[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]



                         [H.A.S.C. No. 110-64]
 
 FINDINGS OF THE INDEPENDENT REVIEW GROUP AND AN IN-PROGRESS REVIEW OF 
                         ACTIONS AT WALTER REED

                               __________

                                HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             JUNE 26, 2007

                                     
[GRAPHIC] [TIFF OMITTED] 


                     U.S. GOVERNMENT PRINTING OFFICE

37-326 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office  Internet: bookstore.gpo.gov Phone: toll free (866)512-1800
DC area (202)512-1800  Fax: (202) 512-2250 Mail Stop SSOP, 
Washington, DC 20402-0001



                    MILITARY PERSONNEL SUBCOMMITTEE

                     VIC SNYDER, Arkansas, Chairman
MARTY MEEHAN, Massachusetts          JOHN M. McHUGH, New York, Chairman
LORETTA SANCHEZ, California          JOHN KLINE, Minnesota
SUSAN A. DAVIS, California           THELMA DRAKE, Virginia
NANCY BOYDA, Kansas                  WALTER B. JONES, North Carolina
PATRICK J. MURPHY, Pennsylvania      JOE WILSON, South Carolina
CAROL SHEA-PORTER, New Hampshire
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                      Joe Hicken, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2006

                                                                   Page

Hearing:

Tuesday, June 26, 2007, Findings of the Independent Review Group 
  and an In-Progress Review of Actions at Walter Reed............     1

Appendix:

Tuesday, June 26, 2007...........................................    57
                              ----------                              

                         TUESDAY, JUNE 26, 2007
 FINDINGS OF THE INDEPENDENT REVIEW GROUP AND AN IN-PROGRESS REVIEW OF 
                         ACTIONS AT WALTER REED
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

McHugh, Hon. John M., a Representative from New York, Ranking 
  Member, Military Personnel Subcommittee........................     2
Snyder, Hon. Vic, a Representative from Arkansas, Chairman, 
  Military Personnel Subcommittee................................     1

                               WITNESSES

Cody, Gen. Richard A., Vice Chief of Staff, Department of the 
  Army, U.S. Army................................................    27
Marsh, Hon. John O., Jr., Former Secretary of the Army, Co-Chair, 
  Independent Review Group.......................................     5
Pollock, Maj. Gen. Gale S., Acting Surgeon General, Department of 
  the Army, U.S. Army............................................    28
Schoomaker, Maj. Gen. Eric B., Commander, North Atlantic Regional 
  Medical Command and Walter Reed Army Medical Center, U.S. Army.    30
West, Hon. Togo D., Jr., Former Secretary of the Army, Former 
  Secretary of Veterans Affairs, Co-Chair, Independent Review 
  Group..........................................................     7

                                APPENDIX

Prepared Statements:

    Cody, Gen. Richard A.........................................    76
    Marsh, Hon. John O., Jr......................................    67
    McHugh, Hon. John M..........................................    64
    Pollock, Maj. Gen. Gale S....................................    81
    Schoomaker, Maj. Gen. Eric B.................................    91
    Snyder, Hon. Vic.............................................    61
    West, Hon. Togo D., Jr.......................................    72

Documents Submitted for the Record:

    Independent Review Group Members and Witnesses Biographies...   101

Questions and Answers Submitted for the Record:

    Mr. McHugh...................................................   119
 FINDINGS OF THE INDEPENDENT REVIEW GROUP AND AN IN-PROGRESS REVIEW OF 
                         ACTIONS AT WALTER REED

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                            Washington, DC, Tuesday, June 26, 2007.
    The subcommittee met, pursuant to call, at 1:05 p.m., in 
room 2118, Rayburn House Office Building, Hon. Vic Snyder 
(chairman of the subcommittee) presiding.

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

    Dr. Snyder. The hearing will come to order.
    The purpose of today's hearing is for members to get an 
update on what has happened at Walter Reed and in the military 
medical program since the full Armed Services Committee hearing 
in March.
    To refresh everybody's memory, in late February, The 
Washington Post published a story titled, ``Soldiers Face 
Neglect, Frustration at Army's Top Medical Facility.''
    In the following weeks, a series of shortcomings at Walter 
Reed were revealed, such as substandard living conditions, 
inadequate management of outpatient medical care, and poor 
follow-up from the ill, recovering or wounded soldiers' chain 
of command.
    Many members were concerned that these problems were not 
limited to Walter Reed, but this was actually a sentinel event 
that raised a possibility of similar features across the 
military medical system.
    This concern was heightened by the fact that both this 
subcommittee and the full committee had expressed concern, 
though in less dramatic manner, during earlier hearings dating 
back to 2005 about some of the same issues found at Walter 
Reed.
    Since then, the Independent Review Group (IRG) set up by 
Secretary Gates following the revelation at the Walter Reed 
Army Medical Center has completed its review and released its 
findings.
    We are fortunate to have both of the Independent Review 
Group's co-chairs with us today: Mr. Togo West, the former 
secretary of Veterans Affairs, as well as the former secretary 
of the Army. Mr. John Marsh is also a former secretary of the 
Army, as well as a former member of this body.
    Gentlemen, we appreciate you being here.
    During this hearing, we will also get an update on what 
steps the Army has taken to remedy conditions at Walter Reed 
and to hear how the Army plans to address or preclude similar 
problems at other medical facilities.
    I should also mention that, while we have had Army leaders 
testify about Walter Reed before the committee previously, we 
have here today new leaders.
    With us on our second panel are: General Cody, vice chief 
of staff of the Army, who has been tasked by the acting 
secretary of the Army with oversight of the Army's medical 
action plan; Major General Gale Pollock, the acting Army 
surgeon general; Major General Eric Schoomaker, commander of 
the North Atlantic Regional Medical Command and Walter Reed 
Army Medical Center; Brigadier General Michael Tucker, deputy 
commander of the North Atlantic Regional Medical Command and 
Walter Reed Army Medical Center; and Colonel Terrence 
McKenrick, commander of the Warrior Transition Brigade.
    This entire episode has demonstrated the power of focus. 
Throughout this process, virtually everyone--wounded soldiers, 
ill soldiers, recovering soldiers, family members, 
commissioners--have had nothing but good things to say about 
the quality of inpatient care our wounded and ill soldiers have 
received at Army hospitals. Our military hospitals are among 
the best in the world.
    However, once soldiers leave the focused care environment 
of the hospital and continue their treatment as outpatients, 
the system has appeared unable to provide the same level of 
support.
    The challenge for all of us to is to make sure the military 
health-care system remains focused on the recovery of our 
wounded and injured and ill soldiers across the continuum of 
care, not just at the time of injury, not just at the time of 
public and press scrutiny, not just at the time of great 
individual leadership and personality, but all the time. And 
this hearing is part of that ongoing oversight.
    I would now like to yield to my partner for the last 
several years, Mr. McHugh.
    [The prepared statement of Dr. Snyder can be found in the 
Appendix on page 61.]

  STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE FROM NEW 
     YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. McHugh. Thank you, Mr. Chairman. Let me, first of all, 
thank you, Vic, for the great leadership that you have provided 
in your time as chairman of this, I think, critical 
subcommittee, but also for the partnership that you and I have 
shared over the previous six years, prior to that, in a 
leadership role.
    And I have mixed emotions. I am excited about Ms. Davis, 
the gentlelady from California, taking over the gavel, as she 
will here in short order, but clearly we will miss the kind of 
insight that you bring with your medical degree, with your 
compassion and your passion for these issues. And I wish you 
all the best.
    I don't want to sound like we are saying something that is 
sending you on to the next life, but it is a different life. 
And you can leave this subcommittee, Mr. Chairman, knowing that 
you have made a tremendous difference, and the men and women 
who bravely serve this nation and its families that stand 
beside them are far better off than when you came to your post.
    So, thank you for that.
    I also want to congratulate you on your decision to hold 
this hearing.
    I think we can all agree that the conditions and problems 
uncovered at Walter Reed are a dark chapter in what, as the 
chairman suggested, is an otherwise stellar history and 
tradition of the fine military medical institution that has 
served our nation's warriors so ably since 1909.
    With that in mind, certainly, my goal today is to get a 
sense as to whether or not the immediate issues have been 
resolved, but beyond that, also, that the policies and 
resources have been put in place to prevent these problems from 
occurring again at Walter Reed or, more to the point, any other 
military medical facility.
    I have to tell you I am encouraged by the immediate--and I 
think it is fair to describe them as aggressive--responses by 
the Department of Defense (DOD), by the Army to the 
deficiencies that existed, particularly in the outpatient 
medical system.
    Secretary Gates is to be commended for establishing the 
Independent Review Group to identify those shortcomings and to 
make the recommendations to improve the quality of life for our 
wounded combat veterans and their families as they recover at 
Walter Reed and the National Naval Medical Center at Bethesda.
    I certainly look forward to hearing the findings and 
recommendations from, as you described so very aptly, Mr. 
Chairman, the distinguished members of the Independent Review 
Group for our first panel.
    I have to tell you that I have had the honor of serving on 
this committee now for 15 years, and we have a habit of 
describing every panel as distinguished, and most often they 
are. But rarely have we assembled a group of individuals on 
both panels who have served this nation more effectively and in 
more important times and important roles than the first panel.
    Gentlemen, thank you so much--and the second panel is not 
just gentlemen, but in the first panel it is--for your service 
on this panel, but also for what you have done for our nation 
and its warriors in your so-called previous lives.
    I am equally encouraged by the Army medical action plan 
that appears to be a roadmap for short-and long-term solutions 
to the problems encountered by wounded and injured soldiers.
    And with that said, my enthusiasm, I have to tell you, is 
tempered by continuing to hear from soldiers, as I suspect many 
of us are, in the wounded transition units about problems, 
particularly with the medical evaluation board (MEB) and 
physical evaluation board (PEB) systems.
    Most recently, during a session with committee and member 
staff at Walter Reed, I heard about the kinds of challenges 
that continue to persist. And I know we all want to try to 
overcome those, and I look forward to discussing the details of 
the plan with the members of our second panel.
    So with that, Mr. Chairman, I would yield back.
    I would say, as a brief note, I do have to make an apology 
at the firsthand. I have an amendment on the appropriations 
bill that is on the floor presently that will come up that I do 
have to present. When I get the call, I will have to slip out. 
I hope everyone understands, but I assure you I will be 
continuing to follow this issue very, very closely.
    And, again, Vic, Mr. Chairman, thanks for holding this 
hearing, and more importantly, thank you for your service.
    A special note of welcome back to Joe Schwarz, a former 
distinguished member of this august committee, who, too, has 
great background in the medical field. And it is good to see 
him with us here again today.
    I yield back, Mr. Chairman.
    [The prepared statement of Mr. McHugh can be found in the 
Appendix on page 64.]
    Dr. Snyder. Thank you, Mr. McHugh.
    I want to give Susan Davis, our colleague from California, 
who will be the incoming chair of this subcommittee when I take 
over for Mr. Meehan when he leaves at the end of this month, 
for any comments she might want to make at this time.
    Ms. Davis.
    Ms. Davis. Thank you, Mr. Chairman.
    I really just want to take this opportunity, and I am sure 
I will have several more, to thank you for your steady 
leadership of the committee.
    This is such a critical committee. Representing a 
community, a military community like San Diego, I know how 
important it is that we honor and respect our families and 
those who are serving in the armed services. And we can only do 
that through our actions and through what we actually produce 
on their behalf and the way that we relate, and this committee 
is a very important vehicle for that.
    So I want to thank you for that leadership.
    I want to thank Mr. McHugh, who I believe had to leave 
quickly, but I will look to both of you, because you have been 
a tremendous mentor. And I know that we are going to deliberate 
as we have in the past, and I just look forward to all the work 
that we will be doing on the committee.
    And I know that the support is across the board in a very 
bipartisan fashion on this committee, and I welcome that as 
well.
    Thank you all for the work that you have done, as it 
relates to this issue. We know that, probably more than any 
other issue that came before the citizens of this country, I 
think that Walter Reed really captured people, made them think 
again about what the impact, what the consequences of going to 
war really are and how we have to care for our troops.
    And so you have brought that forward with, again, a very 
deliberate way, and we appreciate that. And I look forward to 
the hearing.
    Thank you very much.
    Dr. Snyder. Thank you, Ms. Davis.
    Let me introduce the first panel.
    I understand that, Secretary Marsh and Secretary West, you 
will be the two having formal opening statements. Is that 
correct? Then you have got your sidekicks on each side when you 
get in trouble. Is that the way we will handle this?
    I want to introduce everyone: the Honorable John O. Marsh, 
Jr., former secretary of the Army and co-chair of the 
Independent Review Group; the Honorable Togo D. West, Jr., 
former secretary of the Army and former secretary of Veterans 
Affairs, the co-chair of the Independent Review Group; 
accompanied today by our friend--it says John Schwarz, but it 
is Joe Schwarz, just to the folks here.
    Joe, it is great to see you and have you back here.
    Joe Schwarz, former Member of Congress and an Doctor of 
Medicine (M.D.) and a former member of this House Armed 
Services Committee; Mr. Arnold Fisher, senior partner of Fisher 
Brothers; General John Jumper, former Air Force chief of staff, 
now retired; Command Sergeant Major Lawrence Holland, also 
retired, former senior enlisted advisor to the assistant 
secretary of defense for reserve affairs.
    Gentlemen, we are glad you are all here.
    And, Secretary Marsh, is that the order we will go in? You 
all decide that one.
    Gentlemen, we have got six people with four microphones. If 
you will pull that right in close to you, it will enable people 
like me to hear you.

