believe it is important to incorporate specialty dental 
care within this benefit?
    Answer. Concur. The Bureau of Medicine and Surgery recommends that 
Sec. 1074i of title 10 United States Code be amended incorporate 
specialty dental care within this benefit. By providing a travel 
reimbursement to military families in need of specialized dental care 
who must travel over 100 miles to seek that care, we demonstrate our 
utmost support and recognition of their roles as critical members of 
the Navy healthcare team.
    Currently family members who are enrolled in TDP (TRICARE Dental 
Program) (Sec. 1076a.--TRICARE dental program) are not eligible for 
care in military DTFs except for emergencies or when OCONUS. All other 
(nonenrolled) Family Members are only eligible for ``Space A'' Care in 
CONUS. The USAF (with input from USN/USA) is currently sponsoring a 
proposal to change Title 10 to permit limited treatment of AD family 
members to meet training, proficiency and specialty board 
certification.
    Question. Do you think this benefit would improve the standard of 
living of our military families?
    Answer. Yes. Dental care is a quality of life enhancement. Reducing 
out of pocket costs for specialty dental care available only at 
distances away the homebases of Military Family Members would increase 
the likelihood that needed dental services would be accessed and result 
in increased dental health.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell

              RESEARCH ON COMPOSITE TISSUE TRANSPLANTATION

    Question. Admiral Cowan, it is my understanding that the Navy 
Bureau of Medicine and Surgery has been engaged in important research 
into composite tissue transplantation. Clearly, such research has great 
potential to radically advance our ability to perform reconstructive 
surgeries on limbs and patients with considerable burn injuries. I have 
followed similar research into hand-transplantation that is being done 
in my hometown of Louisville, Kentucky, and have been impressed with 
the great potential for such surgical and tissue regeneration 
techniques.
    Could you please provide information regarding the extent of 
injuries sustained by members of our Armed Services who could benefit 
from reconstructive or transplantation surgeries due to combat or 
service related injuries?
    Answer. During the period of March through May 2003, NNMC received 
a total of 251 medevac casualties transferred from the Iraqi theater of 
operations, primarily via Army Medical Center--Landstuhl, Germany and 
Naval Fleet Hospital--Rota, Spain. Of these, 135 patients required 
admission to NNMC (112 Marines, 22 Sailors, and 1 Soldier) and 116 were 
evaluated as transient ``RONs'' in the NNMC Ambulatory Procedures Unit 
(104 Marines and 12 Sailors) during their transit through the Aero-
Medical Staging Facility at Andrews Air Force Base, Maryland.
    Of the 135 patients admitted to NNMC, 63 percent were combat 
casualties. Of the combat casualties, the majority of patients 
sustained either blast injuries to upper or lower extremities, crush 
injuries, or gun shot wounds. These injuries resulted in many extremity 
fractures, both open and closed. Many of these patients underwent 
emergency surgery at forward treatment sites which included emergency 
fasciotomies. As a result, many of the patients required subsequent 
plastic surgical repair as part of their tertiary care at NNMC. This 
might be one area of combat injury that would be enhanced by 
reconstructive or tissue transplantation surgeries.
    In addition to the large number of fractures, 6 patients sustained 
significant traumatic amputations of extremities (3 lower leg, one 
foot, one forearm, and two patients with finger amputations). These 
would also be patients who might benefit from tissue transplantation 
advances.
    Question. Could you describe the Navy's composite tissue 
transplantation program? What is the current level of annual funding 
for this program? And could you describe work being done under related 
extramural grants funded by this program.
    Answer. The Navy Bureau of Medicine and Surgery has had, for many 
years, a research effort in the induction of ``tolerance'' in 
transplanted tissues with the hope of developing non-immune suppressing 
therapies to allow active duty victims of trauma to return to active 
duty. To this end, a kidney transplant model has been studied, since 
the mechanisms of rejection are similar to other tissues, though the 
kidney is a less immune-provoking organ than composite tissues. Thus, 
the kidney transplant serves as a simpler model for studying rejection 
and developing therapies against it. The transplant effort is now 
contained within the Combat Injury and Tissue Repair Program of the 
Combat Casualty Care Directorate at the Naval Medical Research Center 
(NMRC), under the leadership of Barry Meisenberg, M.D. The funding for 
``transplantation'' research has been reduced over the past 5 years, 
leading to a significant scale-back and unfortunate turnover in 
personnel. The current funding is through the direct Congressional 
appropriation via the Office of Naval Research. The lead physician 
investigator on this effort is Dr. Stephen Bartlett, Director of Organ 
Transplantation at the University of Maryland School of Medicine in 
Baltimore. The Navy laboratory supports Dr. Bartlett's efforts with 
laboratory investigations into the science of transplantation and 
mechanisms of rejection. The sum of $964,690 was received from fiscal 
year 2002 Congressional funding for these efforts. In addition to this, 
the NMRC supplied $250,000 from internal ``core competency'' dollars 
for a specific project, initiated in fiscal year 2002. In fiscal year 
2003, no core competency funds were available to continue this 
research. It is anticipated that approximately another $1 million will 
be received from direct Congressional appropriation for fiscal year 
2003.
    Question. Has the Navy conducted research on efforts to reduce the 
extent to which current procedures rely on immuno-suppressive drugs to 
combat rejection of tissue in transplant patients?
    Answer. A brief description of the work that is being performed at 
NMRC is provided:
    Project 1: Cytokine mediators of rejection in kidney transplant 
patients. This study performs real-time PCR to measure low levels of 
inflammatory molecules, such as cytokines that may predict rejection 
among actual patients receiving clinical kidney transplants who undergo 
periodic surveillance kidney biopsies. Specimens are obtained in a 
clinical program at the University of Maryland Transplant Program and 
transported to laboratories at the NMRC in Bethesda.
    Project 2: Cytokine mediation of rejection in primate composite 
tissue transplant. Pre-clinical research at the University of Maryland 
School of Medicine involves transplantation of complex tissues (bone, 
muscle and skin) in primates. The Navy research laboratories perform 
assays on biopsied tissue, looking at mediators of information and 
rejection. Tailored immunosuppressive therapies are being developed and 
studied featuring an anti-CD154 ligand to block the pathways of immune 
rejection.
    Project 3: Studies into the mechanism of action of anti-CD154 
ligand--Studies into the mechanisms of thrombotic complications with 
the use of anti-CD154 ligand. Currently, available supplies of anti-
CD154 ligand do inhibit immune recognition, but may also cause 
activation of platelets leading to clinical thrombosis. These 
investigations look at the mechanisms involved in both lymphocyte 
blockade, as well as the mechanisms of thrombosis.
    Project 4: Cell-signaling mechanisms after CD154 binding. This 
study is funded by core capability money from fiscal year 2002 and 
looks at the cell-signaling mechanism after CD154 binds the lymphocyte 
to look for potential targets for blockade of lymphocyte activation. A 
skin transplant model in mice is being developed and potential 
therapies will be tested in the mice model and available for use in the 
primate model currently at the University of Maryland. In addition to 
the above projects, funding has been requested from ONR for studies 
into the problem of ischemia/re-perfusion injury, which injures tissues 
both in the hemorrhagic-shock battle field situation, as well as 
transplantation of harvested tissues.
    Additional techniques for immune suppression, including the use of 
immature dendritic cells, bone marrow cells, expanded bone marrow 
cells, other ligands with inhibitory properties against lymphocyte 
activation, are in the preparatory stages pending funding availability.
    Question. Does the Navy plan to extend this program to the stage of 
human clinical trials?
    Answer. The Navy would like to see advances in the pre-clinical 
biology of ``tolerance'' inducing molecules so that clinical trials can 
be conducted. More pre-clinical science, however, needs to be 
performed, including animal models. There are many potentially 
interesting avenues of investigation, which require collaboration with 
university laboratories and biotechnology companies.
    Question. Are you aware of the clinical research and experience in 
human hand-transplantation at the University of Louisville and Jewish 
Hospital in Louisville, Kentucky?
    Answer. The Combat Injury and Tissue Repair Program of the NMRC has 
had informal contacts with the University of Louisville Jewish Hospital 
in Louisville, Kentucky. There is interest on both sides in conducting 
collaborative efforts into the pre-clinical biology of tolerance. 
Currently, there is no funding for such collaboration, although both 
sides see scientific merit. Other collaborations exist with other 
universities that also show promise and need further development.

                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby

                       PATIENT PRIVACY (TRICARE)

    Question. I would like to get your comments about several concerns 
and questions I have related to the December 14, 2002 break-in of the 
offices of TriWest, a TRICARE contractor. I am told that TriWest did 
not notify the Department of Defense of the break-in and theft of 
personal information of over 500,000 TRICARE beneficiaries for almost a 
week after the event. Apparently, TriWest didn't have even basic 
security equipment--guards, locks, cameras--and, as a result, this 
incident amounts to the biggest identity theft in U.S. history.
    Is this information true?
    Has the Department of Defense finished its investigation of this 
case and have sanctions been levied against TriWest or punitive actions 
taken against TRICARE officials?
    Answer. The criminal investigation is being conducted by the 
Defense Criminal Investigative Service (DCIS) and the Federal Bureau of 
Investigation (FBI), in coordination with other Federal and local law 
enforcement agencies. The Assistant Secretary of Defense, Health 
Affairs [ASD(HA)] directed the Services and TRICARE Managed Care 
Support Contractors to conduct an assessment of their information 
security safeguards using a matrix composed of Defense Information 
Systems Agency physical security requirements and industry best 
practices. TRICARE Management Activity (TMA) conducted on-site 
validation of these assessments. The ASD(HA) asked the DOD Inspector 
General to conduct facility security evaluations and a draft report is 
expected by July 2003.
    Sensitive information pertaining to TRICARE beneficiaries is 
maintained by TRICARE contractors subject to the Privacy Act of 1974, 
as implemented by the DOD Privacy Program (DOD 5400.11-R). The Act 
provides criminal penalties for any contractor or contractor employee 
who willfully discloses such protected information, in any manner, to 
any person or agency not entitled to receive the information. The Act 
also provides for civil penalties against DOD if it is determined that 
the Department (or contractor) intentionally or willfully failed to 
comply with the Privacy Act. To date, no sanctions have been levied 
upon or punitive actions taken against TriWest or TRICARE officials. 
The investigation is still ongoing, and its findings are pending.
    Question. Would you please share what you can about the lessons 
learned as a result of this incident and the steps the Department and 
the TRICARE organization and its contractors are taking to guarantee 
beneficiary privacy?
    Answer. Maintaining information security controls and awareness has 
always been a critical priority for the senior leadership of the 
Military Health System (MHS), in the interest of both national security 
and beneficiary privacy.
    Some of the lessons learned as a result of the TriWest incident 
include:
  --Scrutinized security practices across the entire MHS;
  --Emphasized the necessity of staying alert to new information 
        security threats; and
  --TriWest widely publicized a new process whereby individual 
        beneficiaries may, through TriWest, seek to place fraud alerts 
        on their records at national credit bureaus.
    Some of the steps taken by the Department and its TRICARE 
contractors to enhance beneficiary privacy include:
  --Led and coordinated a health care information security assessment 
        at MTFs and contractor locations;
  --Reviewed existing procedures at all locations;
  --Ensured physical security of facilities that house beneficiary 
        information;
  --Conducted on-site validations of its contractors' assessments;
  --Initiated DOD Inspector General facility physical security 
        evaluations;
  --Verified that DOD health information systems are compliant with 
        Health Insurance Portability and Accountability Act Protected 
        Health Information requirements;
  --Established plan of action for TRICARE contractors to correct 
        deficiencies of the facility security assessment;
  --Strengthened the overall security posture of the Military Health 
        System (TRICARE Management Activity, its contractors, and 
        Military Treatment Facilities); and
  --Broadened the scope of information assurance and security programs.

                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                      MEDICAL TREATMENT FACILITIES

    Question. Healthcare, pay, and housing are the greatest Quality of 
Life issues for our troops and their families. With the numbers of 
health care staff deployed from your Military Treatment Facilities, 
what strategies did you use to effectively plan and care for 
beneficiaries back home?
    Answer. Navy Medicine implemented core doctrine and conducted 
intense scrutiny of Military Treatment Facilities (MTFs) services 
availability. We identified the appropriate reservists to support the 
Military Treatment Facilities (MTFs) in maintaining services, in some 
cases adding contract personnel. Navy Medicine made every effort to 
take care of our patients in the MTFs, and assisted in both referral 
and care management for those patients that required care in the local 
healthcare network. Each week we tracked the availability of services 
at each MTF. Personnel (both active duty and reservists) exerted 
extraordinary efforts (which were possible in the short term but would 
not be sustainable indefinitely) to ensure access to care was 
maintained at all MTFs. The health care team felt the same devotion to 
their special duties during the conflict as did the deployed forces. 
They recognized that providing care for both returning casualties and 
local beneficiaries was their part in the war effort. For these 
reasons, individual productivity was particularly high and resulted in 
minimal reductions in health care access. A comprehensive survey of 
activated reservists and MTF operations during Operation Iraqi Freedom 
is now underway to fully assess the productivity and effectiveness of 
our MTFs in ensuring that access to care was maintained for all 
beneficiaries.
    Question. How are you able to address the needs of patients coming 
in from the battlefields and is this affecting the care of 
beneficiaries seeking regular care?
    Answer. We have been able to maintain services required to address 
the needs of both patients coming in from the battlefields and those 
seeking regular care through significant deliberate planning. We 
implemented core doctrine and deployed active duty forces that were 
well trained in providing advanced medical care in the field. As a 
result, intense scrutiny of Military Treatment Facilities (MTFs) 
services availability and their ability to sustain the Graduate Medical 
Education (GME) programs were conducted, and we identified the 
appropriate reservists to support the Military Treatment Facilities 
(MTFs) in maintaining services and future readiness via sustainment of 
GME programs.
    Question. What authority were you given to back-fill your vacancies 
and are the funds sufficient to attain that goal?
    Answer. Navy Medicine issued $18 million that was originally 
targeted for our Maintenance of Real Property, Facility Projects in 
order to provide MTFs with the funding needed to obtain contract 
physician and medical personnel needed as backfill in addition to the 
50 percent Reserve Recall. The commands were able to obligate $11 
million of that $18 million and obtained critical physician specialists 
on short timeframe contracts and other medical support personnel.
    Question. What measurements were used in determining what the 
services were able to back-fill and how does that compare to current 
requirements?
    Answer. The measurement tool used to assess services requiring 
augmentation was based on weekly reports that monitored facility 
services by beneficiary category i.e. AD/ADFM/RET/RETFM. This tool 
provided the level of detail needed to reflect which MTFs were in need 
of support based on the services identified, taking into account 
geographic issues related to Network availability and GME program 
sustainability. The report is being utilized to follow the flow of 
returning forces ensuring efficient demobilization of reserve personnel 
while maintaining MTF service availability.

                       RETENTION AND RECRUITMENT

    Question. With increasing deployments in support of Operation Iraqi 
Freedom and the Global War on Terrorism, can you describe your overall 
recruitment and retention status of the Medical Department in each of 
your services? What specific corps or specialties are of most concern?
    Answer. There is no way to predict the influence the current 
increased operational tempo will have on recruiting and retention. 
Because active duty personnel must request release from active duty 9-
12 months in advance in order to arrange for their billet to be 
backfilled, the effect upon release from active duty rates won't be 
known until approximately spring/summer 2004.
Dental Corps: The Dental Corps is currently undermanned at 93 percent
    The loss rate for dentists in fiscal year 2002 was 12.2 percent, 
which was above the 11-year average of 10.8 percent. Projections are 
for increasing shortfalls with manning at 90 percent or below at the 
end of fiscal year 2003.
    Accession goals have not been reached over last 3 years; accessed 
only 85 percent of goal. Most significant shortfall is in the Direct 
(non-scholarship) accession category.
    Recruiting goals are not being met with only 10 percent of the goal 
for Direct accessions (3/39), Reserve Recalls (2/7) and 1925i Dental 
Student program (0/5) met midway through the third quarter fiscal year 
2003. The primary accession pipelines for Navy dentists are the 
scholarship programs. The Health Professions Scholarship Program (HPSP) 
and the Health Services Collegiate Program (HSCP) have both been 
successful in meeting 100 percent of goal for fiscal year 2003 and we 
expect to access 67 HPSP and 22 HSCP students upon graduation from 
dental school. HSCP has in the past been a significant but not the 
largest source of accessions for the Dental Corps. Currently only 25 
percent of the combined fiscal year 2004/05 recruiting goal has been 
attained for HSCP accessions in fiscal year 2004 (12/25) and fiscal 
year 2005 (0/25). Interest in this program has significantly declined 
due to the increasing cost of dental school education, which continues 
to diminish the benefits offered through this program.
    Retention rate at first decision point for junior officers steadily 
declined over past 6 years; low point was 38 percent in fiscal year 
2001 from high of 64 percent in fiscal year 1995. Disparity between 
military and civilian pay and education debt are major factors in low 
retention rates.

Medical Corps
    The Medical Corps continues to have difficulty in retaining certain 
specialties. The Medical Corps has less than 80 percent manning in 
Anesthesia, Radiology, General Surgery, Pathology, and Radiation 
Oncology. Internal Medicine and subspecialties (84 percent) and 
Dermatology (83 percent) are near the critical point of under manning.
    Inability to access or retain specialties noted above can be 
attributed to significant military-civilian pay gaps and declining 
number of quality of work attributes that once made practicing in Navy 
Medicine enticing over the private sector (e.g., increased operational 
tempo). Additionally, the changing face of medicine in the civilian 
sector (e.g., fewer applicants for medical school and even fewer 
medical school graduates going into the above specialties) is affecting 
Navy Medicine as well.
    The primary pipeline for Navy physicians is the Health Professions 
Scholarship Program (HPSP), which brings in 300 of the 350 individuals 
entering as medical students. The HPSP recruiting goal for fiscal year 
2003 is 300. The Navy is behind in recruiting, in that by May, there 
are usually about 150 recruited. Presently there are only 51. It should 
be noted that not only is the number of HPSP recruits diminishing, but 
the quality has also decreased when utilizing MCAT scores as an 
indicator of quality. In he past, HPSP recipients had MCAT scores of 
26-30. Applicants with scores as low as 22 are being considered in 
order to fill quotas.

Medical Service Corps
    Retention in the Medical Service Corps is good overall. End of 
fiscal year 2002 manning was at 98.5 percent with projections for the 
next two years at or near 98 percent manning. However, difficulties 
remain in retaining highly skilled officers in a variety of clinical 
and scientific professions.
    The Medical Service Corps is comprised of 32 different health care 
specialties in administrative, clinical, and scientific fields. The 
education requirements are unique for each field; most require graduate 
level degrees, many at the doctoral level.
    Biochemistry, Entomology, and Podiatry are undermanned by more than 
10 percent. Average yearly loss rates are high in Biochemistry, 
Physiology, Environmental Health, Dietetics, Optometry, Pharmacy, and 
Psychology. Loss rates this year are very high for Microbiologists & 
Social Workers.
    The Medical Service Corps does not have available to them retention 
tools or special pays for scientists and very limited ones for 
clinicians such as Optometrists, Pharmacists, and Podiatrists.

Nurse Corps
    The Nurse Corps continues to be healthy considering the national 
nursing shortage. The affect of a decreasing number of students who 
choose nursing as a career and the ever-increasing demand for 
professional nursing services will need to be closely monitored to 
ensure that the Navy Nurse Corps is able to meet the requisite number 
and specialty skill mix.
    The successful ability of the Nurse Corps to meet requirements is 
due to concerted efforts in diversifying accession sources and 
increased retention as a direct result of pay incentives and graduate 
education opportunities.

Hospital Corps
    HM and DT Retention has never been higher and we have met/fulfilled 
recruiting goals for the last two years. In the past two years our 
overall manning has significantly increased from 87 percent to 97 
percent.
    8404 HM E1-6 are on STOP LOSS per NAVOP 005/03 over 2,616 Sailors 
are affected by this program.
    Per the OPHOLD MSG NAVADMIN 083/03 all hospital corpsmen assigned 
to deployed USMC units, possessing NEC's 8403, 8404, 8425 and 8427 may 
be OPHELD.
    The HM Rating ended fiscal year 2002 at 95.8 percent manning 
(23,218 INV/24,320 BA or -1,102). The HM Rating has been undermanned 
since 1997 (low point was 89.1 percent manning as of end fiscal year 
2000), but has steadily increased to current end February 2003 of 97.1 
percent (23,843/24,553). The improved manning is the result of an 
increase in the HM A-School plan from a traditional 3,000 inputs to 
4,500 inputs per year along with a reduction in HM A-school attrition 
from 18 percent to 8 percent. Out year projections have the rating 
maintaining 98 percent manning for the next two years.
    As overall HM rating manning has improved, C school seats are 
increasingly being filled. Along with realignment of SRB and SDAP to 
retain existing and attract applicants, inventories in the shortfall 
NECs are steadily improving. Of the 40 distinct HM NECs, the following 
are critically manned (manning <90 percent) as of end February 2003.

------------------------------------------------------------------------
   NEC                NAME              INV      EPA      PCT      +/-
------------------------------------------------------------------------
  HM-8401 SAR TECH                       89      111       80      -22
  HM-8403 RECON IDC                      26       29       90       -3
  HM-8408 CARDIOVASULAR TECH             77      105       73      -28
  HM-8416 CLIN NUC MED TECH              59       70       84      -11
  HM-8425 SURFACE IDC                   868    1,020       85     -152
  HM-8427 RECON IDC                      43       70       61      -27
  HM-8432 PREV MED TECH                 642      710       90      -68
  HM-8452 ADV XRAY TECH                 566      654       87      -88
  HM-8466 PHYS THERAPY TECH             201      252       80      -51
  HM-8467 OCC THERAPY TECH               12       19       63       -7
  HM-8478 MED REPAIR TECH               197      270       73      -73
  HM-8485 PSYCH TECH                    273      376       71     -103
  HM-8486 UROLOGY TECH                   68       87       78      -19
  HM-8489 ORTHO TECH                    124      153       81      -29
  HM-8492 HM SEAL                       124      164       76      -20
  HM-8493 HM DIVER                       83      106       78      -23
  HM-8494 HM DIVER IDC                   69       80       86      -11
  HM-8495 DERMATOLOGY TECH               40       54       74      -14
  HM-8506 LAB TECH                    1,246    1,594       78     -348
  HM-8541 RESP THER TECH                102      147       69      -45
------------------------------------------------------------------------

Dental Technicians
  --Overall DT rating manning has held constant over the last several 
        years with end February 2003 inventory at 102 percent (3,177/
        3,150). The DT NECs listed below are critically manned.

------------------------------------------------------------------------
   NEC                NAME              INV      EPA      PCT      +/-
------------------------------------------------------------------------
  DT-8703 DT ADMIN TECH                 241      268       90      -27
  DT-8708 DT HYGIENE TECH                53       84       63      -31
  DT-8753 DT LAB TECH                   100      113       89      -13
  DT-8783 DT SURGICAL TECH               99      111       89      -12
------------------------------------------------------------------------

    The shortages in these NECs have been caused by limited 
availability of school quotas at tri-service schools. The exception is 
DT Hygiene Tech, established in fiscal year 2000. The Hygiene Tech 
school pipeline is two years long and inventory has been slowly growing 
toward the billet target. For the remaining shortages, efforts continue 
to obtain quotas at the tri-service schools to ensure that we obtain 
the seat increases we need to maintain the inventory.
    Question. Did the Critical Skills Retention Bonus given for this 
year help these specialties? In light of shortages and the disparity 
between military and civilian salaries, how have you planned for 
additional retention bonuses in future years?
    Answer. A detailed explanation is provided by Corps in order to 
detail the impact of the CSRB.