 STATEMENT OF HON. JOHN O. MARSH, JR., FORMER SECRETARY OF THE 
            ARMY, CO-CHAIR, INDEPENDENT REVIEW GROUP

    Secretary Marsh. Thank you, Mr. Chairman. I appreciate your 
opening comments and the attention and interest of the 
committee.
    We are very fortunate to have as our co-chair Togo West, 
who has a very distinguished career both in law, in the 
Department of Defense, in the field of legal affairs, as the 
secretary of the Army, and then as a Cabinet officer in 
Veterans Affairs. And he brought to our efforts, I think, an 
unusual combination of knowledge and also interest and 
background.
    I would like to thank you for doing this, for holding this 
hearing.
    Ultimately, the armed forces of the United States is a 
joint responsibility between the executive branch and the 
congressional branch and providing for some of the things that 
need to be done in the American medical community of the Army 
cannot be accomplished by the Department of Defense nor can it 
be accomplished by the executive branch, because they will 
require changes in law in a number of instances to achieve the 
kind of medical delivery systems that we would like to have.
    I should mention to you that in pursuing this effort, we 
had complete cooperation from every area of the Department of 
Defense, every service, the military. The departments fully 
cooperated in our investigation, which really occurred in less 
than 40 days. We had 45 days to do that.
    I would like to point out that it has been my experience, 
both having served in the armed forces and having been 
associated in civilian leadership, there is an American ethic 
in our armed forces about care of wounded. And it is the finest 
care that is given to members of the military of any nation in 
the world--the American ethic of care of the wounded.
    Now, I don't want to diminish the role of the active 
forces, because we have to understand the enormous hardships 
that are being visited on the families of guard and reservists. 
Their needs are different sometimes than the needs of the 
active force, and I would ask you to investigate and look into 
that. Their family support structures are different than those 
of the active force. But they also play an equally important 
role in support of our soldiers and sailors, Marines and 
airmen. And they also play a significant role in sharing the 
burdens and hardship of being wounded.
    We on the committee often referred in our deliberations to 
what had happened at Walter Reed. It had encountered the 
perfect storm, and by that we meant there came into confluence 
several unforeseen difficult to deal with issues, not wholly 
the responsibility of the hospital.
    The first of those is an increased casualty load of Iraq, 
which is a very heavy casualty load, and you will find that the 
bulk of casualties are moved to Walter Reed Hospital.
    Then there was the A-76 contracting out requirement which 
comes from Office of Management and Budget (OMB), which, oh, 
six or seven years ago, required Walter Reed to contract a 
series of civilian occupations and jobs that were very integral 
to the operation of the hospital, and that competition dragged 
on and on and on. And the hospital first won the bid, and it 
was appealed, and then it lost the bid. But it introduced an 
era of uncertainty.
    And then, finally, the Walter Reed Hospital, a decision was 
made by the base re-alignment and closure (BRAC)--we did not 
take issue to that; we did not get into that. But the BRAC 
decision had significant impacts on the quality of medical 
care. It impacted on issues that related to certification of 
physicians and retaining essential physicians on the staff of 
the hospital.
    It boiled down to that we divided the issue and it would 
evolve into sort of two issues.
    One of those was trauma care, which occurred first on the 
battlefield, then the hospital in Baghdad, then evacuation to 
Landstuhl, Germany, then evacuation to the United States, 
frequently to Walter Reed. Sometimes that occurred in less than 
36 hours, unbelievably. That care was outstanding, and Walter 
Reed maintained the standard of the trauma care. As Dr. Schwarz 
said, finest trauma operation in the world.
    But where the system broke down was for those soldiers who 
had completed their hospitalization, ready for discharge from 
the hospital, but continued to have care needs, and they will 
become known as holdovers. This was the major problem, and this 
was not handled well. It was not sufficient, and it created 
enormous problems.
    To correct this, as I pointed out, is not just the 
Department of Defense. It is OMB, it is the Veterans 
Administration, and other departments and agencies of 
government.
    Now, ultimately, the Congress, in my view, can do more to 
correct this problem than anyone. I ask you to devote your time 
and effort to pursue it, to have the persistence to pursue it, 
and to have commitment. And through that congressional 
interest, which I place enormous emphasis on, we will have a 
great American medical community and we will meet that standard 
of the American ethic.
    If I could close with--if you will forgive a personal 
statement, but it gives some insights. Both of our sons were 
recalled to active duty in Marine combat in the first Persian 
Gulf War. Our oldest son, who had been a Green Beret, Special 
Forces 18 medic, had decided to come back and study medicine. 
And he was with one of our very significant lead forces in 
Somalia, and he was terribly wounded.
    I went down to Andrews, and my wife, when the Medical 
Evacuation (MEDEVAC) arrived at Andrews. That MEDEVAC comes in 
several times a week. If you have not done that, I would ask 
you to do that and to go on and see on that aircraft. The care 
that those young soldiers are receiving is awesome. The Air 
Force does an enormous job on that.
    I recall my son said to me, he said, ``Dad, they told you 
this flight was 11 hours.'' He said, ``It was 13 hours for 
us.'' He is a doctor. He said, ``The last two,'' he said, ``we 
were strapped in two hours before flight time.''
    The care that we get from the Air Force, their efforts to 
alleviate the pain of those they bring back here to this 
hospital is a very significant thing.
    Also, I invite you to go down to Andrews sometime and meet 
one of those MEDEVACs and follow them out to Walter Reed. It 
will be a very rewarding experience, and they will deeply 
appreciate it.
    And I deeply appreciate the fact that you are demonstrating 
your interest in this subject.
    [The prepared statement of Secretary Marsh can be found in 
the Appendix on page 67.]
    Dr. Snyder. Secretary West.

 STATEMENT OF HON. TOGO D. WEST, JR., FORMER SECRETARY OF THE 
     ARMY, FORMER SECRETARY OF VETERANS AFFAIRS, CO-CHAIR, 
                    INDEPENDENT REVIEW GROUP