Dental Corps
    When the CSRB was combined with the renegotiation of Dental Officer 
Multi-year Bonus (DOMRB) contracts, the effect was increased obligation 
for those that took DOMRB contracts. This in effect tied the one-year 
CSRB to a multi-year obligation, having some positive effect. However, 
a more comprehensive pay plan is needed for the long term.
  --The NDAA fiscal year 2003 increased the caps on the Dental Officer 
        Multi-year Retention Bonus (DOMRB).
  --Fiscal year 2004 and fiscal year 2005 dental pay plans need to take 
        advantage of the increase in the cap for the DOMRB as provided 
        by the fiscal year 2003 NDAA which would help bring pay to 
        higher levels, although are not in parity with civilian pay, 
        demonstrate a commitment by Navy to increase compensation. 
        However, in fiscal year 2004, funds have not been budgeted for 
        increases in Medical Special Pays.
  --The Health Professions Incentives Work Group (HIPWG) is working on 
        a ULB fiscal year 2006 proposal that will raise Additional 
        Special Pay (ASP) for targeted year groups to enhance retention 
        after the first decision point for junior officers and after 
        training obligations are paid off by mid-career officers. This 
        ULB also proposes retaining ASP while in a training (DUINS) 
        status in efforts to attract more qualified applicants for 
        residency training. This proposal is under review within the 
        Department.
  --A comprehensive pay plan is needed to enhance retention and narrow 
        the civilian-military pay gap. In the absence of such a plan 
        and in recognition that the status of the Incentive 
        Optimization Plan previously worked by OSD/TMA is unknown, the 
        Navy has proposed utilizing a multi-year dental CSRB to 
        critical shortages, namely dental officers with 3 to 7 years of 
        service. This is designed to address a significant downward 
        trend in retention of LT/LCDR General Dentists (anecdotally due 
        to high debt load). This shortage in turn has significantly 
        diminished our pool of applicants for residency training. 
        Applications for post-graduate residency training are down 54 
        percent over past 10 years, which has resulted in increasing 
        difficulty of producing specialists with the skills required to 
        meet mission requirements. This proposal is under review within 
        the Department.

Medical Corps
    The CSRB helped retain some individuals in Anesthesia, Radiology, 
Orthopedics, and General Surgery who would have otherwise gotten out of 
the Navy. Because the CSRB was limited to a one year contract, the long 
term benefit is minimal.
    The fiscal year 2003 NDAA raised the maximum on special pays to 
increase flexibility and utility of special pays. Development of a 
special pay plan for fiscal year 2005 by OOMC and N131 is in progress 
which takes advantage of the new maximums and increases the Multiyear 
Special Pay (MSP) to levels that although not in parity with civilian 
pay, demonstrates a commitment by the Navy to increase compensation. 
Because of the process involved in creating a DOD Pay Plan, the final 
pay plan for fiscal year 2005 may not emphasize the Navy's needs, 
reflecting instead the overall needs of DOD (Air Force and Army.) This 
proposal is under review within the Department.

Medical Service Corps
    The Critical Skills Retention Bonus was not offered to any of the 
Medical Service Corps specialties.
    During fiscal year 2001, DOD (HA) provided guidance allowing the 
Services to begin paying an Optometry Retention Bonus and a Pharmacy 
Special Pay based on each Service's ``own accession requirements and 
capabilities.'' The Army and Air Force have funded the new pays. Due to 
funding constraints, the Navy has not yet begun paying the Optometry 
Retention Bonus or the Pharmacy Special Pay, however, the Navy has 
planned and budgeted for future funding of these bonuses and specialty 
pays.

Nurse Corps
    The Critical Skills Retention Bonus was offered to qualified nurses 
resulting in acceptance rates of 87 percent for Certified Registered 
Nurse Anesthetists (CRNAs) and 98 percent for Perioperative Nurses. For 
the CRNAs, it has been a positive influence for staying beyond their 
obligated service period. We are presently at end-strength in both 
communities based on a combination of factors such as special pays, 
scope of practice satisfaction and a focus on quality of life issues. 
Therefore because the process involved in creating a DOD Pay Plan must 
reflect the overall needs of DOD (including Army and Air Force,) the 
final pay plan for fiscal year 2005 may not emphasize the Navy's 
specific requirements.
    The fiscal year 2003 NDAA raised the maximum on special pays to 
increase flexibility and utility of special pays. Development of a 
special pay plan for fiscal year 2005 by the Nurse Corps Office and 
N131 is currently under review within the Department. The proposal, 
which takes advantage of the new maximums and increases the Nurse 
Accession Bonus and CRNA Incentive Pay to levels that although not in 
parity with civilian pay, demonstrates a commitment by the Navy to 
increase compensation.

Hospital Corps
    We are working on an increase in our critical NEC's in SRB, SDAP 
and accelerated advancement programs.
    Question. Are there recruitment and retention issues within certain 
specialties or corps? If so, what are your recommendations to address 
this in the future?
    Answer.

Dental Corps
    As a result of a significant downward trend in retention of LT/LCDR 
General Dentists coupled with significant under execution of CNRC DC 
accessions, the Dental Corps is undermanned.
  --Dental Corps overall manning has been trending downward for the 
        last three years, ending fiscal year 2002 at 94.4 percent 
        (1,294 INV/1,370 BA or -76). The EFY 2003 projection is 
        estimated at <90 percent.
  --A BUMED-BUPERS working group is evaluating the following 
        recommendations for the future: increase in HPSP Scholarships 
        from 70 to 85 per year, establish a special pay that targets 
        General Dentists with 3 to 7 years of service; establish Dental 
        Corps Health Professions Loan Repayment (HPLRP) Program; 
        increasing the number of years of service for statutory 
        retirement to 40 years of service for 06s, along with raising 
        the age limit to 68. Active Duty dentists tend to leave the 
        service at 22 years vice 30 in order to enter the civilian 
        market at a competitive age range. If given the option of a 
        career for an additional ten years of service, many dentists 
        would choose to stay on Active Duty. Prior to approval 
        additional study is required on how this will impact the 06 
        promotion cycle.
  --The shortage of General Dentists has directly impacted the Oral 
        Surgery and Endodontic communities, which are also 
        significantly undermanned. Since we train the vast majority of 
        our specialists from within, the shortage of General dentists 
        and the increase in loss rates has resulted in a reduction in 
        the numbers of officers available to enter the training 
        pipeline.

----------------------------------------------------------------------------------------------------------------
                                                                                                 Fiscal   Fiscal
                  Corps Specialty (PSUB)                      INV       BA      PCT      +/-      Year     Year
                                                                                                  2004     2005
----------------------------------------------------------------------------------------------------------------
DC--Dentist (1,700).......................................      486      594       82     -108       80       78
DC--Oral Surg(1,750J/K)...................................       66       82       80      -16       78       72
DC--Endodontist (1,710J/K)................................       44       52       85       -8       83       80
----------------------------------------------------------------------------------------------------------------

  --The remaining Dental Corps specialties are stable at this time with 
        sufficient gains to compensate for losses, but that will take a 
        turn for the worse if the problems with General Dentist 
        retention and accessions are not corrected, as this is the 
        applicant pool for specialty training.

Medical Corps
    Although pay is just one part of the benefits of a military career, 
the civilian to military pay gaps are so large in some specialties that 
it is difficult to recruit or retain someone after completion of their 
obligated service for training. A comparison of civilian and military 
average pays is as follows (this data was retrieved from an internet 
physician pay site used by medical students):

------------------------------------------------------------------------
                                     Civilian    LCDR Mil
             Specialty                  Pay         Pay     Differential
------------------------------------------------------------------------
Anesthesia........................    $278,802    $140,556     $138,246
Radiology.........................     319,380     140,556      178,824
General Surgery...................     261,276     133,556      127,720
Pathology.........................     197,300     120,556       76,744
Internal Medicine.................     160,318     118,556       41,762
Dermatology.......................     232,000     122,556      109,444
Orthopedics.......................     346,224     140,556      205,668
Neurosurgery......................     438,426     140,556      297,870
------------------------------------------------------------------------

    To improve accessions (in the above specialties), the following 
monetary and marketing tools are being evaluated by CNP/BUMED 
Integrated Process Team (IPT):
  --A Health Professional Loan Repayment Program (HPLRP).
  --An increase in recall and direct accession goals for medical 
        officers.
  --An increase in accession bonuses for health professionals from 
        $30,000 to an $80,000 cap for high demand specialties.
  --An increase in Incentive Specialty Pay (ISP) and Multiyear 
        Specialty Pay (MSP) to decrease the pay gap. Emphasis is being 
        placed on increasing MSP so that retention may be improved.

Medical Service Corps
    All specialties have met (or are expected to meet) fiscal year 2003 
recruiting goals except for:
  --Entomology (Goal: 4; 0 attained) have not met direct accession goal 
        since fiscal year 1999. There are limited Medical Entomology 
        graduate programs in the United States. Fiscal year 2002 
        manning was 89 percent.
  --Physiology (Goal: 2; 0 attained) have not met direct accession goal 
        since fiscal year 1998. Fiscal year 2002 manning was 86 
        percent.
    Use of the Health Services Collegiate Program (HSCP), a Navy 
student pipeline program for Entomology was instituted in fiscal year 
2002 and for Physiology in fiscal year 2003.
    Retention in the Medical Service Corps is good overall. However, 
difficulties remain in retaining highly skilled officers in a variety 
of clinical and scientific professions.
    Explore the possible use of Engineering and Scientific Career 
Continuation Pay (U.S. Code: 37, Section 315) to improve the retention 
of our highly skilled scientific officer.
    Other tools being considered:
  --Health Professional Loan Repayment Program (HPLRP). Those HPLRP 
        scholarships allocated to Medical Service Corps will be used 
        for both retention and accession.

Nurse Corps
    The Active Duty force is expected to meet fiscal year 2003 
recruiting goal.
    The Reserve force has met 61 percent of the fiscal year 2003 
recruiting goal, maintaining the same pace as last year. Successful 
recruiting incentives for reservists in the critically undermanned 
specialties include: The $5,000 accession bonus and loan repayment and 
stipend programs for graduate education.
    The BUMED Integrated Process Team (IPT) will evaluate two 
initiatives to improve the end-strength of the Reserve force:
  --Allocating the $5,000 accession bonus for all new nursing graduates 
        to the Reserve force. With the civilian recruiting bonuses and 
        loan repayment programs for student graduates, new nurses are 
        deferring entry into the Navy Nurse Corps Reserves until they 
        gain the one-year experience required to qualify for a bonus.
  --Instituting ``pipeline'' scholarship nursing programs for the 
        reserve enlisted component similar to those available to active 
        duty enlisted.

Hospital Corps
    No recruitment issues as CNRC has been able to fill requirements.
    We have increased retention and programs have been put in place 
directing Sailors into our undermanned NEC's. Some of the programs 
instituted include job fairs, Detailers visits along with visits from 
the Force Master Chief.
    Question. Have incentive and special pays helped with specific 
corps or specialties?
    Answer.

Dental Corps
    Although pay is just a portion of the military benefits package, 
the dental military-civilian pay disparity is so large in certain 
specialties that it is very difficult to recruit or retain a dental 
officer after completion of their obligated service for training.
  --There was a slight enhancement in overall retention as a result of 
        increases in dental ASP in 1997 and the initial offering of 
        DOMRB in 1998 when compared to previous years, but that effect 
        has since worn off. Despite the introduction of the DOMRB and 
        increase in ASP rates, the overall loss rate continues to climb 
        to the highest it has been at 12.2 percent in fiscal year 2002, 
        higher than the 11-year average of 10.8 percent. The majority 
        of losses are junior officers (LT-03) releasing from active 
        duty at the completion of their initial obligated service. 
        These year groups are not eligible for the DOMRB at this point 
        in their careers and the current ASP rates are too low to 
        impact their decision to stay on active duty.

Medical Corps
    There is no study that correlates retention and accession with 
special pays.

Medical Service Corps
    The Medical Service Corps has very limited incentive and special 
pays.
  --Optometry Special Pay (U.S. Code: Title 37, Section 302a).--Each 
        optometry is entitled to a special pay at the rate of $100 a 
        month. This special pay has not been increased in thirty years 
        and therefore has lost value as an incentive or retention tool. 
        Fiscal year 2001 and 2002 manning was 88 percent and 98 
        percent. The manning is expected to drop below 98 percent 
        during fiscal year 2003.
  --Psychologist and Nonphysician Health Care Providers Special Pay 
        (U.S. Code: Title 37, Section 302c).--This Special Pay is 
        better known as Board Certification Pay. Board Certified 
        Nonphysician Health Care Providers are entitled to a pay of 
        $2,000 per year, if the officer has less than 10 years of 
        creditable service; $2,500 per year (10-12 yrs); $3,000 per 
        year (12-14 yrs); $4,000 per year (14-18 yrs); and $5,000 per 
        year (18 or more). This special pay does not become a 
        significant annual amount until late in an officer's career and 
        therefore has a minimal impact as a retention tool. The Navy is 
        manned at 70 percent licensed psychologists.
  --Accession Bonus for Pharmacy Officers (U.S. Code: Title 37, Section 
        302j).--This accession incentive of $30,000 may be paid to a 
        person who is a graduate of an accredited pharmacy school and 
        who, executes a written agreement to accept a commission as an 
        officer and remain on active duty for a period of not less that 
        four years. This accession bonus was first used in fiscal year 
        2002 and accession quotas were met in that year. Long-term 
        effectiveness as a successful accession incentive has not yet 
        been established. Fiscal year 2002 manning was 96 percent. The 
        manning is expected to drop below 96 percent during fiscal year 
        2003.

Nurse Corps
    The Nurse Accession Bonus, Incentive Pay for Certified Registered 
Nurse Anesthetists (CRNAs), and Board Certification Pay (for those 
eligible) contribute to successful recruitment and retention efforts. 
Current CRNA manning is 108 percent. Manning is expected to drop to 100 
percent throughout the year as members depart.
    The increase of the maximum allowable compensation amount under 
NDAA for the CRNA Incentive Pay and the Accession Bonus will further 
enhance our competitive edge in the nursing market.
Hospital Corps
    When incentive and special pays have been put in place for 
undermanned specialties, accessions have increased.
    Psychiatry Technician and Respiratory Therapy Technician 
communities manning increased, 36 percent and 28 percent respectively, 
after implementation of the Selective Training and Reenlistment (STAR) 
Program and increased Selective Reenlistment Bonus.
    Question. How does the fiscal year 2004 budget request address your 
recruitment and retention goals?
    Answer.

Medical Service Corps
    The fiscal year 2004 budget request includes funding for the 
Optometry Retention Bonus and the Pharmacy Special Pay (both 
discretionary pays).

Nurse Corps
    The fiscal year 2004 budget request includes increases to both the 
Nurse Accession Bonus and the Incentive Pay for Certified Registered 
Nurse Anesthetists.

                     FORCE HEALTH PROTECTION (FHP)

    Question. As a result of concerns discovered after the Gulf War, 
the Department created a Force Health Protection system designed to 
properly monitor and treat our military personnel. What aspects of the 
Department's Force Health Protection system have been implemented to 
date? What are the differences between the system during the Gulf War, 
Operation Iraqi Freedom, and Operation Enduring Freedom and Operation 
Noble Eagle?
    Answer. There has been a fundamental shift in Navy Medicine from 
treating illness, to focusing on prevention and health. Our mission is 
to create a healthy and fit force, so that when we deploy a pair of 
muddy boots, the Sailor or Marine wearing them is physically, mentally 
and socially able to accomplish any mission our nation calls upon them 
to perform. This focus on prevention and health includes the delivery 
of care to the spouses and families at home because by caring for them, 
our warriors can focus on the fight. The Navy Medicine ``office place'' 
is the battlefield because our Sailors and Marines deserve the best 
possible protection from all potential hazards that could prevent 
mission execution. A critical element of our FHP continuum is having in 
place, along with the Department of Veterans Affairs (DVA), mechanisms 
for making sure that people who become ill after deployment are 
evaluated fully. Navy Medicine has several established mechanisms with 
the DVA regarding post deployment illnesses. Between the Gulf War and 
Operation Noble Eagle, several specific Force Health Protection (FHP) 
measures were implemented. These include: Pre-Deployment Health 
Assessment with the DD2795, Disease and Non-Battle Injury (DNBI) 
surveillance, Post-Deployment Health Assessment with the DD2796, pre- 
and post-deployment serum archival at the DOD Serum Repository, anthrax 
and smallpox vaccination programs, occupational and environmental 
health surveillance, formation of specialized deployable teams for FHP 
(Navy Forward Deployable Preventive Medicine Units, Theater Army 
Medical Laboratory, and Air Force Theater Medical Surveillance Team), 
and the Post Deployment Health Clinical Practice Guideline. Just before 
Operation Iraqi Freedom, the Joint Medical Work Station (JMeWS) was 
deployed in the CENTCOM theater of operations, providing the capability 
to collect patient encounters, DNBI, and general medical command and 
control reports. With over 26,000 patient encounters and 1,000 DNBI 
reports, this system has provided a substantial analysis and archival 
tool for the combatant commanders and senior leadership.

                              OPTIMIZATION

    Question. Congress initiated optimization funds to provide 
flexibility to the Surgeons General to invest in additional 
capabilities and technologies that would also result in future savings. 
It is my understanding that a portion of these funds are being withheld 
from the Services. Can you please tell the Committee how much 
Optimization funding is being withheld from your service, what are the 
plans for distributing the funds, and why funds since fiscal year 2001 
are being withheld?
    Answer. In fiscal year 2002 59 Optimization Projects were approved 
but only one was funded before April 2002. Total funding for fiscal 
year 2002 was $49.6 million. Twenty-seven of the projects were funded 
in late September 2002 and are in their infancy. Since most of the 
projects involved personnel actions, up to six months passed before 
personnel were in place due to required DOD civilian hiring processes. 
Hard evidence of financial return on investment is not yet available. 
Anecdotal positive feedback, however, is plentiful, especially in the 
following areas:
  --Case management ($8.5 million fiscal year 2002).--All facilities 
        are reporting that the recently hired case managers are 
        champions for the transition from intervention to prevention. 
        Commanders have commented that case management is ``one of the 
        best BUMED programs in 30 years.'' The primary barrier to 
        success is the lack of integration of case management software 
        with the Composite Health Care System (CHCS).
  --Clinic manager's course ($400,000 fiscal year 2002).--Over 500 
        personnel have benefited from the week long course and 80 
        percent of participants reported in follow up surveys that the 
        course adequately prepared them to implement optimization 
        concepts within their clinics. Barriers to achievement of the 
        goal of improved clinic effectiveness include lack of reliable, 
        readily available performance data and high turnover of clinic 
        management teams.
  --Population Health Website ($400,000 fiscal year 2002).--Access to 
        real time patient level data regarding disease prevalence, care 
        provided, and patient panel demographics was viewed as 
        ``extremely valuable'' by the 103 users trained thus far. Key 
        to success is WEB access (begun January 2003) and dedicated 
        training.
    $11.4 million was devoted to critical advances in Medical Practice 
supporting longer term goals of sustaining quality and reducing 
invasive procedures where possible. The remaining $29.3 million was 
devoted to targeted improvements in the Primary Care Product Line, 
Birth Product Line and Mental Health Product Line as well as specific 
interventions designed to ensure continued excellence in training in 
mission-critical specialties (radiology and cardiology). Many of the 
initiatives are designed to correct staffing ratios allowing clinicians 
more time to devote to direct patient care. A full review of financial 
and non-financial performance measures is underway for each of the 
projects but conclusive data is not yet available given the recent 
start up of the vast majority of the initiatives.
    Question. How have you benefited from optimization funds? What 
projects are on hold because OSD has not released funding?
    Answer. Navy Medicine has not delayed projects due to OSD 
withholding funds.
    Question. What are the projected projects using the proposed $90 
million in the fiscal year 2004 budget request?
    Answer. If the Navy's share of the $90 million in the fiscal year 
2004 budget request amounted to $30 million, the following is the 
current proposal for the use of funds. Continuation of current 
optimization projects is expected to require $16.6 million, planned 
advances in medical practices (AMP) programs will require an additional 
$10 million, and focused improvements in perinatal care, early mental 
health intervention and training of clinic managers will require the 
final $3.4 million. A full review of the proposed use of the funds is 
underway as part of the annual budget and business planning process.

                                 ______
                                 
        Questions Submitted to Lieutenant General James B. Peake

               Questions Submitted by Senator Ted Stevens

                    DEPLOYMENT OF MEDICAL PERSONNEL

    Question. The staff's discussions with The Surgeons General 
indicate that the Services have backfilled for deployed medical 
personnel at the Medical Treatment Facilities at varying levels.
    Some of the Services are relying more heavily on private sector 
care rather than backfilling for deployed medical personnel.
    To what extent has the recent deployment of military medical 
personnel affected access to care at military treatment facilities?
    Answer. Recent deployments of medical personnel have had varying 
impacts upon access to care in individual Army medical treatment 
facilities (MTFs). With the initial deployment of medical personnel, 
there was an approximate 15-30 day underlap until Reserve Component 
(RC) personnel arrived at the various MTFs. Additionally, RC backfills 
were authorized only at approximately 50 percent of the deployed 
losses. Although some have indicated that there should be no impact on 
access to care because medical personnel were deployed as well as 
troops (i.e., patients), this assumption is flawed. Troops are 
generally the healthiest of the patient population served and do not 
comprise a significant portion of the care provided at any one MTF. In 
addition, at several posts, the medical personnel deployed long before 
the troop populations mobilized.
    While MTFs had varying strategies in dealing with these significant 
shortages, there was some impact on access to routine and wellness 
care. Strategies included utilization of the network, hiring/
contracting for civilian positions and reserve backfill. Success was 
limited by network inadequacy, inability to hire, and insufficient 
reserve backfills. Success varied by location due to the variability of 
these factors.
    Question. What are you doing to ensure adequate access to care 
during this time?
    Answer. Most MTFs have skillfully attempted to manage the access to 
care issue by closure/consolidation of clinics, beds and operating 
rooms; shifting of care to the network; extending shifts for both 
physicians and nurses; double-booking appointments; overtime, including 
mandatory weekend overtime; increasing resource-sharing contracts and 
increasing contract hires. Urgent care access was maintained, but all 
MTFs have had varying degrees of success in maintaining access to 
routine and wellness visits. They have managed to decrease the number 
and significance of access-to-care issues, but most MTFs continue to 
struggle with the issue.
    Question. What percentage of mobilized reservists in medical 
specialties are being used to backfill positions in the United States?
    Answer. The Reserve Component (RC) provided 22 percent of its 
mobilized medical specialties to backfill the Army's Active Component 
(AC) losses in the Medical Treatment Facilities (MTFs). This accounts 
for 1,631 reservists' backfilling AC personnel losses in MTFs out of 
the total mobilized RC medical force of 9,195. This does not take into 
consideration the physicians, dentists, and nurse anesthetists that are 
on a 90-day rotation policy. There are 485 scheduled 90-day rotators in 
the aforementioned 1,631 RC personnel backfill. To further compound the 
backfill requirements the Senior Civilian Leadership only authorized a 
50 percent backfill cap or one RC backfill for every two AC losses.
    Question. Are there shortages of personnel in some specialties?
    Answer. Yes.
    Question. If so, which specialties are undermanned and by how much?
    Answer. The Reserve Component (RC) backfill was initially 
undermanned by seven medical specialties for a total of sixteen 
personnel. These medical specialty shortages were Nuclear Medicine 
Officer, Pulmonary Disease Officer, Dermatologist, Allergist, Pediatric 
Cardiologist, Peripheral Vascular Surgeon, and ten Obstetrics Nurses. 
The 90-day rotation policy added additional requirements by having to 
rotate physicians, dentists, and nurse anesthetists. In the second 90-
day rotation the following medical specialties were undermanned by an 
additional ninety-five physicians and dentists: three Urologists, an 
Obstetrician and Gynecologist, six Psychiatrists, thirty-six Family 
Physicians, six General Surgeons, five Thoracic Surgeons, five 
Orthopedic Surgeons, two Radiologists, five Emergency Physicians, and 
twenty-six Dentists.
    Question. Are there other ways of structuring the staffing of 
military medical units that might help address shortages in a few 
specialties, such as making increased use of civilian contractors or 
DOD civilian personnel in MTFs stateside?
    Answer. The staffing of Army Medical Treatment Facilities (MTF) is 
a mix of Active Duty military, direct hire civilians, and resource 
sharing/contract arrangements. The Active Duty component is based upon 
the wartime needs of the numbers and types of health care providers 
needed to staff the deploying medical support units (Professional 
Filler System and cadre hospital organizations). Many of the more 
expensive specialties required at the MTF are the same specialties 
needed for deployments. Even though more than 50 percent of the MTFs' 
staffing is non-military, this tends to be in specialties that can be 
afforded by the General Schedule payment tables. Beyond the direct hire 
civilian staffing, MTFs also form a number of resource sharing 
agreements and local contracts for services available in the area. 
These contracting efforts are in addition to the TRICARE network that 
may have some health care resources in the area. Healthcare providers 
not already engaged with the MTF are fulltime engaged in their own 
practices with limited expansion capability. The sudden demand for 
additional health care services in an area is an immediate shock and 
drain on the limited healthcare resources in the area.
    Changes to structure and policy would assist in the future. There 
should be a restructuring of Reserve Component Table of Distribution & 
Allowance assets to match those of PROFIS losses in our MTFs. Modules 
within Combat Support Hospitals (CSHs) and Forward Surgical Teams 
(FSTs) to facilitate the mobilization/movement of mission-specific 
teams should have corresponding backfill modules in the reserves. 
Military authorizations for high OPTEMPO specialties--61J (General 
Surgery), 61M (Orthopedic), 60N (Anesthesia), 66F (Nurse Anesthetists), 
66H8A (Intensive Care Nursing) and 66E (Operating Room Nurse)--should 
be increased for these hard-to-hire specialties. Pay scales need to be 
increased for health care specialties as current scales and funding 
levels for Civil Service and contracts are out-of-sync with the 
civilian market. Increasing military authorizations for primary care 
specialties in order to fill the PROFIS requirements for 62Bs (Field 
Surgeon) would prevent the military from having to use critically short 
subspecialties, such as pediatric cardiologists, to fill these slots. 
Some specialties--60C (Preventive Medicine) and 61N (Flight Surgeons)--
have had to be structured to the military setting and it is difficult 
to recruit for these same positions through the civilian sector since 
the training, education, and experience levels are so different. This 
lack of military-focused training in these specialties has made it 
impossible to backfill losses in these specialties with the reserves.

          MONITORING THE HEALTH OF GUARD AND RESERVE PERSONNEL

    Question. What improvements have been made to the medical 
information systems to track the health care of reservists? Are they 
electronic, do they differ among services?
    Answer. The Army Medical Department's (AMEDD) Medical Operational 
Data System (MODS) has added modules to address the need of improving 
the health care for both the Guard and Reserve. The Active Duty Medical 
Extension (ADMR) Web Reporting module manages those Guard and Reserve 
soldiers requiring medical treatment that cannot be completed in less 
than 30 days. The Line of Duty (LOD) Automated module automates the 
completion of LOD Investigations and ancillary activities. To assist 
the National Guard (NG) MODS has a NG Physical Web Reporting module 
that allows the NG to obtain the physical information on each soldier 
by state. The Automated Voucher System (AVS) facilitates scheduling 
physical exams, dental exams, and immunizations for Army National Guard 
and Army Reserve personnel. As a closeout to the AVS cycle, AVS 
provides Medical Readiness results to MEDPROS module. MEDPROS provides 
the Army Knowledge On-line (AKO) with a real time update of Active 
Duty, National Guard and Army Reserve Individual Medical Readiness 
elements to over 1.2 million registered AKO users at logon.
    There is no significant difference in the Individual Medical 
readiness tracking between the active or reserve component of the Army.
    Question. During the mobilization for Operation Iraqi Freedom, how 
many reservists could not be deployed for medical reasons?
    Answer. Overall the medically non-deployable rate for reserve 
component (RC) soldiers was 2.2 percent or 3,147 out of 141,365 RC 
soldiers processed for mobilization. 566 of these non-deployable 
soldiers are currently undergoing a medical board. More than 80 percent 
of the non-deployable soldiers had a chronic medical problem. The most 
common medical reasons for non-deployability were orthopedic and mental 
health problems followed by adult onset diabetes. 27 percent of reserve 
component soldiers had orthopedic conditions with the most common 
problem areas being the back (32 percent), knees (24 percent), and 
shoulders (14 percent). 8 percent of the non-deployable RC soldiers had 
mental health problems and 6 percent had diabetes. Orthopedic 
conditions and diabetes are expected to be more common in reserve 
component soldiers given their generally older average age.
    This information will be used to guide policy changes. Health 
Affairs has mandated an Individual Medical Readiness metric that 
requires the armed services to monitor compliance with required 
periodic health assessments and identification and management of those 
soldiers with deployment limiting conditions. Improving and enforcing 
the profile process will enable earlier identification of significant 
medical problems. However, until a digital profile process is in place 
early identification of deployment limiting conditions will remain 
problematic.
    Question. An April 2003 GAO report documents deficiencies by the 
Army in monitoring the health of the early-deploying reservists. Annual 
health screening is required to ensure that reserve personnel are 
medically fit for deployment when called upon. Review found that 49 
percent of early-deploying reservists lacked a current dental exam, and 
68 percent of those over age 40 lacked a current biennial physical 
exam. In addition, monitoring the health of reservists returning from 
deployment will be critical to ensuring the long term health of those 
service members, and assisting in the identification of common 
illnesses, such as those associated with the Gulf War Syndrome.
    How many deployments (soldiers) were delayed due to dental reasons, 
and how many reservists are not in Dental Class 1 or 2?
    Answer. Only 192 soldiers (0.11 percent of 176,846 mobilized) were 
delayed due to dental reasons; 33 were disqualified (0.02 percent). 
However, several factors contributed to this extremely low number. 
First, dental assets at mobilization sites, composed of both active and 
reserve dental assets, worked very assiduously to bring mobilizing 
reservists to deployable standards. Despite poor dental health of many 
reservists, dental facilities worked tirelessly to accommodate their 
acute oral health needs. Second, as funding for dental readiness of the 
reserve components is lacking, Army G-3 provided an additional $23 
million in OMA funds to support medical and dental readiness. As a 
result, many reservists obtained dental examinations and requisite 
dental care prior to mobilization. This care was provided primarily by 
contracts with civilian network providers. Recent figures from 
mobilization sites reflect that only 14 percent of those reporting to 
mobilization sites were dental class 3 (non-deployable), reflecting a 
vast improvement in dental readiness of our reserve forces over 
previous mobilizations.
    Current dental readiness of the reserves, reflected in MEDPROS 
data, reflects that 64.4 percent (223,140) of the Army National Guard 
are dentally non-deployable, and 72.9 percent (241,907) of the U.S. 
Army Reserve (USAR) are dentally non-deployable. For the USAR, a 
significant number of Class 4 soldiers are in the Individual Ready 
Reserve, who are not considered early deployers. With adequate funding, 
these statistics would be greatly improved.
    Question. What is the current enrollment rate in the TRICARE Dental 
Program (TDP) for reservists, and what action has DOD taken to 
encourage reservists to enroll in TDP?
    Answer. Data provided by TRICARE Management Activity (TMA) reflects 
an overall DOD reserve component enrollment rate of 4.9 percent as of 
January 2003. Mobilizations and deployments have decreased enrollment 
temporarily; as a result, latest numbers were not used. Army specific 
numbers are: USAR = 4.3 percent, and ARNG = 3.1 percent.
    The TDP contractor markets the plan to its potential beneficiaries. 
The initial marketing effort by the contractor entailed sending TDP 
information to each reserve and guard unit. Quantities of information 
sent were based on unit end strengths. The Defense Manpower Data Center 
provides the TDP contractor quarterly files listing newly eligible 
sponsors. This file is used for the ongoing marketing efforts under the 
TDP. The contractor has also established a website for TDP. The 
contractor has a staff of Dental Benefits Advisors that travel to 
military installations to include reserve and guard facilities. TMA's 
Communication and Customer Service marketing office has worked with 
Reserve Affairs to develop and post TDP fact sheets on the TMA website 
that are linked to other reserve and guard websites.
    Question. What needs to be done and what will it cost to ensure 
that reservists are medically and dentally fit for duty?
    Answer. Despite numerous initiatives, the active component dental 
assets shoulder the majority of Reserve Component (RC) mobilization 
workload, a requirement for which they are not resourced. Additionally, 
when active component dental assets are shifted to accommodate RC 
mobilization requirements, a concomitant drop in active component 
dental readiness occurs (a 7 percent drop in dental readiness of the 
3rd Infantry Division occurred at Fort Stewart during mobilization of 
the 48th Infantry Brigade [ARNG]). Use of active component dental 
assets will remain a necessity, but ideally only as a back up and not 
the primary means of preparing RC soldiers for deployment.
    Title 10 USC Section 1074a authorizes members of the Selected 
Reserve that are assigned to units scheduled for deployment within 75 
days after mobilization, an annual dental screen and dental care 
required to ensure deployability, at no cost to the soldier. However, 
funding for this requirement is lacking. When OMA funds were recently 
shifted to support this requirement for current operations, dental 
Class 3 (non-deployable) rates dropped to 14 percent for RC soldiers 
reporting to mobilization sites, a vast improvement from earlier 
deployments that documented a range of 20-35 percent dental Class 3 
(depending on mobilization and units involved). If a greater response 
time had been available, even greater improvements in dental readiness 
would have been realized. Adequate funding for this requirement would 
greatly enhance dental readiness of the RC.
    Several avenues are being studied to fulfill the dental 
requirements outlined in Title 10 USC Section 1074a. DOD(HA) has 
chartered an integrated process team to determine the best course of 
action. However, one estimate of Class 3 costs, based on a Tri-Service 
Center for Oral Health Studies Year 2000 Recruit Study of oral health 
needs reported a cost of $334 per trainee. Annual dental examination 
and required radiographs are estimated at $116 per soldier. Another 
estimate using the TRICARE Dental Program to pay the entire premium and 
selected co-pays to eliminate only Class 3 dental conditions resulted 
in a government cost of $124.4 million for premiums and $16.5 million 
for Class 3 dental care.
    Question. Are there any repercussions for commanders who do not 
ensure that their troops are fit for duty?
    Answer. Fitness for duty effects overall readiness of a unit. It is 
the commander's responsibility to ensure that all of his soldiers are 
medically fit. He can do this by ensuring the soldiers have current 
physicals, immunizations, dental exams, and participate in the semi-
annual Army Physical Fitness Test (APFT) and weigh-in. It is also the 
commander's responsibility to take appropriate action when a soldier 
does not meet the medical fitness standards as prescribed in Army 
Regulation (AR) 40-501, Standards of Medical Fitness. Appropriate 
action would include the medical board process and/or separation of 
soldiers in accordance with (IAW) AR 135-175, Separation of Officers or 
AR 135-178, Enlisted Administrative Separations. Repercussions for 
commanders who do not enforce individual medical readiness standards 
are not punitive in nature, but could include relief of command or less 
than adequate comments on the commander's performance evaluations.
                combat treatment in iraq and afghanistan
    Question. How well have your forward deployed medical support units 
and the small modular units performed in Operation Enduring Freedom and 
Operation Iraqi Freedom?
    Answer. The transformation initiatives have greatly enhanced the 
ability of the medical planners and commanders to place the appropriate 
amount of medical care, up close where the soldiers needs it, yet 
balanced with an economical use of the force. The Forward Surgical 
Teams (FST) were used very effectively first in Afghanistan and then 
they demonstrated dramatic results in Operation Iraqi Freedom (OIF). 
The FST is extremely lightweight, 100 percent mobile and has the speed 
to stay close to the combat element and provide immediate surgical care 
close to the place of injury. In OIF a FST was placed with each Brigade 
Combat Team. In addition each Brigade Combat Team was assigned 3 
Medical Evaluation Helicopters to link the FST with the next element of 
care the Combat Support Hospital (CSH). The CSH has a split base 
operating capability demonstrated in OIF with the 21st CSH and the 86th 
CSH. This flexibility allowed for the unit to more appropriately move 
with the flow of Combat, remain with evacuation distance, yet provide 
the next echelon of medical care in the theater. Three CSHs were 
assigned to the 5th Corp and 3 CSHs were in the theater rear.

                    DEPLOYMENT OF MEDICAL PERSONNEL

    Question. What are some of the lessons learned from our experience 
in Iraq?
    Answer. Operation IRAQI Freedom (OIF) reinforced the timeless 
lessons of military medicine of proximity to the wounded, preventive 
medicine, echeloned care, flexibility, and mobility. What was unique 
about this war was the large dimensions of the battlefield and the 
speed of the operation. The AMEDD has applied many of the lessons 
learned from the first Gulf War and recent operations other than war. 
As a result, our service members reaped the benefits of revised 
doctrine and procedures during OIF. During the first Gulf War, Combat 
Support Hospitals (CHSs) designed for the Cold War were large and 
immobile. Today our CSHs are modularized and able to provide split 
based operations. This war validated the importance of Forward Surgical 
Teams (FST), which are attached to brigade combat teams. These teams 
are light, extremely mobile, and have been trained as a trauma team at 
some of the most advanced trauma centers in the United States. FSTs 
take advantage of the ``Golden Hour'' and quickly provide life-saving 
surgery close to the point of wounding. OIF also validated our 91W 
transformation program. The 91W (Health Care Specialist) program 
increased the training of basic combat medics to the Emergency Medical 
Technician (EMT) level. Furthermore, medical planning officers were 
included at the various operational staff levels in the planning of OIF 
military campaign plan.
    The Army and the Army Medical Department (AMEDD) have a formal 
lessons learned process. As part of the initial OIF planning, The 
Surgeon General directed comprehensive data collection to facilitate 
the lessons learned process. Currently data collection is in process 
and additional lessons learned will result from formal data analysis.
    The preliminary analyses of injuries from this war indicate that 
improved ballistic protection for the head and thorax resulted in a 
reduction of immediately life threatening injuries. Patterns of injury 
were very different in Iraqi vs. U.S. soldiers. Iraqi soldiers 
experienced the whole spectrum of injuries: upper and lower 
extremities, chest, abdomen and back. U.S. soldiers have had 
predominately upper and lower extremity injuries. The use of body armor 
has reduced abdominal, chest and head penetrating injury.
    Excellent pre-deployment screening and preventive medicine kept the 
disease rate extremely low. Increased automation of the AMEDD's major 
systems such as logistics and patient tracking highlighted the need for 
improved access to assured data communications throughout the 
battlefield. The TRANSCOM Regulating and Command and Control Evacuation 
System (TRACES) improved the ability to evacuate casualties. However 
this system is still evolving and with appropriate funding, should have 
the capability to electronically track patients from point of injury to 
final disposition. The lessons learned from this war indicate that the 
AMEDD is on the right track and will keep improving as medical 
transformation continues.

           IMPROVEMENT OF EQUIPMENT FOR COMBAT CASUALTY CARE

    Question. What tools/equipment is still required to improve the 
care provided to combat casualties?
    Answer. In order to expedite treatment, it is critical that 
evacuation assets be available to facilitate the continuity of patient 
care. Current modes for patient evacuation include ground and air 
platforms, which includes the modernization of the UH60 Aero-medical 
fleet. As part of the Aviation Modernization Program, the HH60 Aero-
medical evacuation helicopter has demonstrated exceptional capability 
in providing enroute care in Afghanistan and during Operation Iraqi 
Freedom. This is a significant improvement in the standard of care 
provided during Operation Desert Storm. Continued fielding throughout 
the entire MEDEVAC fleet is paramount to continued future success.

            T-NEX, THE NEXT GENERATION OF TRICARE CONTRACTS

    Question. The next generation TRICARE contracts will replace the 
seven current managed care support contracts with three contracts. This 
consolidation is intended to improve portability and reduce the 
administrative costs of negotiating change orders and providing 
government oversight across seven contracts.
    The award date for these contacts has slipped from the scheduled 
date in July of 2003.
    Since the timeline for awarding the contracts has slipped, what is 
the expected start date for the delivery of T-Nex?
    Answer. The Army has not been notified of the slippage of award 
date you describe. However, if that were to occur, we anticipate that 
the currently planned start dates for all regions except Region 11 will 
likely remain the same and that the Region 11 start date will be 
adjusted to allow for a full ten month transition period.
    Question. What planning is taking place to help ensure that when 
the contracts are entered into there will be a seamless transition for 
beneficiaries?
    Answer. It is very important that transition to the T-Nex family of 
contracts be seamless to beneficiaries and that continuity of care be 
preserved to the greatest extent possible. Planning for seamlessness 
and continuity started with the development of the T-Nex contract 
request for proposals (RFP). Rules for interfacing of outgoing and 
incoming contractors to ensure smooth hand off of claims, records, and 
the like are designed into each RFP. A communications plan to inform 
beneficiaries and providers about the change has been developed and is 
being executed. Further, our beneficiary counseling and assistance 
coordinators are trained and ready to assist beneficiaries should T-Nex 
issues, questions, or problems arise. For example, the first T-Nex 
contract--TRICARE Mail Order Pharmacy (TMOP)--occurred March 1, 2003. 
Based on a very low number of patient complaints, hand off of patient 
records and prescriptions and delivery of pharmaceuticals according to 
schedule went well from the beneficiary perspective. When problems 
occurred, they were relatively minor and the incoming contractor moved 
quickly to correct them. Our beneficiary counseling and assistance 
coordinators were prepared and ready to assist beneficiaries if 
problems occurred.
    The larger Managed Care Support Services T-Nex contract, due to be 
awarded this summer, is a larger and more complex contract than TMOP, 
but the principles of execution to support seamless transition and 
continuity still apply: intense prior planning and designing in phase 
in/phase out rules to ensure smooth hand offs of records and claims 
information, develop and execute a communication plan to inform 
beneficiaries and all TRICARE providers of the coming contract change, 
and intense preparation of the cadre of beneficiary counselors to 
directly assist with beneficiary problems, issues, and concerns should 
they occur. Other more specific provisions in this contract include 
requiring the incoming contractor to negotiate with all current network 
providers and encourage them to remain in the network, careful planning 
to preserve continuity of care when resource sharing agreements are 
converted to direct contracts or other contracting arrangements within 
the military treatment facilities, preservation of the access standards 
as in the previous contracts, preservation of the primary care manager 
concept, and continuation of major programs--like TRICARE for Life and 
TRICARE Prime Remote--continue unchanged.
    Question. Are beneficiaries experiencing any change in quality of 
care due to DOD's inability to enter into new long-term managed care 
agreements?
    Answer. Due to extensions of all seven current managed care support 
contracts, beneficiaries continue to access quality health care both in 
military treatment facilities and in the civilian networks just as they 
have over the course of the current contracts. Quality of care 
complaints from beneficiaries remain rare and almost always come from 
beneficiaries in remote areas. When quality of care issues are raised 
by beneficiaries, the complaint is immediately validated and is brought 
to the attention of the relevant Lead Agent medical director. The 
medical director presents the case to the responsible managed care 
support contractor for investigation and resolution of the complaint.
    Question. Under T-Nex, what services currently provided by the 
TRICARE contractors will shift to the direct care system and what are 
the costs associated with this shift in services?
    Answer. Services that shift from the current TRICARE contractors to 
the direct care system are military treatment facility appointing/
referral management, management of all resource sharing agreements, 
internal utilization management services, management of the Health 
Evaluation Assessment Report, management of the health care information 
line, and transcription services. The estimated total cost to implement 
these services by Army facilities is $753.4 million through the last 
contract option, fiscal year 2008.
    The cost for appointing services consists of personnel and 
essential telephone equipment upgrades. To start health care delivery 
in fiscal year 2004 (prorated to account for staggered start ups) $16.7 
million is required with $26.5 million needed for the full fiscal year, 
2005.
    The estimated cost for replacing contractor personnel and equipment 
to perform internal utilization management services for fiscal year 
2004 is $6.5 million and $21.9 million in fiscal year 2005.
    Converting over 1,100 resource sharing providers to direct 
contracts or other arrangements to preserve continuity of care requires 
$15.8 million in fiscal year 2004 and $104.6 million in fiscal year 
2005.
    To manage the health care information line, we estimate $2.3 
million in 2004 and $7.3 million in 2005 is necessary. To assume 
management of the Health Evaluation Assessment Report within our 
facilities, the Army requires $.3 million in 2004 and $1.1 million in 
2005.

                        RECRUITING AND RETENTION

    Question. Personnel shortfalls still exist in a number of critical 
medical specialties throughout the Services. The Navy has reported 
shortfalls in Anesthesiology, General Surgery, Radiology, and 
Pathology, and has stated the civilian-military pay gap is their 
greatest obstacle in filling these high demand specialties. Recruiting 
and retaining dentists appears to be a challenge for all the services.
    To what extent have Critical Skills Retention Bonuses or other 
incentives been successful in helping to retain medical personnel?
    Answer. The table below shows the results of the recent Critical 
Skills Retention Bonus (CSRB).

------------------------------------------------------------------------
              Corps                  Eligible      Takers     Percentage
------------------------------------------------------------------------
Medical Corps....................          753          177           24
Dental Corps.....................          596          416           70
Nurse Corps......................          493          329           67
------------------------------------------------------------------------

    As can be seen, the program seems more successful within the Dental 
and Nurse community than the physician. What overall effect this will 
have on retention has yet to be determined. We are hopeful that those 
who opted for the CSRB in fiscal year 2003 will remain in the force 
beyond that. The increases in the Fiscal Year 2003 National Defense 
Authorization Act (NDAA) to the special pay ceilings may help us retain 
some assuming that appropriation support for these increases is also 
forthcoming.
    Question. What else needs to be done to maximize retention of 
medical personnel?
    Answer. The retention of our highly trained and skilled health care 
professionals is one of our greatest challenges. A recent study 
submitted to Congress indicated that the pay compatibility gap at seven 
years of service is between 13 and 63 percent, depending on the 
specialty. The Fiscal Year 2003 National Defense Authorization Act 
(NDAA) raised the ceilings on discretionary special pays for our health 
care providers for the first time in ten years. We are now working 
within our system to obtain funding to support increases in our special 
pays against these new ceilings. However, we need to recognize that it 
isn't all about the money. The pay compatibility gap will never be 
completely closed. There are a multitude of other factors that we have 
addressed and keep addressing. Such things as adequate and skilled 
administrative support staff to allow our clinicians to maximize the 
time they spend practicing their craft is vitally important. That, 
coupled with modern facilities and equipment, create an environment of 
practice that is attractive to health care providers, and is often more 
important than pure economics. In many cases the scope of practice of 
our non-physician health care providers is greater than that in the 
civilian community and is extremely satisfying. The ability of our 
personnel to enter academic or research fields, in additional to the 
purely clinical is another important facet that we will continue to 
support. Quality of life is equally important to many of our personnel. 
The benefits of service, such as housing, paid leave, and base 
facilities, are difficult to replicate in the civilian sector. By 
addressing the whole package--money, quality of life and environment of 
practice, we hope to retain dedicated health care professionals that 
will insure the soldier on point will not be alone and will have world 
class health care both at home and while deployed.