    Secretary West. Thank you, Mr. Chairman and members of the 
committee, for holding this hearing, and for not just your 
interest today but for your continuing interest in the care and 
support of our men and women in uniform, both as they perform 
their duties, whether on the training fields or in the fields 
of combat, and once they have completed their duties.
    It is a pleasure to appear before you, appear before this 
subcommittee again, and for several of you with whom I have had 
the opportunity to have interaction before.
    Taking up from where my distinguished colleague, Secretary 
Jack Marsh, left off, that plane, of course, comes in every day 
at Andrews, about mid-afternoon, 3 or 4, except on Thursdays. 
And it is one of several factors that has simply lent the 
weight of numbers to the problem you address as much as 
anything else.
    The numbers who come in, the plane comes in every day, 
except one, the numbers, the percentages of those who are able 
to be saved, who, in the past, could not have been saved, the 
numbers of those who are saved but with complicated, more 
complicated injuries and more injuries and more of a variety of 
injuries than at any other time of war in our history.
    And perhaps just as significant as anything is the number 
three, that we are able to get service members back from the 
theater of combat in as little as three days from the time that 
they suffered their injury on the field.
    As Secretary Marsh said, the bulk of those come directly to 
Walter Reed, others to Bethesda, because that is where the most 
complicated, most sophisticated medical assistance, both 
whether civilian or military, is available to them.
    And when their time, their clinical service, their clinical 
time is done, many remain there in what we call an outpatient 
circumstance, but what is really a kind of outpatient/
inpatient. They are held nearby right on the campus for 
continuing rehabilitation and for the beginning of their 
process.
    That is at the heart of the report that we produced and at 
the heart of what you review today.
    You have my written statement. I will just touch on a few 
things, because much of it has already been done by Secretary 
Marsh, and, that way, I won't take up your time with prepared 
statements and you can get right to questions.
    I would like to say a word about what is in our report, 
which we published at the completion of our review, findings 
and recommendations on a wide range of things which I have 
lumped, for convenience, into four groupings of four questions.
    First, who are we as a country, as an Army, as an Army Reed 
Medical Center, a place where care is delivered?
    If you consider the reports that were being carried in the 
paper and the press and elsewhere about the lapses in care, we 
would not have been happy with the image that was produced. 
Indeed, we do say much about ourselves as a nation by the way 
in which we display our care and our concern for those who have 
given of themselves in support of this nation, especially 
during the most vulnerable times of their lives.
    And so, included in our report are a number of findings and 
recommendations in how we address that, assignment and training 
of case workers, increases in the numbers of case workers, 
adjustment of the case worker-patient ratio, assignments of 
primary care physicians, and attention to the nursing 
shortages.
    Second, what are we to become or, perhaps more accurately, 
and a larger question that requires study, what is our military 
health-care system to become?
    In this instance, I refer to something already raised by 
Secretary Marsh, but I remind you of that larger question, and 
that is the impact of A-76 and the BRAC recommendation on 
Walter Reed.
    The twin effects of those caused almost incalculable damage 
certainly at Walter Reed. Obviously, we have concluded in our 
report that the BRAC decision should proceed for a host of 
reasons, but we have expressed concern and made recommendations 
with respect to the coordinated efforts between the two 
installations and an increase for the pace of the transition to 
what would be the new Walter Reed.
    Third, the question of, how are our service members doing?
    There are four signature injuries of this conflict that we 
identify in our report and that are routinely discussed 
whenever one discusses what is happening in the two theaters of 
conflict in Afghanistan and Iraq: traumatic brain injury (TBI), 
post-traumatic stress disorder (PTSD), amputations and burns.
    And it is fair to say--in fact, it is an understatement to 
say--that both our health-care system for veterans and our 
health-care system for active military are still wrestling and 
having a great deal of trouble with addressing traumatic brain 
injury and post-traumatic stress disorder. They are challenging 
both in terms of how DOD and Department of Veterans Affairs 
(DVA) diagnose, evaluate and treat them.
    We believe there is need for greater and better coordinated 
research in this area. And we have made a detailed 
recommendation in our report with respect to a center of 
excellence and increased attention to cooperative efforts by 
both Cabinet departments.
    And, I might say, there is evidence that the cooperative 
efforts are at least resumed, if not perhaps reinvigorated. 
They have been under way for some time and may have been 
reinvigorated.
    The fourth I call, ``how long?'' I refer to this in my 
formal written statement as one of the areas on which there is 
the greatest amount of unanimity on an Independent Review Group 
that I think can claim quite a bit of unanimity in what we have 
done. And that is what I refer to as the horrors that are 
inflicted on our wounded service members and their families in 
the name of physical disability review processes, known at the 
Department of Defense as the MEB/PEB process, must be stopped. 
The horrors must be stopped; that is, the process must be 
significantly improved.
    It is no surprise to you and it was no surprise to us that 
every part of government can make sound arguments to defend and 