                                 ______
                                 
            Questions Submitted by Senator Pete V. Domenici

               JESSE SPIRI MILITARY MEDICAL COVERAGE ACT

    Question. In 2001, a young Marine Corps 2nd LT from New Mexico lost 
his courageous battle with cancer. Jesse Spiri had just graduated from 
Western New Mexico University and was awaiting basic officer training 
when he learned of his illness. However, because his commission had 
triggered his military status to that of ``inactive reservist,'' Jesse 
was not fully covered by TRICARE. As a result, he was left unable to 
afford the kind of special treatment he needed. I believe it is time to 
close this dangerous loophole. That is why I intend to offer a bill 
entitled the ``Jesse Spiri Military Medical Coverage Act.'' This bill 
will ensure that those military officers who have received a commission 
and are awaiting ``active duty'' status will have access to proper 
medical insurance.
    Would you agree that this type of loophole is extremely dangerous 
for those who, like Jesse, suffer with a dreaded disease?
    Answer. Yes, we agree that for someone like Jesse, who has a 
terminal illness, having no health insurance is very dangerous. We 
mourn, as well, for the tragic loss of Jesse Spiri. The death of one's 
child is perhaps the most difficult thing a parent must bear, and my 
heart goes out to his family. The more potent issue for the Military 
Health System is that Jesse suffered from a disease which made him 
unable to perform military duties, and that existed prior to service 
(EPTS). Similarly, any soldier on active duty who had Jesse's condition 
would have been separated from active duty. And for those on active 
duty less than 8 years who suffer from congenital or hereditary 
conditions, they would not receive any disability benefits or coverage 
for health care after they are discharged.
    Question. And do you agree that our military health care system 
should close this loophole, and can do so very cost effectively (given 
the relatively low number of officers it would affect)?
    Answer. We agree that individuals such as Jesse, who are part of 
the 41.2 million uninsured (2001) in our country, face negative health 
and financial consequences from terminal illnesses. We also recognize 
that finding solutions to the problem of health coverage for the 
uninsured is difficult and will require the efforts of both the 
government and private sectors. The mission of the Military Health Care 
System is to meet the challenge of maintaining medical combat readiness 
while providing the best health care for all eligible personnel. These 
include active duty and retired members of the uniformed services, 
their families, and survivors, which today total approximately 8.5 
million. Congress can expand the categories of eligible personnel, but 
there are significant policy and equity issues of expanding eligibility 
only to selected inactive Reserve Component officers. And any expansion 
of TRICARE benefits to any Reserve Component personnel and/or families 
must be accompanied by increases in Defense Health Program budgets. The 
list of hereditary or congenital components (e.g., brain damage from an 
Arteriovenous malformation, certain types of breast cancer, retinitis 
pigmentosa) is continually growing as medical science advances, making 
it impossible to implement fairly a system that mandates denial of 
benefits if a condition is determined to be hereditary or congenital. 
The Army would like to attain congressional approval of an initiative 
that would reduce the 8-year provision to requiring only 18 months of 
continuous active service before pre-existing conditions are covered.

               MILITARY FAMILY ACCESS TO DENTAL CARE ACT

    Question. I think everyone here is familiar with the adage that we 
recruit the soldier, but we retain the family. That means taking care 
of our military families and giving them a good standard of living. I 
have introduced a bill that would provide a benefit to military 
families seeking dental care, but who must travel great distances to 
receive it. Specifically, my bill, the ``Military Family Access to 
Dental Care Act'' (S. 336) would provide a travel reimbursement to 
military families in need of certain specialized dental care but who 
are required to travel over 100 miles to see a specialist. Often, 
families at rural bases like Cannon Air Force Base in Clovis, NM meet 
with financial hardship if more than one extended trip is required. 
This bill reimburses them for that travel and is a small way of helping 
our military families.
    Given that current law provides a travel reimbursement for military 
families who must travel more than 100 miles for specialty medical 
care, do you believe it is important to incorporate specialty dental 
care within this benefit?
    Answer. I fully concur with the concept of providing a travel 
reimbursement for military families who must travel more than 100 miles 
for specialty dental care. However, most active duty family members 
participate in the TRICARE Dental Program (TDP), the DOD-sponsored 
dental insurance program. If these family members must travel greater 
than 100 miles for specialty dental care at a civilian TDP provider, 
travel reimbursement would ease some of their financial burden. 
Management of this program may prove difficult, however. Unlike the 
TRICARE Health Plan, DOD does not monitor nor control where TDP 
enrollees go for care. Verification of that travel may prove 
problematic, as greater reliance on the contractor (United Concordia) 
for verification would be necessary.
    Question. Do you think this benefit would improve the standard of 
living of our military families.
    Answer. Clearly, this benefit would improve the standard of living 
of our military families.

                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby

                       PATIENT PRIVACY (TRICARE)

    Question. I would like to get your comments about several concerns 
and questions I have related to the December 14, 2002 break-in of the 
offices of TriWest, a TRICARE contractor. I am told that TriWest did 
not notify the Department of Defense of the break-in and theft of 
personnel information of over 500,000 TRICARE beneficiaries, for almost 
a week after the event. Apparently, TriWest didn't even have basic 
security equipment--guards, locks, cameras--and as a result, this 
incident amounts to the biggest identity theft in U.S. history. Is this 
information true?
    Answer. The physical break-in of the locked TriWest Healthcare 
Alliance corporate offices and theft of computer equipment occurred on 
Saturday, December 14, 2002. On Monday, December 16, 2002, the break-in 
and theft was discovered, authorities contacted, and TRICARE Management 
Activity (TMA) operations staff were advised. Back-up tapes were run on 
Tuesday, December 17, 2002, (which took 30 hours), and on Friday, 
December 20, 2002, TMA/HA leadership was notified of the beneficiary 
information theft. TriWest at that time had available from their back-
up tapes beneficiary information including names, addresses, phone 
numbers, Social Security Numbers, some claims information with relevant 
procedure codes, and personal credit card information on 23 
individuals.
    To date, the Army Medical Department has not received notification 
of a single verified case of identity theft related to TriWest stolen 
computer equipment.
    Question. Has the Department of Defense finished its investigation 
of this case and have sanctions been levied against TriWest or punitive 
actions against TRICARE officials?
    Answer. The criminal investigation is being conducted by the 
Defense Criminal Investigative Service (DCIS) and the Federal Bureau of 
Investigation (FBI), in coordination with other federal and local law 
enforcement agencies.
    To date, no sanctions have been levied upon or punitive actions 
taken against TriWest or TRICARE officials. The investigation is 
ongoing, and its findings are pending.
    Sensitive information pertaining to TRICARE beneficiaries is 
maintained by TRICARE contractors subject to the Privacy Act of 1974, 
as implemented by the DOD Privacy Program (DOD 5400.11-R). The Act 
provides criminal penalties for any contractor or contractor employee 
who willfully discloses such protected information, in any manner, to 
any person or agency not entitled to receive the information. The Act 
also provides for civil penalties against DOD if it is determined that 
the Department (or contractor) intentionally or willfully failed to 
comply with the Privacy Act.
    Question. Would you please share what you can about the lessons 
learned as a result of this incident and the steps the Department and 
the TRICARE organization and its contractors are taking to guarantee 
beneficiary privacy?
    Answer. As a result of close evaluation of our physical and 
information security we found the following:
  --Backup tapes not protected. For example, tapes left on the top of 
        servers, or left lying out in the open.
  --A general lack of proper security in areas where servers reside. In 
        particular, Defense Blood Standard System and Pharmacy servers 
        were not being properly protected.
  --Most sites had excellent password management policies and 
        guidelines in place, but they were not being followed.
  --In general, there were proper locks on doors, but in several cases, 
        not being properly used. Many doors that should have been 
        locked after hours were found open which allowed entry to areas 
        where patient information is kept. Most items not secure were 
        portable medical devices containing patient medical information 
        and medical records.
  --In many cases contingency plans for disaster recovery were lacking 
        or out-of-date.
  --Lost hardware not reported through official channels.
  --Hardware being turned in without data being wiped from hard drives.
  --Concerning recent physical security self-assessments, a second look 
        found almost 60 percent of local assessments were inaccurate or 
        inexact.
  --As a result of the TriWest issues all Army medical activities 
        participated in a Health Affairs directed self-assessment of 
        local physical security practices. Mitigation plans for all 
        deficiencies are due on May 16, 2003.

                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                      MEDICAL TREATMENT FACILITIES

    Question. Healthcare, pay, and housing are the greatest Quality of 
Life issues for our troops and their families. With the numbers of 
health care staff deployed from your Military Treatment Facilities, 
what strategies did you use to effectively plan and care for 
beneficiaries back home?
    Answer. The most expeditious means to maintain services for our 
beneficiaries was accomplished by looking across our own regional 
medical commands for opportunities to cross-level providers when 
possible. The TRICARE Health Plan was designed with contingency 
operations in mind and the Managed Care Support Contractor's (MCSC) 
network of providers becomes the second echelon for health care 
services if the MTF is unable to provide the care. Before requesting 
any reserve component activation for backfill support, the MEDCOM staff 
coordinated with the TRICARE Lead Agents and the MCSC to evaluate the 
adequacy of the civilian provider network, especially in relation to 
specific clinical specialties and locations that were hard hit. When 
network adequacy was less than adequate, the request for reserve 
component backfill request was prepared to maintain health care 
services. Additionally, the MCSC provided backfill providers and 
support staff through resource sharing agreements. A summary of 
resource sharing backfill by DOD Region and skill type is provided 
below for Army MTFs. The MCSC was successful in providing 88 percent of 
the requested backfill. The majority of those filled by the MCSC were 
in the Registered Nurse and Para-Professional skills. For those 
positions capable of being filled with resource sharing personnel, the 
MCSC's average ``fill time'' was 16 days compared to the industry 
standard of 90 days.

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                    DOD TRICARE Region
               Skill Type                                    Data                    -----------------------------------------------    Grand    Percent
                                                                                         3        5        6        12       7/8        Total    By Type
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physicians.............................  Subtotal FTEs Requested....................        3        5      0.5     1.66        8.5       18.66       12
                                         Subtotal FTEs Filled.......................        3        5      0.5     1.66        8.5       18.66       14
PAs/NPs................................  Subtotal FTEs Requested....................        1        1  .......  .......  .........        2           1
                                         Subtotal FTEs Filled.......................        1        1  .......  .......  .........        2           1
RNs....................................  Subtotal FTEs Requested....................       21        9  .......  .......       39         69          45
                                         Subtotal FTEs Filled.......................       11        9  .......  .......       39         59          43
Paraprofessionals......................  Subtotal FTEs Requested....................       19        5  .......  .......       30         54          35
                                         Subtotal FTEs Filled.......................       10        5  .......  .......       30         45          33
Administrative.........................  Subtotal FTEs Requested....................  .......        9  .......  .......        2         11           7
                                         Subtotal FTEs Filled.......................  .......        9  .......  .......        2         11           8
                                        ----------------------------------------------------------------------------------------------------------------
      Total FTEs Requested.............  ...........................................       44       29      0.5     1.66       79.5      154.66  .......
      Total FTEs Filled................  ...........................................       25       29      0.5     1.66       79.5      135.66       88
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Question. How are you able to address the needs of patients coming 
in from the battlefield and is this affecting the care of beneficiaries 
seeking regular care?
    Answer. Casualties evacuated from Operation IRAQI Freedom (OIF) and 
Operation Enduring Freedom (OEF) were initially sent to either the 
fleet hospital at ROTA Spain or Landstuhl Regional Medical Center 
(LRMC). The staffing of LRMC was increased to manage the flow of 
casualties. This enabled LRMC to execute both its peacetime mission of 
providing health care to beneficiaries stationed in Europe and its 
wartime mission of the primary OCONUS military treatment facility (MTF) 
supporting the Global War on Terrorism. Evacuation from Europe was 
facilitated by the TRANSCOM Regulating and Command and Control 
Evacuation System (TRACES). This system improved the ability to send 
casualties to medical centers best equipped to manage their specific 
medical problem. For example: TRACES expedited the evacuation of burn 
patients to the specialized burn center at Brooke Army Medical Center 
(BAMC).
    Army Medical Centers, such as Walter Reed Army Medical Center and 
Womack Army Medical Center/Fort Bragg, and Army Community Hospitals, 
such as the hospital at Fort Hood, deployed many health care providers 
and paraprofessionals. Reserve component backfill and cross leveling 
within the Army Medical Department maintained the capacity of most MTFs 
in the Army. Localized shortages of certain beneficiary services did 
occur. However, when the network capability was adequate, beneficiaries 
were able to obtain health care on the local economy through TRICARE if 
care within the MTF was not available or if waiting times exceeded 
TRICARE access standards. In some locations, the TRICARE network 
capability and the adequacy of that network, remains problematic. In 
these areas, TRICARE access standards were exceeded. Across the Army 
there has been approximately a 20 percent increase in purchased care. 
This increase combined with the augmented numbers of reserve soldiers 
on active duty, and the need to send health care providers on extended 
temporary duty, will significantly increase the resource requirements 
of the Army Medical Department.
    Question. What authority were you given to backfill your vacancies 
and are the funds sufficient to attain that goal?
    Answer. The Army Medical Department has supported and is supporting 
a number of missions requiring the deployment of medical personnel in 
addition to those deployed in support of Operation Iraqi Freedom (OIF) 
and Operation Noble Eagle. None of our MTFs are overstrength, and the 
impact of these deployments is always felt, but can generally be 
managed for the short duration missions.
    Dr. David Chu, Under Secretary of Defense for Personnel and 
Readiness, authorized a 50 percent backfill by Reserve Component 
personnel of the number of vacancies created by the deployment of 
active duty in PROFIS (professional filler system) positions to OIF 
only. Additionally, limiting the amount of active duty time to 90-day 
rotations for RC physicians, dentists, and Nurse Anesthetists has been 
problematic as there are insufficient reserves to fill multiple 
rotations in some specialties. Attempting to maintain the high quality 
of care and the access to care for our beneficiaries with this 
reduction in personnel has been extremely challenging. Increasing the 
amount of funding for reserve backfill would increase the ability to 
replace losses, especially in areas of inadequate TRICARE networks. To 
accommodate the 90-day rotational policy, a significant increase in the 
number of slots for reserves will be needed.
    Question. What measures were used in determining what the services 
were able to backfill and how did that compare to current requirements?
    Answer. Current staffing before deployment; staff losses, by 
specialty, due to deployment; loss of borrowed military manpower; 
losses due to other taskings; TRICARE network adequacy; non-network 
adequacy; historical ability to hire/contract healthcare workers; 
reserve availability; and the ability of the regions to cross-level 
losses, especially low-density specialties, were all taken into account 
to determine the level and kind of backfill needed. As deployment 
schedules, troop mix and actual units changed for this fluid operation, 
reserve backfill and cross-leveling were and continue to be adjusted.

                       RETENTION AND RECRUITMENT

    Question. With increasing deployments in support of Operation Iraqi 
Freedom and the Global War on Terrorism, can you describe your overall 
recruitment and retention status of the Medical Department in each of 
your services?
    Answer. Our current accession projections for the year (as of May 
7, 2003) are in the table below:

----------------------------------------------------------------------------------------------------------------
                              Corps                                   Mission       Projection      Percentage
----------------------------------------------------------------------------------------------------------------
Army Nurse Corps................................................             373             283           75.87
Dental Corps....................................................             117             112           95.73
Medical Corps...................................................             389             389          100.00
Medical Service Corps...........................................             369             369          100.00
Medical Specialist Corps........................................              83             106          127.71
Veterinary Corps................................................              40              43          107.05
                                                                 -----------------------------------------------
      Total.....................................................           1,371           1,302           94.97
----------------------------------------------------------------------------------------------------------------

    Our current loss projections seem to be following a historical 
glide path, but this may have been influenced by the various programs 
put in place to stop personnel from exiting the service. Once these 
programs are no longer in place, it is unclear how our force will 
react. If we utilize, for example, the number of people eligible for 
Incentive Special Pay compared to those that elected to execute a 
contract, we see that this fiscal year is significantly below the last 
three years. This may well indicate a problem within the Medical Corps. 
We project meeting our accession program for Medical Corps officers. 
However, chronic shortages in some specialties (such as surgical 
subspecialties) continue to exist in the Medical Corps.
    Question. What specific corps or specialties are of most concern?
    Answer. Currently, the Army Nurse Corps is of the most concern. The 
nation wide shortage, coupled with two years of an inability to achieve 
our accession target, has created a significant shortage of skilled 
nurses. We are hopeful that utilization of the Health Professions Loan 
Repayment Program, changes with United States Army Cadet Command and 
planned increases in the Accession Bonus will enable us to more 
successfully compete within the civilian market place for these skills. 
Within the Medical Corps, our surgical specialties continue to present 
us with the largest challenge. General surgery, orthopedic surgery and 
anesthesiology continue to be specialties with a high Operational 
Tempo. This high Operational Tempo, coupled with a significant pay gap 
when compared to civilian situations, makes the retention of these 
specialties difficult. Our radiology community is also experiencing a 
decline in the inventory. Our past efforts within the Dental Corps are 
now starting to pay dividends. While still short in terms of total 
inventory, past increases in our student program support for this Corps 
has resulted in positive strides toward eliminating our accession 
problems.
    Question. Did the Critical Skills Retention Bonus given for this 
year help these specialties?
    Answer. Within the Nurse Corps, 55 percent of the Nurse 
Anesthetists and 76 percent of the Operating Room Nurses that were 
eligible for the Critical Skills Retention Bonus (CSRB) opted for the 
program. Within the Dental Community, 70 percent of those eligible took 
the program. Medical Corps response was somewhat less than this with 
only 24 percent of the eligible physicians opting for the program.
    Question. In light of shortages and the disparity between military 
and civilian salaries, how have you planned for additional retention 
bonuses in future years?
    Answer. The Fiscal Year 2003 National Defense Authorization Act 
(NDAA) increased the ceilings on our retention and accessions pays. In 
the absence of any appropriation to support these additional 
authorizations, we have attempted to make small modifications within 
existing budgets for fiscal year 2004. However, working with our sister 
services and Health Affairs, we are developing an aggressive plan with 
increases in all specialties for fiscal year 2005 and beyond. The 
actual amount of the increase will be determined based on projected 
inventory. The proposed increases range anywhere from $2,000 to $25,000 
(assuming a four year contract) depending on the specialty. This plan 
is contingent on the availability of funds. Currently funds are not 
programmed within the Defense Health Program or the services military 
personnel accounts for this initiative.
    Question. Are there recruitment and retention issues within certain 
specialties or corps?
    Answer. Currently, the Army Nurse Corps is of significant concern. 
The nation-wide shortage, coupled with two years of an inability to 
achieve our accession target--86 percent (288 of 333 authorizations) 
and 79 percent (291 of 367 authorizations) for fiscal year 2001 and 
fiscal year 2002 respectively--has created a significant shortage of 
skilled nurses. Our predominant nursing shortages are for Operating 
Room Nurses--86 percent (290 of 339 authorizations), Nurse 
Anesthesists--72 percent (200 of 277 authorizations) and OBGYN Nurses--
73 percent (129 of 177 authorizations). We are hopeful that utilization 
of the Health Professions Loan Repayment Program, changes within United 
States Army Cadet Command and planned increases in the Accession Bonus 
will enable us to more successfully compete within the civilian market 
place for these skills. Within the Medical Corps, our surgical 
specialties continue to present us with the largest challenge. General 
Surgery--50 percent (126 of 251 authorizations), Orthopedic Surgery--54 
percent (116 of 215 authorizations) and Anesthesiology--84 percent (138 
of 164 authorizations) continue to be specialties with a high 
Operational Tempo. This high Operation Tempo, coupled with a 
significant pay gap when compared to civilian situations--36 percent 
for General Surgeons, 48 percent for Orthopedic Surgeons and 42 percent 
for Anesthesiologist (data as of fiscal year 2000 for providers at 
seven years of service as reported in the Health Professions' 
Retention-Accession Incentives Study Report to Congress by the Center 
for Naval Analysis) makes the retention of these specialties difficult. 
Our radiology community--58 percent (119 of 204 authorizations) is also 
experiencing a decline in the inventory. Our past efforts within the 
Dental Corps are now starting to pay dividends. While still short in 
terms of total inventory--87 percent (987 of 1,136 authorizations), 
past increases in our student program support for this Corps has 
resulted in positive strides toward eliminating our accession problems 
(achieved an average of 77 percent of accession requirements over the 
past five years, as opposed to an average of 64 percent success rate 
over the last ten years). We continue to use a variety of bonus 
programs as well as initiatives to improve the quality of medical 
practice to enhance provider satisfaction and improve retention.
    Question. If so, what are your recommendations to address this in 
the future?
    Answer. Fully funded student programs coupled with accession 
incentives comparable with those offered within the civilian market 
place will be critical to maintaining our force structure. Aggressive 
utilization of the Health Professions Loan Repayment Program as a 
retention tool within the Nurse Corps will hopefully change some 
retention behavior. We are also increasing the use Reserve Officer 
Training Corps scholarships, restructuring bonuses and seeking 
increased funding to increase bonus payments. We are also working to 
improve our providers' satisfaction with the quality of their clinical 
practice to improve retention. If this is successful within this Corps, 
we will evaluate its utility within other Corps.
    Question. Have incentive and special pays helped with specific 
corps or specialties?
    Answer. This is a difficult question to quantify. The percentage of 
officers who elected to avail themselves of these special pays can be 
an indication of success. For example, when we offered new retention 
pays to our Optometry and Pharmacy community, 86 percent and 88 percent 
respectively, opted for the pays. There is no way to refute the 
argument that some of these individuals would have been retained 
without these pays, however the bottom line is they work and are a 
valuable aid to retention.
    Question. How does the fiscal year 2004 budget request address your 
recruitment and retention goals?
    Answer. The Army has funded to 100 percent the requested Program 
Objective Memorandum (POM) through fiscal year 2004. Even though the 
fiscal year 2003 NDAA increased the discretionary special pay caps, 
additional dollars were not appropriated. The Army is supportive of 
validated POM requirements submitted for fiscal year 2005-09. We 
anticipate the ability to implement partial changes in fiscal year 2004 
and further aggressively increase special pay rates in fiscal year 2005 
and the out-years.

                        FORCE HEALTH PROTECTION

    Question. As a result of concerns discovered after the Gulf War, 
the Department created a Force Health Protection system designed to 
properly monitor and treat our military personnel.
    What aspects of the Departments' Force Health Protection system 
have been implemented to date?
    Answer. The Persian Gulf War and experience with illnesses among 
Gulf War veterans highlighted some deficiencies in the Army's force 
health protection capabilities. The Army Medical Department (AMEDD) has 
made significant progress in addressing these shortfalls, but more 
needs to be done.
    The U.S. Army Center for Health Promotion and Preventive Medicine 
(USACHPPM) was formed in 1994 to improve integration of AMEDD's force 
health protection efforts for the warfighter. The emerging capabilities 
of USACHPPM allow the AMEDD to anticipate, communicate, and protect 
against health threats to deployed soldiers, including those posed by 
the environmental health threats on the battlefield, through 
Occupational and Environmental Health Surveillance. The USACHPPM, in 
collaboration with the Armed Forces Medical Intelligence Center (AFMIC) 
and other elements of the Defense intelligence community, has 
dramatically improved the intelligence preparation of the battlefield 
so that commanders are informed about potential environmental health 
risks before they occupy a site that could cause their soldiers to 
become ill. This is accomplished in part through a secure website. The 
USACHPPM deploys preventive medicine teams to survey the occupational 
and environmental health (OEH) risks to our forces. As these potential 
OEH risks are identified, control measures are quickly recommended to 
local commanders in the field. In addition, these exposure data are now 
archived and will be included as part of the Defense Occupational and 
Environmental Health Readiness System (DOEHRS) for review in later 
retrospective health studies. Occupational and environmental health 
surveillance policy, doctrine, tactics, techniques and procedures are 
also continually being developed and updated by the AMEDD to further 
promote the safety of our deployed forces.
    The AMEDD tracks soldiers health throughout the career life-cycle 
through the Defense Medical Surveillance System, which includes data on 
pre- and post-deployment health assessments, episodes of health care, 
immunizations, reportable disease conditions for over 7.6 million 
personnel serving on active duty since 1990, and is linked to the DOD 
Serum Repository in Silver Spring, MD, housing over 31 million serum 
specimens collected from active duty service members since the late 
1980's.
    The 520th Theater Army Medical Laboratory, bringing state-of the-
art medical laboratory science and technical support for the combatant 
commander, was established in 1995 and first deployed to Bosnia in 
early 1996.
    The Medical Protection System (MEDPROS) automates the Army's 
medical readiness system, including tracking immunizations for 
soldiers, beginning with anthrax vaccine in 1998, and continuing with 
smallpox and other militarily important vaccines today.
    The Army is Executive Agent for the DOD Global Emerging Infections 
Surveillance and Response System (GEIS), established in 1996. Since 
2001, GEIS has operated Project ESSENCE to provide early notification 
of outbreaks of infectious diseases in military communities around the 
world, including those that may represent manifestations of use of a 
biological weapon.
    Since 1991, the U.S. Food and Drug Administration has licensed 
vaccines against hepatitis A, Japanese encephalitis, and smallpox, and 
Soman Nerve Agent Pretreatment, Pyridostigmine (SNAPP). These and other 
products of military medical research allow the AMEDD to provide high 
quality disease countermeasures to protect the deployed force.
    As always, the AMEDD attends to the health care needs of soldiers 
while they are deployed. In 2000, the AMEDD began the transformation of 
the combat medic into the 91W (``Whisky''), the medical soldier for the 
objective force.
    The AMEDD provide quality care for soldiers following deployment, 
employing valuable lessons learned from the first Persian Gulf War in 
the Deployment Health Clinical Practice Guideline, and establishment of 
the DOD Deployment Health Clinical Center at Walter Reed Army Medical 
Center, Washington, DC in 1998.
    Question. What are the differences between the system during the 
Gulf War, Operation Iraqi Freedom, and Operation Enduring Freedom and 
Operation Noble Eagle?
    Answer. All accomplishments listed above reflect the growth and 
evolution of the Army's robust deployment surveillance capability since 
1991. Probably the most significant improvements in this capability are 
the Deployment Health Clinical Practice Guideline and the extensive 
longitudinal baseline health database provided by the Defense Medical 
Surveillance System.
    The Deployment Health Clinical Practice guideline is a very useful 
tool for health care providers to assist patients with any health 
problem or concern that the patient judges to be related to a military 
deployment. By addressing deployment-related concerns proactively, we 
anticipate that this guideline will facilitate appropriate, timely, and 
trusted health care for soldiers and their families following 
deployments.
    The Defense Medical Surveillance System permits extensive analysis 
of health issues among deployed personnel from all Services. In the 
wake of the Gulf War, we were unable to answer many basic questions 
about health and disease among military members due to lack of 
appropriate data. With the establishment and growth of the Defense 
Medical Surveillance System, including the DOD Serum Repository, we can 
provide much more timely, accurate, and comprehensive answers to 
questions about the health of the service members, individually and 
collectively, including those deployed on contingency operations.
    For Operation Iraqi Freedom, the deployment health surveillance 
program has been enhanced with the addition of a more extensive post-
deployment health assessment questionnaire, a requirement for face-to-
face encounter between a health care provider and each service member 
before demobilization, and the collection of a post-deployment serum 
specimen to be added to the DOD Serum Repository. In this way, we are 
collecting adequate information on the health of redeploying service 
personnel to satisfy our surveillance requirements while assuring that 
each service member receives the appropriate medical attention and care 
he or she deserves before demobilization.