explain why three--in the case of the Army, four--separate 
board proceedings, with associated paperwork demands on service 
members and family, accompanied by delays and economic 
dislocation for family members who are assisting, and 
characterized primarily by differences in standards and 
results, could be justified.
    We are a Nation to trust the common sense of our citizens, 
and that common sense would say that this is simply too 
complicated a process for wounded service members and their 
families to be asked to tangle with, at least without 
significant assistance. And even then, we have recommended that 
one combined physical disability review process for both DOD 
and VA be the objective of planning by this government, this 
executive branch and with support from you.
    Thus, every finding and recommendation we have made can be 
traced back to these four concerns: leadership and attitude; 
the transition from Walter Reed Army Medical Center to Walter 
Reed National Medical Center, as commanded by BRAC; the 
extraordinary use of improvised explosive devices (IED) in the 
current theaters and their impacts on the brains and psyches of 
our service members; and, fourth, the longstanding and 
seemingly intractable problem of reforming the disability 
review process.
    Let me remind us all, Mr. Chairman and members of the 
subcommittee, our report was issued in April. This is now late 
June. That means that the Defense Department and the Army have 
been able to get a number of steps under way in response not 
only to our recommendations, but the recommendations of other 
review bodies which have reported since then.
    Much has been done, and I anticipate that you will hear 
much about that as you proceed.
    Certainly, from our point of view, three factors are 
important.
    One, Secretary Gates has made this a personal priority. He 
said so when he impaneled us. He said it again when he received 
our report. And all of the Department of Defense, especially 
the Department of the Army, have taken that to heart.
    Second, as I referred to earlier, the Department of the 
Army has stepped out smartly in ways that I expect you will be 
hearing shortly.
    And, third, we are not the only body that has been doing 
this review and that I suspect is reporting to you. You are 
getting a lot of attention to a problem that is much needed.
    There is so much to do, Mr. Chairman and members, and, in 
many ways, we are only part of the way along the road to our 
improved process, an ability to provide better care for service 
members and families, both for their health, but also for their 
futures. This they are entitled to, and this you and I and we 
and the Department of Defense I believe are committed to 
helping them find.
    Thank you.
    [The prepared statement of Secretary West can be found in 
the Appendix on page 72.]
    Dr. Snyder. Thank you both, Secretary Marsh, Secretary 
West.
    What we will do, we will all go on the five-minute clock, 
including me and Mr. Kline. Mr. McHugh had to go to the House 
floor. And the five-minute clock is for our benefit. If you all 
have something to say, we want you to say it. Don't be 
constrained by that.
    I want to start.
    General Jumper, I want to start with you, if I might. I 
figure if I call on the people who didn't do opening 
statements, it will kind of keep you keyed up there for future 
questions.
    One of the issues, as you know, that you have had to deal 
with in your career is, we Members of Congress are always 
willing to try to fix things, and the hammer that can come down 
can be legislation. And we are aware that sometimes legislation 
can get in the way of fixes.
    And so you have the situation of you can bring in good 
people, outstanding leaders to correct a problem. As time goes 
by, it may not get the same kind of leadership focus in the 
military, and things can slide.
    As you look at this issue, as somebody who has just 
recently been part of this whole system, do you see this as--
well, how do you think this can be solved? Is there a need for 
Congress to be stepping forward in a statutory way, oversight 
role? Or do you think that the military, particularly the Army, 
is on the right track?
    How do you see this, as we are looking ahead?
    General Jumper. Well, thank you for that question, Mr. 
Chairman. I think that is probably the relevant question in 
this entire issue.
    I will tell you, sir, that there is a role for legislation 
here, and I will cover that in just a second.
    First, though, I would like to say that the leadership of 
the United States Army, as we have just been briefed, members 
of the committee were briefed this morning, has done a 
magnificent job of stepping out with what I call the first part 
of the continuum of care, and that is the primary care. And the 
inpatient care we all know and understand well what the faults 
were, that included taking care of families.
    The medical care was never in question. It is that second 
part, when you get to the outpatient and the rehabilitation, 
that all of a sudden that system, to the average soldier, 
sailor, airman or Marine going through the process, that system 
turned suddenly adversarial and without explanation, and that 
is because we introduced this process of disability evaluation.
    And this process, to the soldier who is looking up at this 
mountain of bureaucracy, that bureaucracy has never been 
tackled or cleaned up by the policy level of our government 
that would be charged to do that.
    In order to do that, Mr. Chairman, is where the legislative 
part of this comes in. If you go through what they call the 
Veterans Administration Schedule for Rating Disability (VASRD) 
process and you look at how diseases are coded, you discover 
very quickly that the signature diseases discussed by Secretary 
West are not properly coded in the reference manuals that all 
of our medical teams have to refer to, and this is a matter of 
legislation.
    So I would implore the committee, sir, to stay after this 
in a persistent way to make sure that the signature diseases, 
once they are properly understood, are indeed coded properly 