                              OPTIMIZATION

    Question. Congress initiated optimization funds to provide 
flexibility to the Surgeons General to invest in additional 
capabilities and technologies that would also result in future savings. 
It is my understanding that a portion of these funds are being withheld 
from the Services.
    Can you please tell the Committee how much Optimization funding is 
being withheld from your service, what are the plans for distributing 
the funds, and why funds since fiscal year 2001 are being withheld?
    Answer. The AMEDD validated and approved 23 projects in fiscal year 
2003. At this point, 15 of those projects with a fiscal year 2003 cost 
of $2,143,800 have not been funded by OSD. My staff is reviewing an 
additional 14 Optimization projects targeting fiscal year 2003 funding. 
Once approved, they will be forwarded to OSD for funding. Optimization 
funding is being held by OSD to resource a portion of their fiscal year 
2003 $800 million shortfall. OSD does not plan to distribute funding 
until they resolve the funding shortfall.
    Question. How have you benefited from optimization funds?
    Answer. Army Medical Treatment Facilities have benefited greatly 
from your support to optimize the direct care system. This support 
enables the Army to exploit cost effective opportunities to achieve 
maximum benefit from existing MHS structure. The AMEDD actively manages 
32 Optimization initiatives with an annual investment value of $16 
million and a projected net annual savings at maturity of $5 million. 
Although these projects are in varying stages of maturity the majority 
have achieved self-financing status and are positioned to recoup their 
initial investment. Much of the savings occur in private sector care 
expenditures. Optimization funding is being used not simply to 
recapture workload from the private sector but rather optimize the mix 
of services making the most efficient use of existing MHS 
infrastructure and private sector care capability. The benefits of 
optimization may not always be apparent due in large part to the gap 
between budgeted and actual medical inflation rates and changes to the 
medical benefit. Optimization funding reduces the overall cost to the 
MHS. Those costs would be rising at an increased rate absent your 
support and commitment to the Optimization program.
    Question. What projects are on hold because OSD has not released 
funding?
    Answer. The AMEDD has 15 Optimization projects on hold awaiting OSD 
release of funds. Although time may not permit me to go into great 
detail on each, there are some interesting characteristics of this 
group. A VA/DOD sharing agreement brings MRI capability to the Fort 
Knox community while increasing the VA's capacity to deliver those same 
services in their local market. Optimization projects targeting child 
mental health in the Northwest, active duty inpatient psychiatry in the 
Southwest, and substance abuse in Hawaii are awaiting funding. A number 
of projects such as lithotripsy at Fort Bliss and automated surgical 
clothing swap stations at Fort Campbell can be implemented quickly and 
offer rapid return with a modest investment.
    Question. What are the projected projects using the proposed $90 
million in the fiscal year 2004 budget request?
    Answer. My subordinate commanders continue to develop optimization 
opportunities in anticipation of fiscal year 2004 and beyond funding. 
The AMEDD has institutionalized the optimization process. Early 
successes improved our ability to develop and implement initiatives. I 
anticipate increasing incremental benefit of the Optimization program 
going forward.

                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein

                       PATIENT PRIVACY (TRICARE)

    Question. In December, 2002, one of the Department's managed care 
support contractors for the military's TRICARE program experienced a 
significant theft of military beneficiary personal identification--
possibly the largest personal identification theft in U.S. history. 
This theft has potentially significant and serious implications for 
those beneficiaries, and the vulnerability of these individuals may 
well extend for years.
    The Department pledged a full investigation of this matter, yet 
little has been heard on the status and outcome of internal and 
external reviews and investigations.
    What is the status and outcome of the Department's Inspector 
General investigation into this theft?
    Answer. As requested by the Assistant Secretary of Defense for 
Health Affairs [ASD(HA)], the DOD Inspector General will complete all 
facility physical security evaluations, by the end of May 2003. Soon 
thereafter, they will brief the ASD(HA) on their preliminary findings.
    Question. Has the Department determined that its policies and 
oversight of its TRICARE managed care support contractors' personal 
information security are adequate given the December incident?
    Answer. We believe that our policies are strong, sound and 
adequate, and this has been verified by a study conducted by the 
Gartner consulting group. Each TRICARE contractor has the primary 
responsibility for implementing sufficient security safeguards to 
prevent unauthorized entry into its data processing facility and 
unauthorized access to TRICARE beneficiary records in contractor 
custody. We have also initiated a review of TRICARE contract language 
to ensure that it incorporates current security policies. In addition, 
we continue with oversight of managed care support contractors through 
DOD's process of ongoing accreditation and certification of contractor 
systems and networks, a process which incorporates into its criteria a 
variety of facility physical security controls.
    Question. Is the Department convinced its policies for the security 
of personal health care information adhere to established industry best 
practices?
    Answer. The results of recent assessments, validations and the 
Gartner study demonstrate that the Department's policies for the 
security of personal health information meet, and in some cases, exceed 
established Federal, DOD, and industry information security standards.
    Question. Does the Department need any new authorities to address 
personal information security and deal appropriately with entities 
failing to adequately safeguard such sensitive information?
    Answer. At this time, DOD does not require any additional 
authorities to address personal information security.
    Question. Is the Department considering implementing a system of 
sanctions or penalties against companies who fail to provide reasonable 
protections for personal information?
    Answer. DOD currently has procedures and mechanisms in place to 
address inappropriate management of personal and medical information. 
Sensitive information pertaining to TRICARE beneficiaries is maintained 
by TRICARE contractors subject to the Privacy Act of 1974, as 
implemented by the DOD Privacy Program (DOD 5400.11-R). The Act 
provides criminal penalties for any contractor or contractor employee 
who willfully discloses such protected information, in any manner, to 
any person or agency not entitled to receive the information. The Act 
also provides for civil penalties against DOD if it is determined that 
the Department (or contractor) intentionally or willfully failed to 
comply with the Privacy Act.

                                 ______
                                 
   Questions Submitted to Lieutenant General George Peach Taylor, Jr.

               Questions Submitted by Senator Ted Stevens

                    DEPLOYMENT OF MEDICAL PERSONNEL

    Question. The staff's discussions with the Surgeons General 
indicate that the Services have backfilled for deployed medical 
personnel at the Medical Treatment Facilities at varying levels.
    Some of the Services are relying more heavily on private sector 
care rather than backfilling for deployed medical personnel.
    To what extent has the recent deployment of military medical 
personnel affected access to care at military treatment facilities? 
What are you doing to ensure adequate access to care during this time?
    Answer. Despite deployments, access to routine health care in the 
Air Force Medical Service (AFMS) has improved seven percent since 
August 2002. Currently, military medical treatment facilities (MTFs) 
are able to provide routine access to health care (within seven days) 
83 percent of the time. MTFs are able to provide access to acute care 
(within 24 hours) 96 percent of the time. MTFs have met peacetime 
standards, but there has been an overall increase in costs, 
particularly to supplemental care, in order to meet the health care 
needs of Guard and Reserve members called to active duty.
    Through the working relationships between our Managed Care Support 
Contractors (MCSCs) and our MTFs, gaps in beneficiary access were 
determined and resolutions sought throughout the activation and 
deployment of service members to contingency locations. A multi-level 
communication plan was developed and disseminated to support our MTF 
effort to educate our beneficiaries of where and how medical services 
could be accessed.
    Question. What percentage of mobilized reservists in medical 
specialties are being used to backfill positions in the United States?
    Answer. No Air Force medical reservists were activated as backfill 
during Operation Iraqi Freedom.
    Question. Are there shortages of personnel in some specialties? If 
so, which specialties are undermanned and by how much?
    Answer. The Air Force Medical Service has personnel shortages in a 
variety of specialty areas. According to the Health Manpower Personnel 
Data System Data from September 30, 2002, some of our more significant 
shortages can be found in:
  --Anesthesiology (63 percent staffed)
  --Aviation/Aerospace Medicine (Residency Trained Only) (81 percent 
        staffed)
  --Cardiology/Cardiovascular (64 percent staffed)
  --Emergency Medicare (79 percent staffed)
  --Otorhinolaryngology (ENT) (77 percent staffed)
  --Radiology (65 percent staffed).
    Question. Are there other ways of structuring the staffing of 
military medical units that might help address shortages in a few 
specialties, such as making increased use of civilian contractors or 
DOD civilian personnel in MTFs stateside?
    Answer. The TRICARE Next Generation (T-Nex) of contracts addresses 
this very issue. While the current contracts provide staffing during 
times of war, the new contracts allow for civilian backfill staffing 
through a spectrum of military operations. Specifically, the T-Nex 
Statement of Work states: ``a contingency plan designed to ensure that 
health care services are continuously available to TRICARE eligible 
beneficiaries as the military treatment facilities respond to war, 
operations other than war, deployments, training, contingencies, 
special operations, et cetera.'' Additionally, contingency plans 
require an annual review and require the contractor to implement their 
contingency plan within 48 hours of notification.
    Question. Is DOD considering any changes to the mix of active duty 
and Reserve personnel in medical specialties?
    Answer. The mix of skill sets in the Active and Reserve Components 
is currently being examined in several forums. The Operational 
Availability Study, the OSD AC/RC Mix study, as well as individual 
Service studies are all looking at the right mix of Active and Reserve 
capabilities to ensure that the needs of the National Security Strategy 
are met through the key factors of availability, responsiveness, 
agility, and flexibility. The studies are ongoing, but initial results 
indicate some capabilities need to be addressed. We will be examining 
the possibility of rebalancing capabilities within war plans and 
between the Active and Reserve Components. While recent mobilizations 
have highlighted shortages in certain capabilities that stressed 
Reserve forces, there are multiple solutions to address those issues. 
Application of a variety of actions, including innovative management 
techniques for the Reserves, will maximize the efficiency of our 
existing forces and may therefore require very little change to 
existing force structure.

          MONITORING THE HEALTH OF GUARD AND RESERVE PERSONNEL

    Question. An April 2003 GAO report documents deficiencies by the 
Army in monitoring the health of the early-deploying reservists. Annual 
health screening is required to insure that reserve personnel are 
medically fit for deployment when call upon.
    Review found that 49 percent of early-deploying reservists lacked a 
current dental exam, and 68 percent of those over age 40 lacked a 
current biennial physical exam.
    In addition, monitoring the health of reservist returning from 
deployment will be critical to ensuring the long term health of those 
service members, and assisting in the identification of common 
illnesses, such as those associate with the Gulf War Syndrome.
    What improvements have been made to the medical information systems 
to track the health care of reservists? Are they electronic, do they 
differ among services?
    Answer. Although I am not familiar with the capabilities of the 
other services, both the Air Force Reserve Command, and Air National 
Guard unit programs have developed independent state-of-the art 
computer physical exam management systems that track the health and 
dental status of all assigned personnel, in real time. Data is 
available at each supervisory level so all commanders can know the 
status of their troops.
    The Air National Guard and the Air Reserve Personnel Center 
implemented the Reserve Component Periodic Health Assessment and 
Individual Medical Readiness (PIMR) software this fiscal year to track 
the medical readiness of the Air National Guard. Air Force Reserve 
Command will soon attain this milestone. This software tracks six key 
elements identified by Health Affairs for monitoring individual medical 
readiness.
    Headquarters Air Reserve Personnel Center has developed an access 
database for all the 12,000+ Individual Mobilization Augmentees. It 
provides Direct demographics downloaded from personnel system; 
Tracking/recording of physical exam dates; Tracking/management of 
medical/dental deferment, assignment and deployment restrictions, and 
medical board action; Tracking/management of deployment and post-
deployment medical information (DD2796). Post-deployment assessment has 
recently been upgraded to include a more robust questionnaire, an 
interview with a provider, and a blood sample for later analysis.
    Question. During the mobilization for Operation Iraqi Freedom, how 
many reservists could not be deployed for medical reasons?
    Answer. The Air Force Reserve Unit program was able to meet 100 
percent of its taskings with 1.5 percent not being able to deploy for 
medical reasons (only 22 out of 1,450 total mobilized).
    Five percent of our Individual Mobilization Augmentees were unable 
to deploy; 40 out of 800 mobilized. Of these 40, four were later 
mobilized by exception to policy (ETP) due to mission requirements. A 
plan of care for these members was identified before mobilization and 
approved by the wing commander.
    The Air National Guard was able to meet 100 percent of its mission 
taskings with 5,500 members deploying, each being medically and 
dentally qualified for deployment. Local units may have substituted 
personnel, but numbers are not available at this time.
    Question. How many deployments were delayed due to dental reasons, 
and how many reservists are not in Dental class 1 or 2?
    Answer. Air Force Reserve Command: Five personnel had deployments 
delayed for dental reasons. Currently 1,470 reservists are dental class 
three and 34,473 are in dental class four (35,943 are not class one or 
two). It is important to note that the majority of class three or four 
reservists are in that category because of administrative and dental 
records issues that can be corrected quickly if notified of deployment. 
At a minimum, 78 percent of all class three and four members are in 
that category because they have yet to insert their most recent 
civilian dental examination paperwork into their Air Force dental 
record. This issue is usually rectified immediately upon notification 
of deployment and has not had negative impact on readiness during 
Operation Iraqi Freedom or previous contingencies.
    Air Reserve Personnel Center had 21 personnel out of 800 (2.6 
percent) with delayed deployments for dental reasons. Currently the 
Immediate Medical Associates (IMA) dental program has 328 personnel in 
class three, and 4,616 (37 percent) who are class four.
    Air National Guard had no deployments delayed due to dental 
reasons. As of April 15, 2003 with 50 percent of the Air National Guard 
units reporting: One percent was Class III (622); five percent was 
Class IV--no exam (2,488). NOTE: When PIMR gets 100 percent populated 
(July 2004) with data, the Air National Guard will be able to see 
percentages on a real time basis.
    Question. What is the current enrollment rate in the TRICARE Dental 
Program for reservists, and what action has DOD taken to encourage 
reservists to enroll in TDP?
    Answer. Air Force Reserve Command (unit and IMA programs): 11 
percent (8,290 Personnel with Dental Contracts of the 73,961 assigned); 
Air National Guard 8 percent (6,158 Personnel with Dental Contracts of 
the 78,663 assigned).
    The Air Force Reserve and Air National Guard have all fully 
advertised the TDP including notices on their web pages, coverage of 
the program at major conferences and direct mailings to all personnel.
    Question. What needs to be done and what will it cost to ensure 
that reservists are medically and dentally fit for duty?
    Answer. Both the Air Force Reserve Command and the Air National 
Guard welcome enactment of legislation authorizing funding for annual 
dental exams.
    The Air Force Reserve favors funding annual dental exams, which 
would cost approximately $3 million to $4 million. It is likely this 
cost will be offset by the number of personnel who see their civilian 
dentists and provide a completed DD Form 2813 (DOD Active Duty/Reserve 
Forces Dental Examination). To ensure that reservists are medically 
ready for duty, full funding of validated dental support Unit Type 
Codes and full time manpower requirements will give medical units the 
requirements necessary to accomplish the exams and assessments.
    The Air National Guard favors providing dental treatment as a 
benefit; pay the member's premium for dental insurance. The projected 
cost to provide such a benefit to 78,663 traditional members at $9.00 
per month is $8.5 million.
    Unlike medical examinations, annual dental examinations are a new 
unfunded requirement. Compliance with this requirement is contingent on 
receipt of funds unlike the medical examination process, which is well 
established and fully supported through POM submissions.
    Both Air Force Reserve Command and Air National Guard continue to 
enhance long established medical examination processes and record 
keeping. This evolving process enjoys a robust partnership with active 
duty support, the guidelines for which are included in the Program 
Objective Memorandum (POM). No additional funding is required.
    Question. Are there any repercussions for commanders who do not 
ensure that their troops are fit for duty?
    Answer. Although there are no commander-specific repercussions 
specified in Air Force Regulations, fitness for duty is part of the 
overall unit readiness equation along with factors such as dental 
fitness and training reports. These factors are reviewed at Wing, 
Numbered Air Force (or State), and Command levels. Disciplinary actions 
for low readiness levels are at commander's discretion at each of these 
levels.

                COMBAT TREATMENT IN IRAQ AND AFGHANISTAN

    Question. All of the Services have undertaken transformation 
initiatives to improve how medical care is provided to our front line 
troops.
    The initiatives have resulted in more modular, deployable medical 
units which are scalable in size to meet the mission.
    How well have your forward deployed medical support units and the 
small modular units performed in Operation Enduring Freedom and 
Operation Iraqi Freedom?
    Answer. Our transformation to these smaller, highly mobile, units 
has paid huge dividends in Afghanistan and Iraq. Although many 
Expeditionary Medical Support (EMEDS) activities in Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF) are still classified, I 
can share with you that we have positioned 24 EMEDS facilities in 12 
countries. Four of these units are currently far forward in Iraq.
    When U.S. forces captured one of the Iraqi air bases, elements of 
the Air Force Medical Service were there with the entering forces. 
Prior to creation of EMEDS units, it would have taken two to three 
weeks before we could have erected an Air Force medical facility to 
care for or troops occupying the base. In this conflict, we had the 
capability to provide care to our troops the same day we took the air 
base. Within just a couple days, we had established, equipped, and 
manned a fully functioning EMEDS unit.
    EMEDS not only ensures we can provide health care far forward, it 
also helps us prevent illnesses and injuries. In OIF we have achieved 
the lowest disease and non-battle injury rate in military history--
almost 20 percent lower than Operation DESERT SHIELD/STORM.
    I am also quite proud of the Aeromedical Evacuation (AE) piece of 
the EMEDS system. To date they have moved more than 2,000 patients 
(including 640 battle casualties) in OIF without using dedicated AE 
aircraft.
    Aeromedical Evacuation operations in OIF comprise the most 
aggressive evacuation effort since Vietnam, with not a single patient 
death in transit, which makes it the most successful aeromedical 
operation in military history.
    Question. What are some of the lessons learned from our experience 
in Iraq?
    Answer. The Air Force Medical Service is in the initial stage of 
collecting Operation IRAQI FREEDOM lessons learned. Two major issues 
identified at this point are as follows.
    First, concerns with ``In-Transit visibility'' (ITV). ITV of our 
deploying personnel and equipment is a significant problem. Many man-
hours were spent searching each Aerial Port of Embarkation (APOE) 
pallet yard for medical equipment pallets that did not meet the 
required delivery dates. Additional man-hours were spent tracking down 
individuals who departed their Continental United States (CONUS) duty 
station, but did not make it to the deployed destination by the 
required in-place dates. This severely hampered the ability of 
operational planners and commanders to effectively employ constrained 
resources to meet mission requirements.
    TRANSCOM Regulating and Command & Control system (TRAC\2\ES) was 
designed to provide ITV of patients returning from the theater of 
operations to more definitive care. TRAC\2\ES was never designed to 
provide visibility of patients when they exit the system, nor does it 
provide information to deployed commanders on a return to duty status 
or the patient's medical condition. Therefore, commanders, who have 
overall responsibility for these individuals, in some cases had no 
visibility of their status or medical condition, and no service-wide 
system exists to provide them that critical information.
    Second, validation of our concept of Critical Care in the Air. 
Operation IRAQI FREEDOM demonstrated the value of teaming our Critical 
Care Air Transport (CCAT) teams and our Aeromedical Evacuation (AE) 
system. The CCAT teams are capable of providing critical care in the 
air, a level of medical service that was unavailable to our forces 
until our recent conflicts in Afghanistan and Iraq. Additionally, CCATs 
can accompany their wards on most any cargo aircraft transiting the 
theater through the use of innovative Patient Support Pallets (PSPs). 
These pallets contain the tools and equipment that permit CCAT team 
members to quickly convert cargo aircraft into aeromedical evacuation 
platforms. The synergistic relationship between our AE, PSPs, and the 
CCAT teams who use them, permitted the AE movement of over 2,000 
patients, some critically ill/injured and unstable, in the first 35 
days of Operation IRAQI FREEDOM, including 640 battlefield casualties.
    Question. What tools/equipment is still required to improve the 
care provided to combat casualties?
    Answer. The challenges facing the deployed medical commander drive 
requirements that the traditional conventional wartime scenario never 
anticipated. As conflicts become more diverse and the potential for 
unconventional warfare increases, so does our need for tools and 
equipment that will assist us in preventing, detecting, and operating 
within an unconventional chemical or biological environment.
    Of great importance is the research and development, testing and 
evaluation of initial patient decontamination equipment. These tools 
are being developed now and will greatly aid our medics by allowing 
them to perform their life-saving activities while protecting both 
provider and patient from the contaminated environment.
    Once biological, chemical, or radiological weapons are detected, 
the Air Force medics will need NBC Casualty Treatment Capabilities 
(ventilators, facility and personal protective equipment, etc.). This 
equipment currently exists, but we require more to ensure a full 
spectrum protection of our fielded medics and the patients for whom 
they will provide care.
    Disease surveillance programs are critical to early identification 
of disease trends and appropriate responses. This includes both Weapons 
of Mass Destruction (WMD) detection units and the software programs 
capable of aggregating their data and providing meaningful information 
to commanders and medics about potential epidemics or WMD attacks.
    Another critical component to any casualty treatment plan is 
oxygen, specifically the ability to generate oxygen for treatment in a 
deployed environment. The Air Force Medical Service requires Deployable 
Oxygen Systems (DOS) that can be inserted into its modular treatment 
facilities in austere environments.
    Finally, although TRAC\2\ES performs successfully to provide us 
visibility of our patients as they are transferred in virtually any 
aircraft, that visibility becomes much more difficult once the patient 
enters the receiving medical facility. As of yet, there is no 
TRAC\2\ES-like system that track the patient's discharge or transfer to 
other locations. The entire Department of Defense health care system 
would benefit from a program that would provide overarching patient 
location visibility in both the sky and on the ground.

              T-NEX--NEXT GENERATION OF TRICARE CONTRACTS

    Question. The next generation TRICARE contracts will replace the 
seven current managed care support contracts with three contracts. This 
consolidation is intended to improve portability and reduce the 
administrative costs of negotiating change orders and providing 
government oversight across seven contracts.
    The award date for these contracts has slipped from the scheduled 
date in July of 2003. Since the timeline for awarding the contracts has 
slipped, what is the expected start date for the delivery of T-Nex?
    Answer. The overall schedule for the suite of T-Nex solicitations 
has not been changed although some award dates may be delayed if 
proposals require more extensive review. The TRICARE Mail Order 
Pharmacy Contract was awarded, and performance began on March 1, 2003. 
The TRICARE Retiree Dental Contract was also awarded and performance on 
this contract began on May 1, 2003. Proposals have been received for 
both the TRICARE Healthcare and Administration Managed Care Support and 
the TRICARE Dual-Eligible Fiscal Intermediary contracts, and the 
evaluation process for both of these is ongoing. Requests for Proposal 
have been issued for the TRICARE Retail Pharmacy and National Quality 
Monitoring contracts, and those proposals are due June 11 and June 3, 
respectively.
    Procurement sensitivity rules prohibit disclosure of any specific 
information or details about the ongoing evaluation of proposals. 
However, I can tell you that the evaluations are ongoing. No decision 
has been made to alter the implementation schedule for any of the 
contracts.
    Question. What planning is taking place to help ensure that when 
the contracts are entered into there will be a seamless transition for 
beneficiaries?
    Answer. No transition of this magnitude is easy. A customer-focused 
perspective in execution is central to making this as seamless as 
possible. We have already transitioned the TRICARE Mail Order Pharmacy 
contract with success. The TRICARE Retiree Dental Plan contract was 
also awarded without protest and now is in its first month of operation 
without issues. With regard to our managed care contracts, going from 
seven contracts to three will simplify administration, but more 
importantly better serve our beneficiaries with incentivized 
performance standards, greater uniformity of service, alleviation of 
portability issues, and simplified business processes.
    I have instituted a solid oversight structure (see attachment), and 
appointed a senior executive to spearhead this transition and supervise 
all aspects of the procurement, including the implementation of the new 
regional governance structure. This operational approach and structure 
requires my direct involvement through the Transition Leadership 
Council made up of the Surgeons General, the Principal Deputy Assistant 
Secretary of Defense for Health Affairs and the Health Affairs Deputy 
Assistant Secretaries of Defense. This body is supported by a TRICARE 
Transition Executive Management Team which is chaired by TMA's Chief 
Operating Officer.
    An area of detailed focus right now is access to care and all 
business processes that will impact access including: networks, 
provider satisfaction, appointing and scheduling, Military Treatment 
Facility (MTF) optimization, and local support for MTF commanders. We 
are optimistic that robust networks can be maintained. On all customer 
service fronts, my staff and other participants are poised to execute a 
smooth transition immediately following contract award. Regular 
meetings are underway to measure our progress and formulate sound 
decisions on any problematic issues. A contract transition orientation 
conference is planned for June 2003 to fully engage government 
participants in all aspects of the transition process.



    Question. Are beneficiaries experiencing any change in quality of 
care due to DOD's inability to enter into new long-term managed care 
agreements?
    Answer. The evaluation of contractor proposals is now underway and 
will culminate in the awarding of three new Health Care and 
Administration regional contracts. A planned 10-month minimum 
transition period will precede start of health care delivery. 
Surveillance for the delivery of services of outgoing contractors 
during the transition period will remain focused to avoid any 
deterioration in customer service standards. Current contracts have 
been extended beyond original termination dates to ensure there is no 
adverse impact on the beneficiary or quality of care.
    Any signs of negative shifts in quality during this transition 
period will be quickly recognized and dealt with on a priority basis. 
Our proactive posture is expected to result in a near-seamless 
transition to next generation contracts.
    Additionally, in T-Nex contracts, industry best business practices 
are fully expected to emerge through the competitive process. Customer 
service protocols will be favorably impacted by outcome-based 
requirements and accompanying performance standards. Additionally, web-
based service applications will also improve business processes and the 
way customers can access information. This is all very exciting and 
bodes well for our customers in the new contracts.
    Question. Under T-Nex, what services currently provided by the 
TRICARE contractors will shift to the direct care system and what are 
the costs associated with this shift in services?
    Answer. Appointing, Resource Sharing, Health Care Information Line, 
Health Evaluation & Assessment of Risk (HEAR), Utilization Management, 
and Transcription services will transition from the Managed Care 
Support Contracts to Military Treatment Facilities (MTFs) under T-Nex.
    The Services have been tasked to provide requirements in each of 
these areas, cost estimates, and transition timelines. We have worked 
with the Services to develop a joint approach to determine local 
support contract methodology.
    Transition of Local Support Contract services must be completed not 
later than the start of health care under T-Nex in each region.
    Based on known contract and staffing lag times, funding is required 
six months prior to the start of health care delivery to ensure smooth 
and timely stand-up of new services. At this stage, cost estimates are 
varied and of limited value until the requirement is validated and 
fully known. Initial rough estimates are in the hundreds of millions of 
dollars. The funding source for Local Support will come from funds 
committed to the current Military Health System (MHS) Managed Care 
Support contracts. Those funds were programmed based on existing 
purchased care contracts that included these services. Because it is 
understood that these funds may not cover the entire spectrum of Local 
Support contracts, the Medical Services have prioritized these services 
across the MHS into three tiers based on impact and need. Initial costs 
may ultimately include some investment in telephone and appointing 
infrastructure, thus driving a significant increase in front end costs.

                        RECRUITING AND RETENTION

    Question. Personnel shortfalls still exist in a number of critical 
medical specialties throughout the Services. The Navy has reports 
shortfall in Anesthesiology, General Surgery, Radiology, and Pathology, 
and has stated the civilian-military pay gap is their greatest obstacle 
in filling these high demand specialties. Recruiting and retaining 
dentist appears to be a challenge for all the services.
    To what extent have Critical Skills Retention Bonuses or other 
incentives been successful in helping to retain medical personnel?
    Answer. Critical Skills Retention Bonuses (CSRB) helped retain 
several hundred medical specialists, but may have had a greater impact 
if it were to have been executed in its original form, as a two-year 
program. This additional impact may have provided each Service with a 
bridge to the long-term initiative of optimizing Special Pay 
incentives, currently a goal for fiscal year 2005. Just over 850 
physicians, dentists, and nurses in critical specialties accepted the 
CSRB despite its one-year design. The CSRB became more of a good faith 
gesture to show that we are making plans for the future, acknowledging 
to those in the field that special pay increases are necessary if we 
value the professions and the investment that the Air Force has made by 
training highly specialized personnel.
    We have a success story with the incentives that were implemented 
to improve recruitment and retention of Pharmacists. We are interested 
in repeating this success for physicians, dentists, and nurses if we 
are allowed to optimize new special pay authority from the Fiscal Year 
2003 National Defense Authorization Act. The Pharmacy accession bonus 
increase to $30,000 in fiscal year 2002 and especially the Pharmacy 
Officer Special Pay (implemented in fiscal year 2002) has greatly 
improved recruiting and retention of pharmacists to the point that we 
will reach our targeted endstrength in fiscal year 2003. Obtaining 
appropriation for optimizing Special Pays by fiscal year 2005 is a 
priority.
    Lastly, we have seen short-term success in applying the Health 
Professions Loan Repayment Program (HPLRP) and hope to continue using 
it over the next several years. We currently offer HPLRP for both 
recruiting (accession) and retention, and the program has been quite 
successful in buying-down debt in our critically manned specialties 
within Biomedical Sciences Corps, Dental Corps, and Nurses Corps with 
133, 74, and 241 HPLRP contracts signed respectively in fiscal year 
2002. The HPLRP not only improves quality of life for personnel by 
reducing their debt, it benefits the Service by adding a minimum of 
two-year active duty commitment for one-year of loan repayment amount 
of up to $26,000. (Note: The recipient of HPLRP has a two year minimum 
active duty obligation attached to the first year of loan repayment and 
for second, third and fourth year of loan repayment it is a one for one 
active duty obligation payback). The goal is to enable officers to 
remain serving and not be overburdened with financial commitments 
(debt). For all Corps it is seen as a good faith gesture and carries 
active duty obligation payback. For the Medical Corps (MC) and Dental 
Corps (DC) and Certified Registered Nurse Anesthetist (CRNA) program it 
is a bridge to the long-term optimization of the Health Professions 
Scholarship Program (increased quotas for MC, DC and CRNAs. It is also 
a bridge to implementing the discretionary pay increases authorized by 
the Fiscal Year 2003 National Defense Authorization Act (mentioned). 
Funding of HPLRP is necessary beyond fiscal year 2005 to offer the 
accession incentive necessary to recruit the critical Nurse Corps and 
Biomedical Sciences Corps specialties. We are hoping to realize 
additional success especially with the new allowance for Health 
Profession Scholarship Program and Financial Assistance Program 
recipients to apply for HPLRP. MC and DC officers will then have better 
access to the benefits of this program. The Air Force has committed 
funding through fiscal year 2005 at $12 million per year (since fiscal 
year 2002). This commitment is a testament to our belief that HPLRP 
should remain a tool for both recruiting and retention in the future.
    Question. What else needs to be done to maximize retention of 
medical personnel?
    Answer. I perceive a three-fold approach to improving retention of 
medical personnel: (1) Increasing incentives such as special pays, 
bonuses, and loan repayment is a key component. The special pays and 
health professions scholarship programs are two high-impact tools used 
to recruit and retain medical professionals. Our collective effort to 
increase the authorizations for these tools under the National Defense 
Authorization Act 2003 was a true victory, but our commitment will be 
proven when we provide funding to see these programs through execution. 
Only then will our people see the benefits of our efforts. (2) Another 
component linked to improving medical officer retention is continued 
support for optimizing the medical officer promotion policy. The policy 
should be enhanced to ensure our clinical staff members are provided 
equitable opportunity for advancement. (3) Another tool to maximize the 
retention of our medical personnel is improving the clinical practice 
environment. This is accomplished by investing in our medical 
infrastructure--our facilities--and optimizing our support staff. Such 
optimization funding improves workplace support, enhances workflow, and 
contributes to both provider and patient satisfaction.

                                 ______
                                 
            Questions Submitted by Senator Pete V. Domenici

                   DOD/VA HEALTHCARE RESOURCE SHARING

    Question. Combining the resources of the Veterans' Administration 
and the Department of Defense to address health care needs of active 
duty personnel and our veterans is a concept that I am proud to say I 
championed a number of years ago. That initial effort combined brought 
together the resources of the VA and AF to provide care for the 
military at Kirtland Air Force Base and the city of Albuquerque's 
sizable veteran population. To date, the results have been very good.
    General Taylor, can you provide an update on the progress of the 
joint venture concept in general, and between DOD and VA at the 
Albuquerque VA hospital specifically?
    Answer. The Air Force Medical Service continues to partner with the 
Department of Veteran's Affairs (VA) in a number of locations. Examples 
include joint ventures at Elmendorf AFB, AK; Nellis AFB, NV; Travis 
AFB, CA; and Kirtland AFB, in Albuquerque, NM.
    The Albuquerque joint venture in particular has demonstrated the 
benefits of joint venture relationships. In fiscal year 2002, the VA 
and Kirtland AFB medical group exchanged $6.5 million in health care 
resources. This facilitated 8,100 outpatient referrals, 3,400 emergency 
department visits, and 14,000 ancillary procedures. If the two partners 
had purchased the services from local providers--as they would have 
before the joint venture--it would have cost an additional $1.32 
million. In fiscal year 2003, the joint venture program will build upon 
its success and expects to execute $6.7 million of sharing.
    Question. What is the status of their agreement to provide 
professional VA psychologist oversight to our Air Force mental health 
services in Albuquerque?
    Answer. The Veteran's Administration and Kirtland Air Force Base 
have been extremely successful in this endeavor. The agreement has been 
in place since 2001 and provides supervision to Air Force psychology 
residency graduates. This supervision is required as 49 of the 50 
states require at least one year of post-doctoral supervision. Without 
this agreement, the Air Force would be forced to hire additional 
psychologists. The agreement with the Veteran's Administration is a 
vital and successful part of the Air Force mental health mission at 
Kirtland.
    Question. Also, has there been progress in reducing the veterans' 
colonoscopy procedures backlog?
    Answer. Over the past year, the Kirtland Air Force Base medical 
facility has provided both operating room space and support personnel 
in assisting the VA in completing colonoscopies on veterans. This is 
another example of the cooperative efforts ongoing between Kirtland and 
the VA, and allowed the Air Force to perform about 40 VA colonoscopies 
a month. However, although I do not know how exactly how many 
procedures are ``backlogged,'' I do know that demand is still outpacing 
supply.
    Recent deployments have required we cease sharing activities for 
colonoscopies. As most of the combat activity appears to be behind us 
now, our facility in Albuquerque will soon be able to turn its 
attention once again toward the joint venture and determine how it can 
best assist the VA with this and other issues.

               JESSE SPIRI MILITARY MEDICAL COVERAGE ACT

    Question. In 2001, a young Marine Corps 2nd Lieutenant from New 
Mexico lost his courageous battle with cancer. Jesse Spiri had just 
graduated from Western New Mexico University and was awaiting basic 
officer training when he learned of his illness.
    However, because his commission had triggered his military status 
to that of ``inactive reservist,'' Jesse was not fully covered by 
TRICARE. As a result, he was left unable to afford the kind special 
treatment he needed.
    I believe that it is time to close this dangerous loophole. That is 
why I intend to offer a bill entitled the ``Jesse Spiri Military 
Medical Coverage Act.'' This bill will ensure that those military 
officers who have received a commission and are awaiting ``active 
duty'' status will have access to proper medical insurance.
    Would you agree that this type of loophole is extremely dangerous 
for those who, like Jesse, suffer with a dread disease?
    Answer. Lieutenant Spiri's tragedy with cancer is a loss not only 
to his family, but also to our country that he spent years preparing to 
serve. This is indeed a tragic case; however, limiting TRICARE coverage 
legislation to commissioned inactive reservists would establish an 
inequity with over 40,000 annual Air Force delayed enlistees that have 
also pledged themselves to our country. Additionally, all new recruits 
and officers are counseled that they must maintain their private health 
insurance until they enter active duty to ensure there are no gaps in 
medical coverage.
    Question. And do you agree that our military health care system 
should close this loophole, and can do so very cost effectively (given 
the relatively low number of officers it would affect)?
    Answer. To understand the scope of the issue, my staff has done 
some preliminary research on the cost of the change in legislation.
    The studied group includes Reserve Officer Training Corps (ROTC) 
and other commissioning sources where there is a delay from 
commissioning to active duty and our delayed enlistment programs. Air 
Force ROTC commissions approximately 2,500 lieutenants annually, while 
our direct commissioning program for the Judge Advocate Corps, 
Chaplains and Medical professions bring in about 1,500 officers 
annually. The delayed entry program for enlistees ensures our military 
training schools have a steady flow of students and provides new 
recruits with increased choice of available career fields. We estimate 
40,000 enlisted enlistees would be affected.
    Your proposed benefit change will affect each source differently 
due to the commissioning/enlistment dates of the various programs. 
These delays may be a month to multiple years based on approved delays 
(i.e. educational delay). For the purposes of this analysis, we used an 
estimate that the average wait is two months prior to active duty.
    Our 2003 evaluation of military compensation and benefits compared 
to the civilian sector equates our healthcare benefit to a monthly 
value of $279.35 per individual and $758.36 family rate respectively. 
Our estimate of 3,000 inactive reserve officers would potentially cost 
$1.6 million annually, while the delayed enlistment program would 
require an additional $22.3 million bringing the total annual cost for 
just the Air Force to about $24 million.
    The impact of this legislation on our Sister Services must also be 
analyzed in order to truly appreciate the total cost and provide an 
informed recommendation.

               MILITARY FAMILY ACCESS TO DENTAL CARE ACT

    Question. I think everyone here is familiar with the adage that we 
recruit the soldier, but we retain the family. That means taking care 
of our military families and giving them a good standard of living.
    I have introduced a bill that would provide a benefit to military 
families seeking dental care, but who must travel great distances to 
receive it. Specifically, my bill, the ``Military Family Access to 
Dental Care Act'' (S. 336) would provide a travel reimbursement to 
military families in need of certain specialized dental care but who 
are required to travel over 100 miles to see a specialist.
    Often, families at rural bases like Cannon Air Force Base in 
Clovis, NM meet with financial hardship if more than one extended trip 
is required. This bill reimburses them for that travel and is a small 
way of helping our military families.
    Given that current law provides a travel reimbursement for military 
families who must travel more than 100 miles for specialty medical 
care, do you believe it is important to incorporate specialty dental 
care within this benefit?
    Answer. Yes, although the proposed legislation (S. 336), as 
written, does not enhance the current travel benefit because travel 
reimbursement is already provided when a Primary Care Manager refers a 
TRICARE Prime enrollee for covered dental adjunctive care under 10 USC 
1074i.
    Question. Do you think this benefit would improve the standard of 
living of our military families?
    Answer. Yes, travel reimbursements do enhance beneficiary quality 
of life. Such benefits become especially important to beneficiaries in 
rural or remote areas since their travel costs can be expensive if they 
are referred to multiple treatment appointments for a dental condition.

                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby

                       PATIENT PRIVACY (TRICARE)

    Question. I would like to get your comments about several concerns 
and questions I have related to the December 14, 2002 break-in of the 
offices of TriWest, a TRICARE contractor. I am told that TriWest did 
not notify the Department of Defense of the break-in and theft of 
personnel information of over 500,000 TRICARE beneficiaries, for almost 
a week after the event. Apparently, TriWest didn't even have basic 
security equipment--guards, locks, cameras--and as a result, this 
incident amounts to the biggest identity theft in U.S. history. Is this 
information true?
    Answer. The physical break-in of the locked TriWest Healthcare 
Alliance corporate offices and theft of computer equipment occurred on 
Saturday, December 14, 2002. On Monday, December 16, 2002, the break-in 
and theft was discovered, authorities contacted, and TRICARE Management 
Activity (TMA) operations staff were advised. Back-up tapes were run on 
Tuesday, December 17, 2002, (which took 30 hours), and on Friday, 
December 20, 2002, TMA/HA leadership was notified of the beneficiary 
information theft. TriWest at that time had available from their back-
up tapes beneficiary information including names, addresses, phone 
numbers, Social Security Numbers, some claims information with relevant 
procedure codes, and personal credit card information on 23 
individuals.
    To date, the Army Medical Department has not received notification 
of a single verified case of identity theft related to TriWest stolen 
computer equipment.
    Question. Has the Department of Defense finished its investigation 
of this case and have sanctions been levied against TriWest or punitive 
actions against TRICARE officials?
    Answer. The criminal investigation is being conducted by the 
Defense Criminal Investigative Service (DCIS) and the Federal Bureau of 
Investigation (FBI), in coordination with other federal and local law 
enforcement agencies.
    To date, no sanctions have been levied upon or punitive actions 
taken against TriWest or TRICARE officials. The investigation is 
ongoing, and its findings are pending.
    Sensitive information pertaining to TRICARE beneficiaries is 
maintained by TRICARE contractors subject to the Privacy Act of 1974, 
as implemented by the DOD Privacy Program (DOD 5400.11-R). The Act 
provides criminal penalties for any contractor or contractor employee 
who willfully discloses such protected information, in any manner, to 
any person or agency not entitled to receive the information. The Act 
also provides for civil penalties against DOD if it is determined that 
the Department (or contractor) intentionally or willfully failed to 
comply with the Privacy Act.
    Question. Would you please share what you can about the lessons 
learned as a result of this incident and the steps the Department and 
the TRICARE organization and its contractors are taking to guarantee 
beneficiary privacy?
    Answer. As a result of close evaluation of our physical and 
information security we found the following:
  --a. Backup tapes not protected. For example, tapes left on the top 
        of servers, or left lying out in the open.
  --b. A general lack of proper security in areas where servers reside. 
        In particular, Defense Blood Standard System and Pharmacy 
        servers were not being properly protected.
  --c. Most sites had excellent password management policies and 
        guidelines in place, but they were not being followed.
  --d. In general, there were proper locks on doors, but in several 
        cases, not being properly used. Many doors that should have 
        been locked after hours were found open which allowed entry to 
        areas where patient information is kept. Most items not secure 
        were portable medical devices containing patient medical 
        information and medical records.
  --e. In many cases contingency plans for disaster recovery were 
        lacking or out-of-date.
  --f. Lost hardware not reported through official channels.
  --g. Hardware being turned in without data being wiped from hard 
        drives.
  --h. Concerning recent physical security self-assessments, a second 
        look found almost 60 percent of local assessments were 
        inaccurate or inexact.
  --i. As a result of the TriWest issues all Army medical activities 
        participated in a Health Affairs directed self-assessment of 
        local physical security practices. Mitigation plans for all 
        deficiencies are due on 16 May 2003.

                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                      MEDICAL TREATMENT FACILITIES

    Question. Healthcare, pay, and housing are the greatest Quality of 
Life issues for our troops and their families. With the numbers of 
health care staff deployed from your Military Treatment Facilities, 
what strategies did you use to effectively plan and care for 
beneficiaries back home?
    Answer. The Air Force Medical Service, our sister Services, TRICARE 
Management Activity, and the Office of the Assistant Secretary of 
Defense for Health Affairs collaborated to develop a Regional 
Contingency Response Plan to be executed by each Lead Agent to ensure 
continued beneficiary care during the current deployments.
    Specifically, each Medical Treatment Facility (MTF) and Managed 
Care Support Contractor (MCSC) were tasked to analyze their capacity 
and that of the local civilian network with attention paid to possible 
mobilized assets deployed over a specific period of time.
    Working together, MCSCs and MTFs identified potential gaps in 
beneficiary access that might be caused by the deployment of service 
members. The MCSCs and MTFs then drafted a comprehensive communication 
plan MTFs could use to educate beneficiaries of where and how medical 
services could be accessed.
    The uncertainty of the duration of the operations precluded a one-
for-one reserve backfill of forces to our MTFs. Specific guidance and 
requirements to mobilize a Guard or Reserve medical backfill in our 
MTFs was developed to guide MTFs and Air Force Major Commands.
    To ensure continuity of care with our current beneficiaries and the 
addition of activated Guard and Reserve members and their families, a 
coordinated Health Affairs letter was disseminated to the field 
directing our MTFs and Major Commands to prioritize and efficiently use 
available resources of the direct care system and network system as 
available. These resources consist of reallocation of internal staff, 
Major Comman leveling manning assistance, expansion by resource sharing 
and continued partnering with the Veterans Affairs.
    Despite deployments, access to routine health care in the AFMS has 
improved seven percent since August 2002. Currently, MTFs are able to 
provide routine access to health care (within seven days) 83 percent of 
the time. MTF are able to provide access to acute care (within 24 
hours) 96 percent of the time.
    Question. How are you able to address the needs of patients coming 
in from the battlefields and is this affecting the care of 
beneficiaries seeking regular care?
    Answer. The operational success of our young women and men was not 
only in our combat victories, but also in our delivery of care from the 
battlefield through our joint evacuation responsibilities to our 
theater hospitals. We were able to address the needs of patients coming 
from the battlefield; one of the most successful was the use of our 
aeromedical evacuation system. Using non-dedicated available aircraft, 
aeromedical evacuation crews and our TRAC\2\ES regulating system 
provided continuity of care and visibility of our patients from the 
theater to our CONUS receiving facilities.
    United States Joint Forces Command (USJFCOM) revised the Concept of 
Operations for patient distribution for treatment in DOD/TRICARE 
facilities ensuring our casualties were closer to their unit's home 
location and individuals support network. These facilities included the 
direct care MTFs, TRICARE network partners including the VA and finally 
the National Disaster Medical System (NDMS) if needed.
    Fortunately our casualties were limited and our Military Healthcare 
System was able to support both missions of caring for patients 
returning from the Theater of Operations and our regular non-
contingency beneficiaries without significant impact to access or 
quality of care to either.
    Question. What authority were you given to back-fill your vacancies 
and are the funds sufficient to attain that goal?
    Answer. The Air Force did not require the Air Reserve Component 
(ARC) forces to backfill our medical facilities during Operation Iraqi 
Freedom; however, if we had required backfill to sustain Graduate 
Medical Education or to expand beds to receive war illness or injuries, 
the policy providing for this activity was developed in concert with 
both Assistant Secretary of Defense (Health Affairs) (ASD/HA) and the 
Assistant Secretary of the Air Force Manpower and Reserve Affairs (SAF/
MR) guidance.
    Funding was readily available for backfills. Funds to support pay, 
allowances, and per diem for mobilized personnel are reimbursable 
funds. Had ARC forces been required, all associated costs would have 
been charged to Emergency Special Program Coded (ESP Coded) fund which 
was reimbursable to the Air Force Major Commands.
    Question. What measurements were used in determining what the 
Services were able to back-fill and how does that compare to current 
requirements?
    Answer. AF/SG backfill policy was developed in concert with both 
ASD/HA and SAF/MR guidance. Backfill requests had to meet the following 
specific criteria listed below. Before using members to backfill:
  --Medical treatment facilities and headquarters certified all non-
        mission essential deployed personnel had been returned to base 
        for mission support.
  --Headquarters re-directed their own personnel who were not mission-
        essential or working in their specialty to be moved to the unit 
        level to support mission essential requirements.
  --Major Commands had to certify that their support requirement could 
        not be met through internal headquarters cross leveling.
  --Efforts to support missions through Major Command-to-Major Command 
        headquarters cross leveling/sharing had been exhausted.
  --Volunteers had to have been unsuccessfully sought for the position.
  --The backfill request had to be in direct support of OPERATION NOBLE 
        EAGLE or OPERATION IRAQI FREEDOM.
  --Before receiving backfills, the gaining unit had to prove that 
        their personnel in the requested specialty were working 
        extended duty hours and that their leave/TDYs had been 
        restricted.
  --Services that would be provided by the requested specialty had to 
        be unavailable in local area TRICARE Support network.
  --Services requested were not currently covered by Resource Sharing 
        Contracts and that ARC assistance was required only for minimum 
        time until a new contract could be approved and funded.
  --Services provided by the requested backfill had to be unavailable 
        through VA partnering.
  --If the member was involuntarily mobilized, his or her mobilization 
        must be for the shortest duration possible.
    Comparison to current requirements is extremely difficult to answer 
as all medical facilities have different situations. Some were not 
heavily tasked with contingency responses and have little impact. 
Others were heavily tasked and have significant numbers of mobilized 
ARC dependents authorized care. Additionally these facilities have the 
added weight of post deployment health assessments and follow-up care 
for both returning active duty and ARC personnel.