and put in a way that you can reference these things and tie 
them to the disability process.
    This will require the committee's attention.
    As far as the steps taken by the Army, sir, I think that 
you will hear today from the United States Army a very thorough 
system that has been put into place that takes care of the 
issues that we had addressing the families and the soldiers 
that had been lost track of and the scheduling problems. I 
think those have been addressed in a commendable way.
    I would also, and I discussed this with General Cody this 
morning, I would pay special attention to watching the budget 
of the United States Army. The fixes that you will hear about 
from General Cody later on this morning were put in out of the 
Army's budget.
    These are resources that are taken from other places in the 
United States Army. There will, no doubt, over time, be a call 
to get those resources back, because they are not part of the 
health affairs budget. So that visibility will, I think, 
require constant attention.
    Also, the final thing is the visibility that the services, 
the uniformed services have over the health affairs budget in 
the Department of Defense has been greatly improved and I think 
that visibility will help get through things like the building 
of the new hospital and issues that were difficult when we 
didn't have--the uniformed services didn't have the visibility 
they should have had over the health affairs budget. I think 
those things are a lot better.
    So that is, I think, the great improvement, sir. There are 
certain things that legislation can help with.
    Dr. Snyder. Mr. Kline, for five minutes.
    Mr. Kline. Thank you, Mr. Chairman.
    I would like to take several minutes to add my praise to 
your work as the chairman. We are going to miss you. We will be 
delighted to work with Ms. Davis when she comes in.
    But since I am on the five-minute clock, I am going to 
limit that to just that.
    Thank you, gentlemen, for being here. I have a number of 
questions, but I am going to cut to the chase here in just a 
minute, beyond the comment----
    Dr. Snyder. Mr. Kline, I should have pointed out we are 
going to go around at least a second round, because I know 
members will have more than one set of questions.
    Mr. Kline. Thank you. Ten seconds of my five minutes.
    There was a conclusion, a finding and recommendation having 
to do with fatigue, compassion fatigue of the nurses at Walter 
Reed. I found that to be striking.
    My wife started her Army nursing career in Walter Reed, in 
the amputee ward, in the Vietnam era, working on a dirty ward. 
And so I am very sensitive to that issue, and I guess that is 
probably better for the next panel, but I just found that 
surprising that this group noticed that and picked up on that.
    And so I will not ask about that now, but just to you, to 
this particular group, I just want to point out that I found 
that to be very striking and we have a compassion fatigue on 
nurses working at Walter Reed.
    What I do want to ask about is this issue of the evaluation 
boards. Clearly, you all agree that it is a mess. We agree that 
it is a mess.
    I think you put your finger right on it, General Jumper, 
when you said that this is an adversarial relationship. One of 
the things that we have done with legislation in Congress was 
worked to put into place these wounded warrior regiments and 
wounded warrior battalions, in part, because we thought it was 
important that our servicemen and women, as they go through 
this process, had an ally, had people that knew them and 
understood their situation and would be an ally for them as 
they go through this process, because it ought not to be 
adversarial, although I understand that it is.
    We have issues of compensation that go on for years and we 
have people trying to be good stewards of the taxpayers' dollar 
and we have all of those things going on. But clearly we need 
to fix it.
    Your recommendation is we overhaul it. I know there is a 
temptation probably for us just to tomorrow pass legislation 
that says make one system and be done with it. I would guess 
that there is some peril with that and I would like to ask any 
one of you to address that approach.
    Your recommendation is overhaul it. I am not sure what that 
means. We all know it is broken.
    But I would like any comment, perhaps from the command 
sergeant major or General Jumper, anybody, about how this 
advocacy on the part of the wounded warrior battalions might be 
working as you saw in Walter Reed or anywhere and if you have 
any specific recommendation about what we might do to 
``overhaul'' it, and we only have about a couple of minutes 
left.
    Major Holland. Sir, thank you very much for that question.
    I gather the microphone is not working.
    And I see a lot of change in the care and the attention at 
Walter Reed, and as General Cody and them will tell you later, 
they have spread this throughout the entire Army.
    But please understand this is a total--as General Jumper 
laid it out and Secretary West laid it out, this is total care 
from start to finish, whether we send them back to duty, 
whether we send them to the VA, whether we send them back to 
civilian life.
    This is long care term and, you know, our cost of going to 
war needs to be this kind of medical care and, in my opinion, 
from what we have seen, that part was sort of left out.
    When we look at the evaluation systems, they are so 
convoluted, they are so complicated, there is only most 
probably a handful of folks in the military that understand it. 
I just retired after 37 years and do not ask me a question 
about them, because I have no clue. That is an honest 
assessment, sir.
    And so the message is let's keep it simple, let's keep it 
right on target. I mean, an amputee that loses a hand through 
an explosion and an amputee that loses a hand from burns is 
coded completely different on the regular system.
    In the VA system, it is characterized completely different, 
also. So I think we need to look at the total system. I think 
our panel, for sure, would like to see one system. Make it 