                       RETENTION AND RECRUITMENT

    Question. With increasing deployments in support of Operation Iraqi 
Freedom and the Global War on Terrorism, can you describe your overall 
recruitment and retention status of the Medical Department in each of 
your services? What specific corps or specialties are of most concern?
    Answer. Recent operations have truly challenged the Services' 
resources, but our people have responded with vigor and determination. 
We have noticed little change in the recruitment of medical 
professionals during recent operations and are on pace to meet or 
exceed last year's recruiting averages. Retention has artificially 
improved due to STOP LOSS policy (effective May 2, 2003 for the Air 
Force) and programs such as Critical Skills Retention Bonus (CSRB).
    The specialties we were forced to STOP LOSS provided a summary of 
our specific concerns (see Table 1). Note that on May 14, 2003, stop 
loss specialties were released due to the winding down of Operation 
Iraqi Freedom.

      TABLE 1.--AIR FORCE SPECIALTIES UNDER STOP LOSS (MAY 2, 2003)
------------------------------------------------------------------------
                  Specialty                               AFSC
------------------------------------------------------------------------
Officer Personnel:
    BIOENVIRONMENTAL ENGINEER................  43EX
    PUBLIC HEALTH............................  43HX
    BIOMEDICAL LABORATORY....................  43TX
    EMERGENCY SERVICES PHYSICIAN.............  44EX
    INTERNIST................................  44MX
    ANESTHESIOLOGIST.........................  45AX
    ORTHOPEDIC SURGEON.......................  45BX
    SURGEON..................................  45SX
    AEROSPACE MEDICINE SPECIALIST............  48AX
    GENERAL MEDICAL OFFICER..................  48GX
    RESIDENCY TRAINED FLIGHT SURGEON.........  48RX
    FLIGHT NURSE.............................  46FX
    NURSE ANESTHETIST........................  46MX
    CRITICAL CARE NURSE......................  46NXE
    OPERATING ROOM NURSE.....................  46SX
Enlisted Personnel:
    MEDICAL MATERIAL.........................  4A1XX
    BIOMEDICAL EQUIPMENT.....................  4A2XX
    BIOENVIRONMENTAL ENGINEERING.............  4B0XX
    PUBLIC HEALTH............................  4E0XX
    CARDIOPULMONARY LABORATORY...............  4H0XX
------------------------------------------------------------------------

    Question. Did the Critical Skills Retention Bonus given for this 
year help these specialties? In light of shortages and the disparity 
between military and civilian salaries, how have you planned for 
additional retention bonuses in future years?
    Answer. Critical Skills Retention Bonus (CSRB) helped retain 
several hundred medical specialists, but may have had a greater impact 
if it was executed in its original form, as a two-year program. This 
additional impact may have provided each Service with a bridge to the 
long-term initiative of optimizing Special Pay incentives, currently a 
goal for fiscal year 2005. Just over 850 physicians, dentists, and 
nurses in critical specialties accepted the CSRB despite the one-year 
design. The CSRB became more of a good faith gesture to show that we 
are making plans for the future, acknowledging to those in the field 
that special pay increases are necessary if we value the professions 
and the investment that the Air Force has made by training highly 
specialized personnel.
    We are currently drafting the fiscal year 2004 Special Pay Plan to 
address critically manned specialties with application of minimum 
increases allowed within our current projected allocation.
    Question. Are there recruitment and retention issues within certain 
specialties or corps? If so, what are your recommendations to address 
this in the future?
    Answer. We do have several challenges in maintaining our required 
number of medical personnel to perform our mission optimally. I believe 
in a three-fold approach to improving retention of medical personnel. 
(1) Increasing incentives such as special pays, bonuses, loan repayment 
and health professions scholarship programs. Our collective effort to 
increase the authorities under the National Defense Authorization Act 
2003 was a true victory, but our commitment will be proven as we 
provide funding to see these programs through execution. Only then will 
our people see the benefits of our efforts. (2) Improving the clinical 
practice environment by investing in our medical infrastructure and 
optimizing support staff. (3) A final component linked to improving 
medical officer retention is continued support for optimizing medical 
officer promotion policies to ensure our clinical staffs are provided 
equitable opportunity for advancement.
    Question. Have incentive and special pays helped with specific 
corps or specialties?
    Answer. The final results of our efforts to increase incentive and 
special pays are not yet available, but we have witnessed a noticeable 
impact from increasing our accession and retention bonuses as well as 
offering Health Professions Loan Repayment. In fiscal year 2002, 241 
nurses signed Health Professions Loan Repayment Program contracts and 
extended their individual service commitments by two years. Likewise, 
we have seen positive trends in our Optometry and Pharmacy specialties 
due to increased accession and retention incentives. We have not 
realized as much improvement in our physician and dental communities as 
the military-civilian pay gap is much wider. However, we are highly 
committed to optimizing our health professions officer special pay 
program.
    Special pays are targeted at professional staff (physicians, 
dentists, nurse anesthetists, and several allied health professionals), 
and are designed to improve both recruiting and retention, as well as 
recognize the market value of these highly trained officers. The 
National Defense Authorization Act 2003 provided significant increases 
in the authorities to fund special pays and the three Services are in 
the process of developing their fiscal year 2004 and fiscal year 2005 
special pay plans with ASD/HA. We plan to increase several 
discretionary special pays for the various specialties that are 
difficult to recruit and retain. Coupled with improved opportunity to 
train medical professionals under Health Professions Scholarship 
Program, increasing these pays will help improve the staffing shortages 
we've experienced in recent years. We would appreciate your continued 
support in these efforts.
    Question. How does the fiscal year 2004 budget request address your 
recruitment and retention goals?
    Answer. The fiscal year 2004 budget request includes three items 
that have significant impact on recruiting and retention:
    Special Pays.--The fiscal year 2004 Special Pays Plan will serve as 
a bridge to better optimization of special pays in fiscal year 2005. We 
are currently drafting the fiscal year 2004 Special Pay Plan to 
addresses critically manned specialties with application of minimum 
increases allowed within our current projected allocation.
    Health Professions Loan Repayment Program (HPLRP).--The Air Force 
has committed funding through fiscal year 2005 at $12 million per year 
(since fiscal year 2002). This commitment is a testament to our belief 
that HPLRP should remain a tool for both recruiting and retention in 
the future. HPLRP not only improves quality of life for personnel by 
reducing their debt and making it more affordable to remain in the 
military, but adds a minimum two-year active duty commitment for a one-
year loan repayment amount of up to $26,000. (Note: The recipient of 
HPLRP has a two-year minimum active duty obligation attached to the 
first year of loan repayment while the second, third and fourth year of 
loan repayment has a one-for-one active duty obligation payback). The 
goal is to enable officers to remain serving and not be overburdened 
with financial commitments (debt).
    Health Professions Scholarship Program/Financial Assistance Program 
(HPSP/FAP).--For fiscal year 2004, Health Professions Scholarship 
Program and Financial Assistance Program will continue to be one of the 
best recruiting tools for physicians and dentists. Even though we would 
like to see an increase in HPSP/FAP allocations in fiscal year 2004, 
this will not be possible because the budget has been locked for that 
fiscal year. With the rising costs of medical and dental schools, we 
will actually have fewer allocations in fiscal year 2003 than we had in 
fiscal year 2002. We hope to increase allocations from 1300 to 2000 
between fiscal year 2006 and fiscal year 2009.

                        FORCE HEALTH PROTECTION

    Question. As a result of concerns discovered after the Gulf War, 
the Department created a Force Health Protection system designed to 
properly monitor and treat our military personnel. What aspects of the 
Departments' Force Health Protection system have been implemented to 
date? What are the differences between the system during the Gulf War, 
Operation Iraqi Freedom, and Operation Enduring Freedom and Operation 
Noble Eagle?
    Answer. The Department places the highest priority on protecting 
the health of military personnel throughout their military careers and 
beyond. Deployments and other military operations often involve unique 
environments that must be addressed by force health protection 
procedures. We use lessons learned from each military operation to 
improve our force health protection program.
    Requirements to assess health before, during and after deployments 
and to assess, monitor and mitigate environmental hazards predate 
OPERATION DESERT STORM. However, the Department has implemented a 
number of significant changes since the Gulf War to further inculcate 
and improve these procedures. In 1997, deployment health surveillance 
policy was released directing pre and post-deployment health 
assessments and the collection of pre-deployment serum samples. If 
concerns or medical problems are identified, a comprehensive evaluation 
by a provider is required. Data from health assessments and serum 
samples are stored in a central DOD repository. Health assessments and 
records of medical evaluations are placed in the member's permanent 
medical record.
    The Chairman of the Joint Chiefs of Staff released an updated 
deployment health surveillance policy in February 2002. The policy 
provides more detailed guidance on required health assessments and 
required prevention countermeasures for deploying personnel. It also 
greatly enhances the requirements for environmental assessments and 
implements operational risk management processes for the theater of 
operations. From the time the Department standardized the requirements 
for pre and post deployment health assessments, the Air Force has 
submitted more that 420,000 pre and post deployment assessments to the 
DOD repository.
    After the Gulf War, the Air Force implemented a deployed electronic 
medical record, called GEMS (Global Expeditionary Medical System), to 
record clinical care provided in theater. The Air Force implemented an 
immunization tracking and management system that allows visibility of 
immunization records and requirements both at home and in theater. The 
Air Force also has had an ongoing quality assurance program to assess 
all Active Duty and Air Reserve Component installations for compliance 
with deployment health surveillance requirements.
    Since the beginning of OPERATIONS ENDURING FREEDOM and NOBLE EAGLE, 
the Department has accelerated efforts to automate the collection of 
deployment heath surveillance information. OSD is developing a theater 
medical record system and is now testing parts of a comprehensive 
theater information management program. Pending implementation of these 
OSD systems, the Air Force has continued to improve GEMS so it now 
captures public health and environmental/occupational surveillance 
information as well as electronically forwards disease and non-battle 
injury data to headquarters. To date, more than 73,000 theater medical 
encounters are stored in GEMS.
    Furthermore, the Department has implemented a policy for checking, 
at every patient visit, whether or not a deployment-related health 
concern exists. The Department implemented a clinical practice 
guideline, developed by Departments of Veterans Affairs and Defense, to 
ensure military members receive orderly, standardized evaluations and 
treatments for deployment-related conditions.
    Despite the myriad improvements implemented since the Gulf War, the 
onset of OPERATION IRAQI FREEDOM illuminated the need for further 
enhancements to the Department's post-deployment health assessment 
requirements. Just released OSD policy enhances post-deployment health 
assessment procedures by requiring that each military member returning 
from deployment have a blood sample sent to the DOD repository and 
receive an assessment by a provider to address potential health 
problems, environmental exposures and mental health issues. The policy 
also requires more detailed quality assurance programs to validate, 
within 30 days, that returning personnel have completed all deployment 
health assessment requirements and that all information is in permanent 
medical records, and to report on compliance.

                              OPTIMIZATION

    Question. Congress initiated optimization funds to provide 
flexibility to the Surgeons General to invest in additional 
capabilities and technologies that would also result in future savings. 
It is my understanding that a portion of these funds are being withheld 
from the Services. Can you please tell the Committee how much 
Optimization funding is being withheld from your service, what are the 
plans for distributing the funds, and why funds since fiscal year 2001 
are being withheld?
    Answer. No optimization funds are being withheld from the Air Force 
Medical Service. Optimization funds have been released relatively 
quickly upon request.
    Question. How have you benefited from optimization funds? What 
projects are on hold because OSD has not released funding?
    Answer. I view optimization funding as critical to patient care and 
staff retention. Optimization funds have enabled the Air Force Medical 
Service to institute loan repayments for selected health professions, 
with anticipated improvement in recruitment and retention in critical 
medical and dental specialties; Automate several pharmacies, thereby 
improving productivity and recapture of pharmacy workload from the 
private sector; Improve the efficiency of the Heating, Ventilation and 
Air Conditioning system at Nellis AFB; Hire coders at Medical Treatment 
Facilities to improve data for billing, population health and 
accounting; Contract with industry leading business consultants to 
identify best practices and industry benchmarks to improve Air Force 
Medical Service business processes; Upgrade Medical Treatment Facility 
telephony for first time in years for many Medical Treatment 
Facilities; Contract for providers/staff to address mission critical 
shortages in Active Duty staffing; Implement a Specialty Care 
Optimization Pilot resourcing strategy to validate new manpower 
standards, metrics, and training to improve readiness and clinical 
currency and increase recapture from network; Perform advanced testing 
of a Light-weight Epidemiology Detection System; Accelerate deployment 
of Tele-Radiology capabilities at bases without Active Duty radiology 
support; Fast-track deployment of counter-chemical warfare training; 
Accelerate refractive surgery pilot to identify the best technology to 
address flight crew refractive deficiencies; Accelerate implementation 
of Long View resourcing strategy Air Force wide for general surgery, 
orthopedics, ENT, Ophthalmology, and Obstetrics and Gynecology (OB/GYN) 
to improve expeditionary and clinical currency and increase recapture 
from private sector to decrease overall DOD cost of healthcare.
    No optimization projects are on hold because OSD has not released 
funding.
    Question. What are the projected projects using the proposed $90 
million in the fiscal year 2004 budget request?
    Answer. The Air Force Medical Service intends to use its portion of 
fiscal year 2004 optimization dollars for Health Professions Loan 
Repayments ($12 million) and Long View Execution ($18 million). The 
Long View is our strategy for achieving the optimal mix of assigned and 
contracted manpower to Medical Treatment Facilities in such a way as to 
maximize expeditionary medical capability, clinical currency and cost 
effectiveness.

                                 ______
                                 
       Questions Submitted to Brigadier General William T. Bester
               Questions Submitted by Senator Ted Stevens

                       RECRUITMENT AND RETENTION

    Question. Recruitment within the services for all the Nurse Corps 
is better than the civilian market. There have been several tools to 
help with the recruitment effort including the accession bonus of 
$5,000 for Nurses joining the services. The greatest retention tool for 
all services has been the opportunity for advanced out-service 
education for a masters or doctorate degree. Other issues that have 
also positively affected retention are: challenging assignments, more 
leadership responsibility, and greater promotion opportunities. Of the 
many tools for recruiting and retention, which tools have been most 
successful?
    Answer. We believe that it is vital to have a combination of 
recruiting and retention tools in order to maintain a successful 
manning posture. All the tools provided allow us to retain the 
flexibility to address regional differences in the civilian recruiting 
market as well as address the retention needs of our officers currently 
on active duty. It is imperative that we proactively anticipate the 
continued civilian competition and must have the money to increase our 
accession bonuses plus our retention bonuses for our critical 
specialties such as nursing anesthesia. We also anticipate strong 
results for both recruiting and retention once we implement the Health 
Professions Loan Repayment Program. Our current promotion percentages 
are strong in all ranks except for Colonel. We are taking the 
appropriate actions to resolve some of the systemic personnel issues 
that have stalled the promotion to Colonel in the past with the intent 
to enlarge the promotion rate in the future.
    Question. Do you think a Loan Repayment Program would be helpful to 
recruit more nurses?
    Answer. Absolutely. The Health Professions Loan Repayment Program 
is absolutely essential to our efforts to remain competitive with the 
recruitment activities currently in place by our civilian counterparts. 
In fact, we plan to execute the Health Profession Loan Repayment 
Program through fiscal year 2005 with monies we obtained through a 
Defense Health Program (DHP) Venture Capital Initiative. We plan to 
program monies for fiscal year 2006 to sustain this program in the 
future.

                  WAR'S EFFECT ON THE NURSE CORPS PLAN

    Question. The number one retention tool is the opportunity for 
advanced education. The war could negatively affect the number of 
Nurses that will be available to begin out-service education 
opportunities in fiscal year 2004, thereby mitigating the effectiveness 
of this important retention tool. How has the war in Iraq and 
deployments of personnel to the Middle East affected your overall out-
service education plan for this year and next?
    Answer. We are taking all measures possible to ensure that all Army 
Nurse Corps officers scheduled to attend an out-service education 
program this year and next year are redeployed in the appropriate 
amount of time to begin their education program. At this time, we do 
not anticipate any education losses due to deployment.
    Question. For instance will you have to send fewer nurses to school 
for advanced degrees this year because of the numbers deployed?
    Answer. At this point, we are taking all measures to ensure that 
officers scheduled to attend out-service education in fiscal year 2004 
are redeployed in a timely manner. If redeployment for some or all of 
the officers is delayed for reasons out of our control, it could result 
in a decrease in the number of officers attending out-service education 
and would negatively affect our overall numbers.
    Question. How will the continued deployments affect you staffing 
plans for the Medical Treatment Facilities?
    Answer. To ensure we have had adequate numbers and mix of 
providers, we have taken the following measures to ensure acceptable 
staffing plans. We have initiated regional cross leveling of staff to 
ensure appropriate distribution of staff to provide care and meet 
patient demand and used internal management decisions by commanders 
such as decreasing the number of beds available for care, and in some 
instances, decreasing the number of surgical cases performed. In 
addition, we have combined patient care units, used creative scheduling 
to ensure appropriate staffing coverage, increased the use of contract 
nurses, requested and received reserve backfill up to the 50 percent 
authorized fill rate and invoked the local commander's consideration to 
send patients to the TRICARE network for care as needed. We will 
continue to use all appropriate staffing management tools to ensure 
that we meet the care needs of our beneficiary population.

                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                        RECRUITING AND RETENTION

    Question. In light of a national nursing shortage, please describe 
the status of your recruitment and retention efforts in the Nurse Corps 
for each of your services?
    Answer. We are approximately 230 Active Duty nurses below our 
budgeted end strength of 3,381. We are proceeding with the following 
initiatives to improve accessions and maintain a steady state retention 
posture. We are developing an implementation plan with the Triservice 
Recruitment and Retention Workgroup to obtain the funding to support an 
incremental increase in the accession bonus starting in fiscal year 
2005. It is imperative that we proactively anticipate the continued 
civilian competition and must have the resources necessary to increase 
our accession bonuses plus our retention bonuses for our critical 
specialties such as nursing anesthesia. Funds for HPLRP are available 
now (fiscal year 2003) until fiscal year 2005 and we plan to POM funds 
beginning in fiscal year 2006. We are also exploring the feasibility of 
reinstituting the Army Nurse Candidate Program as funding permits and 
have expanded the number of slots available for the Army Enlisted 
Commissioning Program from 50 to 85 per year. We will continue to send 
approximately 100 Army Nurse Corps officers to out-service schooling 
each year and will continue to provide specialty care courses in all 
our specialty areas. We will continue to provide a wide variety of 
clinical and work experiences in both the inpatient and ambulatory care 
settings as well as in the field setting, both in the United States and 
overseas. We feel strongly that providing leadership opportunities 
early in the officer's career is crucial in preparing officers for 
positions with greater scope of responsibility. We strongly promote 
collegiality, camaraderie, and teamwork and develop these concepts 
initially in our entry-level officer basic course and reinforce these 
concepts throughout the officer's career. We continue to support career 
progression, educational opportunities, and continuing education for 
all our officers. Finally, we are proud of our excellent promotion 
opportunities as well as the military benefit package that all soldiers 
and their families are entitled.

                      MEDICAL TREATMENT FACILITIES

    Question. With the numbers of nurses and medics/corpsmen deployed 
from your facilities, how have you ensured the delivery of safe patient 
care at the military medical facilities here at home?
    Answer. To ensure we have had adequate numbers and mix of 
providers, we have taken the following measures to ensure acceptable 
staffing plans. We have initiated regional cross leveling of staff to 
ensure appropriate distribution of staff to provide care and meet 
patient demand and used internal management decisions by commanders 
such as decreasing the number of beds available for care, and in some 
instances, decreasing number of surgical cases performed. In addition, 
we have combined patient care units, used creative scheduling to ensure 
appropriate staffing coverage, increased use of contract nurses, 
requested and received reserve backfill up to the 50 percent authorized 
fill rate and invoked the local commander's consideration to send 
patients to the TRICARE network for care as needed. We will continue to 
use all appropriate staffing management tools to ensure that we meet 
the care needs of our beneficiary population.

                      DOCTORATE PROGRAM IN NURSING

    Question. Fiscal year 2003, this Subcommittee appropriated funds to 
create a Nursing PhD program at the Uniformed Services University of 
the Health Sciences. Students will begin in the fall of 2003. How do 
you plan to use this PhD Program to educate your leaders and nurse 
researchers?
    Answer. The Army Nurse Corps has 33 validated Army Nurse Corps 
prepared positions with a current inventory of 26 Active Duty nurses 
holding Doctorate degrees. The Uniformed Services University of the 
Health Sciences (USUHS) PhD program will afford us additional diversity 
for our fully funded doctoral education program. In addition, this 
program will provide the unique focus on content that is out of the 
ordinary from civilian content and specific to the needs of the 
military. This year, we will send two Active Duty Army Nurse Corps 
officers to USUHS and in the future, will attempt to send 3-4 per year. 
We also plan to support attendance by Active Duty personnel on a part-
time basis. We are exploring the options for attendance by Reserve 
personnel.