simple, make it fluent, and take them from one category to the 
other, but we must have a very good, easy handoff between the 
services and the VA.
    If we do that, we can make lots of improvements in whatever 
and being the NCOIM, we are going to err on the side of the 
service member and their family and take care of them, because 
these families must care for this service member for the rest 
of their life.
    And when you look at the wounded we have and the age groups 
of the wounded, 19 to 25, you look at that, that is a long life 
they are going to have. That is a lot of care that that 
family--that we are putting on that family to have, sir.
    Mr. Kline. Thank you, Sergeant Major.
    Secretary Marsh. Mr. Congressman, let me mention something 
to you, because it can be----
    Mr. Kline. Pull your microphone in there a little bit, if 
you would, please, Mr. Secretary.
    Secretary Marsh. A national guardsman is different than a 
reservist and a reservist is different from an active duty 
person and the laws relating to them can be very, very 
difficult in handling or administering medical care, 
particularly if you let the guardsman or reservist, after a 
deployment, come back and be demobilized with some lingering 
medicals.
    He cannot get back into the system without great 
difficulty. So whatever you do, please keep those distinctions 
in mind.
    Dr. Snyder. Ms. Drake.
    Mrs. Drake. Thank you, Mr. Chairman. And I am not going to 
take time thanking you.
    First of all, gentlemen, thank you for your work, and you 
did it very quickly, and we are very anxious to have you in 
here today.
    Mr. Marsh, you have said it repeatedly that there is a 
distinction between the guard and the reserve and we talk about 
that a lot in this subcommittee and one thing I learned in 2005 
was the military thought they were doing what the guard and 
reserve wanted by getting them close to their homes, where what 
we heard from the guard and reserve is they felt like they were 
being gotten rid of.
    And I did see, in some of our materials, that there is an 
effort to make sure we get them as close to home as possible. 
And I would just like to ask you to make sure you ask that 
service member what do they want. Do they want to remain at 
Walter Reed or do they want to go back to their local 
communities, because I was quite surprised by that conversation 
in this subcommittee a couple of years ago.
    But my question is for Secretary West and I am delighted 
that you are here, as a former secretary of the VA, because one 
of the things that we did in 2005 that I thought was very good 
was additional funding so that there would be a better 
interaction between DOD and VA.
    Now, this year, in the Defense Authorization Bill, we have 
also addressed that issue. So my question is, what is wrong? 
What do we need to do differently? Is it a matter of funding? 
Is it a matter of, like we were talking about, both have a set 
that can work together?
    Can you tell us what we need to do and how we bring that 
about?
    Secretary West. Thank you, Congresswoman Drake. There are 
several different elements in that, and the first is this: the 
issue of medical records and of getting them from the active 
duty components to the VA, the sort of seamless transfer we 
hope for.
    The money that the Congress put into the VA a few years ago 
did, in fact, help the VA and it has made significant strides 
in putting the medical records under its control, the ones that 
it has for veterans, on computers. They have taken the off of 
papers.
    It is a paperless process now and the records can be 
available. Veterans don't have to carry them around from place 
to place.
    That system is trying to interface with the system at DOD 
that is still a bit balkanized. Each of the services has a 
system, the Army has two, and those systems don't work as well 
with each other.
    Now, that is not to say that somehow VA has moved out 
smartly and the department has not. The Department of Defense 
has a much bigger problem to be resolved and it has to do with, 
frankly, getting rid of legacy systems and doing the steps and 
exercising the discipline to cause each of the systems at the 
department to standardize and make themselves able to be 
interoperable.
    That will go a long way toward moving across from one 
status to another.
    I think your other question has been, ``Well, but what 
about the point Mr. Kline raised,'' and that is the disparities 
in the disability review processes, the fact that VA apparently 
is more liberal in its criteria than, say, the services and 
that one service may be more liberal than the other.
    I think those are misleading terms. I apologize for using 
them, but that is the impression that is out there. The fact is 
that, though I mentioned it in my comments, that everyone can 
make an explanation as to why their system has to be different, 
there actually are reasons.
    Each of the services has a different need as it looks to 
the question of who can be returned to active duty from being 
wounded and who cannot. The services do that well, each one for 
its own people.
    It is then that the determination as to the percentage of 
disability, if they are not being returned to active duty, that 
has all the disparities. If there was something we could do, if 
there was something you could do, it would be if we let the 
services and DOD do what they do best and what they need to 
do--make the determination as to who can return to the jobs 
they have.
    Once that determination is made, force the VA to do what it 
was established to do--determine the percentage of disability 
and how much this nation needs to provide to each of those 
service members who can no longer serve to make their lives in 
the future lives they can live, lives that can be productive, 
and in which they can continue to be citizens who can make a 
contribution in their neighborhoods.
    Mrs. Drake. Thank you for that.
    And I see I have used up my time. Thank you, Mr. Chairman.
    Secretary West. I apologize for using it up.
    Mrs. Drake. No, no. Thank you. That is very important, and 