                            NURSING RESEARCH

    Question. The Committee appropriated $6,000,000 for the TRISERVICE 
Nursing Research Program and directed the Secretary of Defense to fully 
fund it in the fiscal year 2004 budget request. To my knowledge, there 
are no funds for this program in fiscal year 2004. Why was this not 
funded and what are the potential implications if this is not funded in 
future years?
    Answer. Uniformed Services University of the Health Sciences 
(USUHS) has long been a strong supporter and proponent of nursing 
research and the TriService Nursing Research Program (TSNRP) and any 
decline in this program would have a negative effect on our pursuit of 
nursing research. In addition, TSNRP has historically been physically 
located at USUHS. We have learned that USUHS is exploring the 
development of a center focused on military health and research. If 
this concept is developed and approved, we feel that this may be an 
ideal conduit for research funding in the future. We have made contact 
with USUHS regarding the feasibility of identifying the funding through 
this option and will continue to explore all options regarding the 
feasibility of funding TSNRP via USUHS.

                                 ______
                                 
         Questions Submitted to Rear Admiral Nancy J. Lescavage

               Questions Submitted by Senator Ted Stevens

                       RECRUITMENT AND RETENTION
    Question. Recruitment within the services for all the Nurse Corps 
is better than the civilian market. There have been several tools to 
help with the recruitment effort including the accession bonus of 
$5,000 for Nurses joining the services.
    The greatest retention tool for all services has been the 
opportunity for advanced out-service education for a masters or 
doctorate degree. Other issues that have also positively affected 
retention are: challenging assignments, more leadership responsibility, 
and greater promotion opportunities.
    Of the many tools for recruiting and retention, which tools have 
been most successful?
    Answer. Our recruitment and retention efforts targeting active duty 
Navy Nurses have been successful through a blend of initiatives, such 
as:
  --Diversified accession sources, which also include pipeline 
        scholarship programs (Nurse Candidate Program, Naval Reserve 
        Officer Training Corps, Medical Enlisted Commissioning Program, 
        and Seaman to Admiral Program).
  --Pay incentives (Nurse Accession Bonus, Certified Registered Nurse 
        Anesthetist Incentive Special Pay, Board Certification Pay and 
        Critical Skills Retention Bonus).
  --Graduate education and training programs focus on Master's 
        Programs, Doctoral Degrees, and fellowships. Between 72-80 
        officers/year receive full-time scholarships based on 
        operational and nursing specialty requirements.
  --Initiatives that enhance personal and professional quality of life, 
        mentorship, leadership roles, promotion opportunities, 
        operational opportunities, professional collegiality and full 
        scope of practice.
    Question. Do you think that a Loan Repayment Program would be 
helpful to recruit more nurses?
    Answer. With the increasing number of competitive loan repayment 
programs for student graduates, a Loan Repayment Program with fiscal 
support will be helpful to recruit more nurses as the national nursing 
shortage worsens, particularly if the program has the flexibility to be 
used to repay either baccalaureate degree loans or master's degree 
loans for critically under manned specialties.

                  WAR'S EFFECT ON THE NURSE CORPS PLAN

    Question. The number one retention tool is the opportunity for 
advanced education. The war could negatively affect the number of 
Nurses that will be available to begin out-service education 
opportunities in fiscal year 2004, thereby mitigating the effectiveness 
of this important retention tool.
    How has the war in Iraq and deployments of personnel to the Middle 
East affected your overall out-service education plan for this year and 
next? For instance will you have to send fewer nurses to school for 
advanced degrees this year because of the numbers deployed?
    Answer. Our Navy Nurses in outservice training have continued with 
their curriculum, unaffected by present deployments. We do not 
anticipate any delays in the release of our nurses from their present 
duty stations to begin their advanced education program this coming 
academic year.
    Question. How will the continued deployments affect your staffing 
plans for the Medical Treatment Facilities?
    Answer. Military and civilian nurses who remained at the homefront 
continue to be the backbone and structure in promoting, protecting and 
restoring the health of all entrusted to our care. In addition, key 
Reserve personnel in designated specialties are utilized at specific 
Military Treatment Facilities (MTFs). Ultimately, all MTFs do 
everything possible to conserve and best utilize the remaining medical 
department personnel through appropriate resource management practices 
and staffing plans (i.e. leave control, overtime compensation, 
streamlined hiring practices). Through an active Patient Safety 
Program, our military, civil service and contract personnel are 
constantly monitoring the delivery of patient care. To insure 
consistent superior quality of services, we utilize evidence-based 
clinical practices with a customized population health approach across 
the entire health care team. To maintain TRICARE access standards, 
patients may be guided to the appropriate level of care through the 
Managed Care Support Contract Network resources, assisting them every 
step of the way. The TRICARE network is designed to support the 
military direct care system in times of sudden and major re-deployment 
of MTF staff.
                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                        RECRUITING AND RETENTION

    Question. In light of a national nursing shortage, please describe 
the status of your recruitment and retention efforts in the Nurse Corps 
for each of your services?
    Answer. The Navy Nurse Corps continually strives to be recognized 
as an employer of choice. National shortage projections and civilian 
compensation packages are very closely monitored to determine the best 
course to take in the competitive market. Our recruitment and retention 
efforts targeting active duty Navy Nurses have been successful through 
a blend of initiatives such as:
  --Diversified accession sources, which include pipeline scholarship 
        programs such as the Nurse Candidate Program, Naval Reserve 
        Officer Training Corps (NROTC), Medical Enlisted Commissioning 
        Program, and Seaman to Admiral Program.
  --Pay incentives including the Nurse Accession Bonus, Certified 
        Registered Nurse Anesthetist (CRNA) Incentive Special Pay, 
        Board Certification Pay and the one-time Critical Skills 
        Retention Bonus.
  --Graduate education and training programs that focus on Master's 
        Programs, Doctoral Degrees, and postgraduate fellowships. 
        Between 72-80 officers/year receive full-time scholarships 
        based on operational and nursing specialty requirements.
  --Initiatives that enhance personal and professional quality of life 
        including mentorship, leadership roles, promotion 
        opportunities, operational opportunities, professional 
        collegiality and full scope of practice.
    Recruiting incentives for reservists include:
  --The Nurse Accession Bonus ($5,000) for critical wartime 
        specialties.
  --Loan repayment and stipend programs for graduate education.
  --Several additional initiatives are under review with the 
        Department.

                      MEDICAL TREATMENT FACILITIES

    Question. With the numbers of nurses and medics/corpsmen deployed 
from your facilities, how have you ensured the delivery of safe patient 
care at the military medical facilities here at home?
    Answer. Navy Medicine is committed to high quality, cost-effective 
and easily accessible primary and preventive health care services, such 
as our population health management programs through health promotion, 
disease management and case management. Military and civilian nurses 
who remained at the homefront continue to be the backbone and structure 
in promoting, protecting and restoring the health of all entrusted to 
our care. In addition, key Reserve personnel in designated specialties 
are utilized at specific Military Treatment Facilities (MTFs). 
Ultimately, all MTFs do everything possible to conserve and best 
utilize the remaining medical department personnel through appropriate 
resource management practices (i.e. leave control, overtime 
compensation, streamlined hiring practices). Through an active Patient 
Safety Program, our military, civil service and contract personnel are 
constantly monitoring the delivery of patient care. To insure 
consistent superior quality of services, we utilize evidence-based 
clinical practices with a customized population health approach across 
the entire health care team. To maintain TRICARE access standards, 
patients may be guided to the appropriate level of care through the 
Managed Care Support Contract Network resources, assisting them every 
step of the way. The TRICARE network is designed to support the 
military direct care system in times of sudden and major re-deployment 
of MTF staff.

                      DOCTORATE PROGRAM IN NURSING

    Question. In fiscal year 2003, this Subcommittee appropriated funds 
to create a Nursing PhD program at the Uniformed Services University of 
the Health Sciences. Students will begin in the fall of 2003. How do 
you plan to use this PhD Program to educate your leaders and nurse 
researchers?
    Answer. Navy Nurse Corps participation in civilian PhD programs has 
resulted in a community of nurses with an in-depth knowledge of 
clinical specialty practice, leadership, organizational behavior, 
health policy, education, and/or scientific research. Historically, 
only two or three PhD candidates are trained annually, one of which is 
required to support the Navy Nurse Corps Anesthesia Program. When the 
PhD program is offered at the Uniformed Services University of Health 
Sciences, Navy Nurses will be strongly encouraged to apply. We 
anticipate that one will be selected annually to attend USUHS and 
adjusted accordingly, based on needs. In our vision, nurse researchers 
will take on the most senior executive positions to create health 
policies and delivery systems. Their valued experience will be critical 
to advance and disseminate scientific knowledge, foster nursing 
excellence, and improve clinical outcomes across Navy Medicine and 
Federal agencies. As role models, they will instruct military and 
civilian nurses in the accomplishment and utilization of nursing 
research.

                            NURSING RESEARCH
 
   Question. The Committee appropriated $6,000,000 for the TRISERVICE 
Nursing Research Program and directed the Secretary of Defense to fully 
fund it in the fiscal year 2004 budget request. To my knowledge, there 
are no funds for this program in fiscal year 2004. Why was this not 
funded and what are the potential implications if this is not funded in 
future years?
    Answer. The TriService Nursing Research Office, through their 
component organization, Uniformed Services University of Health 
Sciences, submitted a request for a fully funded program budget of $30 
million beginning in fiscal year 2004 to fiscal year 2009. Since the 
first budget request submission in 1994, Health Affairs determined that 
the fiscal support requirements of other competing programs superceded 
this request. Health Affairs has not released any fiscal year 2004 
funding, however we continue to work within the system to stress the 
importance of TriService Nursing Research. Through your support of 
TriService Nursing Research Program (TSNRP) funding, Navy Nurses have 
expanded the breadth and depth of our research portfolio, increased 
military nursing research capacity, developed partnerships for 
collaborative research and built an infrastructure to stimulate and 
support military nursing research. TSNRP-funded research has been 
conducted at our three major medical centers, our two Recruit Training 
Centers, several Naval Hospitals, onboard more than six aircraft 
carriers and collaboratively with our uniformed colleagues and more 
than thirteen universities across the country. In addition, our Navy 
nursing research has been published in numerous professional journals. 
Without TSNRP funding, the contractual management of 58 current active 
ongoing research grants will cease. Some open studies may require 
additional dollars, which would no longer be available. Promising new 
evidence-based practice initiatives to current and emergency military 
health care delivery and services will be discontinued. Past and 
current findings to affect change will be not systematically 
disseminated and military nursing science will only be a dream.

                                 ______
                                 
        Questions Submitted by Brigadier General Barbara Brannon
               Questions Submitted by Senator Ted Stevens


                       RECRUITMENT AND RETENTION

    Question. Recruitment within the services for all the Nurse Corps 
is better than the civilian market. There have been several tools to 
help with the recruitment effort including the accession bonus of 
$5,000 for Nurses joining the services.
    The greatest retention tool for all services has been the 
opportunity for advanced out-service education for a masters or 
doctorate degree. Other issues that have also positively affected 
retention are: challenging assignments, more leadership responsibility, 
and greater promotion opportunities.
    Question. Of the many tools for recruiting and retention, which 
tools have been most successful?
    Answer. Although the Air Force has many excellent recruiting tools, 
we cannot yet claim to be better than--or to have reached parity with--
the recruitment capabilities of our civilian counterparts. However, 
each tool currently at our disposal has proven to be essential building 
a strong Air Force nursing force--a force with the right numbers and 
the right clinical experience and skills.
    We believe the General Accession Bonus and Health Professions Loan 
Repayment Programs are our most successful recruiting tools. The 
civilian market is flooded with incentives to capture the best nurses, 
and our incentive programs offer us the opportunity to compete for this 
scarce pool. As the nursing shortage grows we feel it is imperative 
that our recruiting tools remain competitive, and funding is crucial.
    Health Professions Loan Repayment Program (HPLRP).--Based on the 
success of HPLRP as a retention tool last year, we have been able to 
offer up to $26,000 in exchange for an additional 2-year obligation for 
new accessions. This is the first time we have offered loan repayment 
as a recruiting tool and will monitor its impact. HPLRP appears to be a 
positive incentive for recruitment, a random data pull of 22 new 
accessions showed 100 percent opted for loan repayment.
    General Accession Bonus.--We currently offer a $5,000 bonus for a 
four-year service obligation. We have the authority to offer up to 
$30,000. The Health Affairs/Services Special Pays Working Group is 
currently working the funding to increase this bonus.
    The Critical Skills Retention Bonus was hugely successful and 
boosted retention 82 percent in the limited specialties targeted, the 
Certified Registered Nurse Anesthetist and Perioperative nurses. This 
year, 66 percent of CRNAs and 98 percent of Perioperative nurses 
accepted the bonus for a one-year obligation. Further application and 
funding would positively impact nurse retention.
    The Health Professions Scholarship Program (HPSP) supports nursing, 
physician, biomedical science and dental education. We are aggressively 
seeking an increase in HPSP scholarships for nursing to boost 
recruiting in the Certified Registered Nurse Anesthetist specialty.
    Critical Skills Accession Bonus (CSAB).--We have the authority to 
provide a CSAB to those specialties manned at less than 90 percent. The 
Air Force Nurse Corps has submitted packages through the appropriate 
channels on those specialties to be considered for this bonus. 
Initiative still pending.
    Retention in the Air Force Nurse Corps appears to be healthy 
overall. We have several specialties that are below the 90 percent 
staffing threshold. They are: Certified Registered Nurse Anesthetists 
(CRNAs), Perinatal Nurses, Neonatal Intensive Care Nurses, Women's 
Health Nurse Practitioners, and Emergency Room Nurses.
    One of the most successful retention tools targeting our Certified 
Registered Nurse Anesthetist is our Incentive Special Pay. We have the 
authority to offer up to $50,000 on an annual basis for a one-year 
obligation. Currently we are funded to offer $15,000 for those 
personnel who are unconstrained by school obligations and $6,000 for 
those with school obligation. The Tri-Service Health Professions 
Incentive Pay Group is working to increase the funding by $5,000 in 
fiscal year 2004 and then incrementally by $5,000 until the desired 
retention is met. This program is instrumental in bridging the pay gap 
between civilian and military systems.
    Health Professions Loan Repayment Program was offered to junior 
Nurse Corps officers with outstanding college debt. Results were 
outstanding, for fiscal year 2002, 241 nurses accepted up to $25,000 
for loan repayment in exchange for a 2-year service obligation.
    Question. Do you think that a Loan Repayment Program would be 
helpful to recruit more nurses?
    Answer. This year the Air Force Nurse Corps was able to offer loan 
repayment as an accession tool. This is the first time we have offered 
loan repayment as a recruiting tool and we will closely monitor its 
impact. Preliminary data indicates this will be a tremendous success. 
Technical challenges have limited our ability to fully implement this 
program and we are working hard to overcome the barriers. Loan 
repayment appears to be a powerful recruiting tool and we will engage 
to sustain this tool for the Air Force Nurse Corps.

                  WAR'S EFFECT ON THE NURSE CORPS PLAN

    Question. The number one retention tool is the opportunity for 
advanced education. The war could negatively affect the number of 
Nurses that will be available to begin out-service education 
opportunities in fiscal year 2004, thereby mitigating the effectiveness 
of this important retention tool.
    How has the war in Iraq and deployments of personnel to the Middle 
East affected your overall out-service education plan for this year and 
next? For instance will you have to send fewer nurses to school for 
advanced degrees this year because of the numbers deployed?
    Answer. The Air Force Nurse Corps has made every effort to ensure 
the integrity of our advanced degree program starts. We have worked 
pre, during and post-deployment personnel actions to ensure all 
selected for programs will be able to start as requested. We will not 
change our requirements based on deployments or operations tempo as 
these programs are vital to retention and the enhancement of quality 
patient care. We will validate all future advanced education 
requirements through our usual Air Force processes and will stay the 
course to ensure system integrity.
    Question. How will the continued deployments affect you staffing 
plans for the Medical Treatment Facilities?
    Answer. The Air Force Nurse Corps could and did meet all of our 
deployment requirements. We sparingly applied stop-loss to three of our 
critical Air Force nursing specialties as an insurance policy against 
potential expanded deployments of a prolonged conflict for future 
requirements.
    The Air Force Nurse Corps uses a variety of staffing options to 
avoid patient risk. We can employ reserve units, individual 
mobilization augmentees, manning assistance and contract personnel.
    In addition, our facilities will continue to be staffed based on 
patient nurse staffing ratios advocated by National Specialty 
Organizations. If we cannot meet safe patient care standards we divert 
to civilian facilities, enroll patients to the civilian network or 
extend clinic hours. This was needed on a limited basis at some of our 
Air Force Medical Treatment Facilities.
    The Air Expeditionary Forces (AEF) cycle continues to be crucial to 
maintaining not only deployment unit integrity, but also to planning 
patient care delivery. Most deployments include multiple personnel 
specialties from physicians and nurses to technicians. The advanced 
deployment projections of the AEF allows a facility to plan for manning 
assistance, service closures and/or contracting of personnel to fill 
voids. By this methodology we ensure safe patient care through 
planning.
                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                        RECRUITING AND RETENTION

    Question. In light of a national nursing shortage, please describe 
the status of your recruitment and retention efforts in the Nurse Corps 
for each of your services?
    Answer. The programs initiated on a national level to address the 
nursing crisis are encouraging. Recruiting nurses will continue to be a 
huge challenge in the coming decade. Fiscal year 2002 was the fourth 
consecutive year the Air Force Nurse Corps failed to meet its 
recruiting goal. We recruited approximately 30 percent less than our 
recruiting goal and shortfall has remained relatively consistent since 
fiscal year 1999. Our fiscal year 2003 recruiting goal is 363 and as of 
March 2003, we had recruited 120 nurses.
    We believe the General Accession Bonus and Health Professions Loan 
Repayment Programs are critical to healthy recruiting. The civilian 
market is flooded with incentives to capture the best nurses and our 
incentive programs offer us the opportunity to be competitive for this 
scarce pool. As the nursing shortage grows we feel it is imperative 
that our recruiting tools remain competitive and funding is crucial.
    Health Professions Loan Repayment Program (HPLRP).--Based on the 
success of HPLRP as a retention tool we have been able to offer up to 
$26,000 in exchange for an additional 2-year obligation for new 
accessions. This is the first time we have offered loan repayment as a 
recruiting tool and will monitor its impact. We received the funding to 
start this program in January 2003 and we are working the loan 
reimbursement constraints. HPLRP appears to be a positive incentive for 
recruitment, a random data pull of 22 new accessions showed 100 percent 
opted for loan repayment. Full accounting will be available once all 
the loan repayments have been made.
    General Accession Bonus.--Currently offering a $5,000 bonus for a 
four-year service obligation. We have the authority to offer up to 
$30,000.
    The Critical Skills Retention Bonus was hugely successful and 
boosted retention 82 percent in the limited specialties targeted, the 
Certified Registered Nurse Anesthetist (CRNA) and Perioperative nurses. 
This year, 66 percent of CRNAs and 98 percent of Perioperative nurses 
accepted the bonus for a one-year obligation. Further application and 
funding would positively impact nurse retention.
    The Health Professions Scholarship Program (HPSP) supports nursing, 
physician, biomedical science and dental education. We are aggressively 
seeking an increase in our HPSP scholarships for nursing to boost 
recruiting in the CRNA specialty. The program covers tuition costs and 
provides a monthly stipend.
    Critical Skills Accession Bonus (CSAB).--We have the authority to 
provide a CSAB to those specialties manned at less than 90 percent.
    Retention in the Air Force Nurse Corps appears to be healthy 
overall. We have several specialties that are below the 90 percent 
staffing threshold. They are: CRNAs, Perinatal Nurses, Neonatal 
Intensive Care Nurses, Women's Health Nurse Practitioners, and 
Emergency Room Nurses.
    One of the most successful retention tools targeting our Certified 
Registered Nurse Anesthetist is our Incentive Special Pay. We have the 
authority to offer up to $50,000 on an annual basis for a one-year 
obligation. Currently we are funded to offer $15,000 for those 
personnel who are unconstrained by school obligations and $6,000 for 
those with school obligation. The Tri-Service Health Professions 
Incentive Pay Group is working to increase the funding by $5,000 in 
fiscal year 2004 and then incrementally by $5,000 until the desired 
retention is met. This program is instrumental in bridging the pay gap 
between civilian and military systems.
    Health Professions Loan Repayment Program was offered to junior 
Nurse Corps officers with outstanding college debt. Results were 
outstanding for fiscal year 2002, 241 nurses accepted up to $25,000 for 
loan repayment in exchange for a 2-year service obligation.

                      MEDICAL TREATMENT FACILITIES

    Question. With the numbers of nurses and medics/corpsmen deployed 
from your facilities, how have you ensured the delivery of safe patient 
care at the military medical facilities here at home?
    Answer. Patient safety remains the central focus of our health care 
delivery. Our staffing models support healthy patient staff ratios 
which will not be breached. The Air Force Nurse Corps endorses and 
supports the standards of practice outlined by nursing specialties or 
organizations. These standards guide nursing practice and provide the 
Chief Nurse Executives at our medical treatment facilities the 
framework for safe care delivery.
    We have many tools available to support safe nursing practice. We 
divert patients to other civilian facilities if patient acuity is 
higher then the nurse staffing can support. The decision for diversion 
is a collaborative decision between all healthcare disciplines. Nursing 
plays a dual role in the diversion option; they are the advocate for 
patients and staff ensuring neither is placed at risk.
    Air Force facilities have embarked on a robust Patient Safety 
Program that prevents patient harm. The focus of this program is 
preventive in nature, putting into place the procedures and processes 
to keep healthcare delivery safe and patients and staff members free 
from harm.
    We have employed the Managed Care Support Contracts and local 
contracts to fill the gap when deployments have taken their toll on 
staffing. Air Force Reserve personnel have also been mobilized to fill 
critical shortfalls.

                      DOCTORATE PROGRAM IN NURSING

    Question. In fiscal year 2003, this Subcommittee appropriated funds 
to create a Nursing PhD program at the Uniformed Services University of 
the Health Sciences. Students will begin in the fall of 2003. How do 
you plan to use this PhD Program to educate your leaders and nurse 
researchers?
    Answer. Each year the Air Force sends nurses back to school for 
doctorate education in Nursing. Currently there are a total of 20 PhDs 
in the Air Force Nurse Corps.
    The Air Force will request two nurse corps doctoral requirements at 
the Integrated Forecast Board in June 2003, which is the process the 
Air Force uses to validate educational requirements. Both of the 
officers will attend the doctoral program at the Uniformed Services 
University of the Health Sciences. This program prepares leaders 
skilled in military-specific health care issues, preparing graduates to 
conduct research and take leadership roles in federal and military 
policy development. This program is integral to provide experts who are 
uniquely qualified in issues specific to the Department of Defense and 
orchestrates research supporting evidenced-based nursing practice that 
positively impacts patient outcomes in peacetime and wartime.

                            NURSING RESEARCH

    Question. The Committee appropriated $6,000,000 for the TRISERVICE 
Nursing Research Program and directed the Secretary of Defense to fully 
fund it in the fiscal year 2004 budget request. To my knowledge, there 
are no funds for this program in fiscal year 2004. Why was this not 
funded and what are the potential implications if this is not funded in 
future years?
    Answer. Uniformed Services University of the Health Sciences 
(USUHS) has long been a strong supporter and proponent of nursing 
research and the TriService Nursing Research Program (TSNRP) and any 
decline in this program would have a negative effect on our pursuit of 
nursing research. In addition, TSNRP has historically been physically 
located at USUHS. We have learned that USUHS is exploring the 
development of a center focused on military health and research. If 
this concept is developed and approved, we feel that this may be an 
ideal conduit for research funding in the future. We have made contact 
with USUHS regarding the feasibility of identifying the funding through 
this option and will continue to explore all options regarding the 
feasibility of funding TSNRP via USUHS.

                          SUBCOMMITTEE RECESS

    Senator Inouye. And I thank all of you for your testimony 
this morning and the subcommittee will reconvene next 
Wednesday, May 7 when we will hear from the chiefs of the 
National Guard and Reserve components. We will stand in recess.
    [Whereupon, at 12:35 p.m., Wednesday, April 30, the 
subcommittee was recessed, to reconvene at 10 a.m., Wednesday, 
May 7.]
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