we appreciate your straightforwardness.
    Dr. Snyder. Our little clock seems to go straight from 
green light to red light today, doesn't it, without a warning 
sign?
    Ms. Davis, for five minutes.
    Ms. Davis. Thank you very much, Mr. Chairman.
    And, again, thank you to all of you for your commitment to 
this effort.
    I wanted to follow up on the issue that we have just been 
discussing in terms of the different services and their 
evaluation. Do you believe, and for any of you to respond, are 
we evaluating all of the injuries that a service member brings?
    And if that is a problem, and I think it might be--I want 
to talk a little bit about traumatic brain injury (TBI) and 
post-traumatic stress disorder--how do we get there?
    Secretary West. I think it is a great question, and 
Congressman Schwarz is waiting on it.
    Ms. Davis. I am delighted to hear from the congressman.
    Dr. Schwarz. Congresswoman Davis, nice to see you again.
    The injuries that have resulted from this war are different 
of a magnitude great enough that they have to be treated 
differently than the chairman's and my war, Mr. Kline's war, 
and the traumatic brain injury, which we called closed head 
injury when I was coming up through the resident ranks, 
probably is, of the signature injuries of this war, the 
signature injury.
    Most of the injuries are from blasts. It has been estimated 
that 80 percent of the casualties in this war in one way or 
another result from blast injuries. They could be soft tissue 
injuries and we are doing a fabulous job of saving people who 
have wounds which, in previous wars, would have been fatal 
within minutes.
    The non-penetrating head injuries are the ones that I think 
are the greatest conundrum and they all fall under the rubric 
of traumatic brain injury.
    You have someone who loses cognitive abilities, loses 
memory, loses ability in some ways to speak logically and 
coherently, is unable to find their way from point A to point 
B, families say something is wrong, we are not quite sure what 
it is, sleep incessantly.
    In the case of one reserve brigadier general who the panel 
encountered, he was found to have an IQ that--and, by the way, 
in the civilian world, he is a judge--was found to have an IQ 
that would be considered below normal now.
    Work is being done, and I have to single out Dr. Maria 
Mouratidis at the National Naval Medical Center, on improving 
the cognitive skills of people who have this diagnosis. The 
problem is that the diagnosis is not made quickly enough and 
frequently the diagnosis is not made at all.
    And in the end, when, two or three decades from now, a 
reassessment is done of the signature injuries of this war, I 
believe that the TBI, the traumatic brain injury and all of its 
sequella, lasting years and years and years, will prove to be 
the most serious and the most long lasting, have the most 
effect on the people who suffer from it and, from the 
standpoint of the Congress and the health-care providers, be 
the most expensive.
    So if you are going to emphasize one, just one of the 
signature injuries of this war, the concept promoted by Mr. 
Fisher and myself and other members of this committee that we 
have a center of excellence established as soon as possible to 
deal with people with TBI, that would be job one, and I hope 
that is something not only that this committee and the Congress 
says should be considered, I truly hope it is something that 
you mandate.
    Ms. Davis. Thank you. I appreciate that, and I hope you 
would include PTSD with that, as well, in terms of the kind of 
signature injury that we don't see readily apparent.
    I think my concern and my question, also, though, is, how 
do we make certain that the boards evaluate not just one injury 
but a group of injuries, several injuries at one time?
    Because traditionally, as I understand it--and please 
correct me--that really is what they have done. And so we have 
missed a lot of the injuries that people must be compensated 
for as they leave the service and as they move on to the VA 
system.
    So is this the kind of thing that we really have to address 
as we address that transition with the VA system?
    And I know my time is up.
    Dr. Schwarz. Congresswoman, my response to that is that 
your premise is correct.
    Ms. Davis. Thank you.
    Dr. Snyder. Thank you.
    Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you very much, Mr. Chair. And we 
certainly will miss you and look forward to a productive 
relationship continuing. So congratulations.
    My first question is addressed to Mr. West. I am concerned, 
as all of us are here, about what has happened, but I picked up 
on a particular statement that reserve component members face 
unique challenges in the military health-care system.
    And I have a particular interest in the national guard. 
They are in my state, of course, and I have heard some 
conversation along those lines and I wanted to ask you to 
please elaborate and address some of those particular concerns 
and what your solutions would be.
    Secretary West. I think you may want to hear Secretary 
Marsh on that. He has devoted a lot of time to that, if I 
might.
    Ms. Shea-Porter. I actually was going to ask both, but, 
yes, feel free, anybody. Thank you.
    Do you want me to repeat it?
    Secretary West. Your question is to elaborate on the 
problems that the guard and reserves are facing----
    Ms. Shea-Porter. Right.
    Secretary West [continuing]. That we have alluded to in 
terms of the care that they are receiving.
    A couple things. One is that, in doing our review at Walter 
Reed, we came across the fact that they are actually separately 
organized in the rehabilitation process. That is, once they 
have finished their clinical part, the immediate part and are 
held there for rehabilitation and for perhaps processing, the 
active duty are kept in something called the medical hold. The 
reserve components are part of something called the holdover.
    And so from the outset of their status there, they find 
themselves segregated for reasons that are not clear to them. 
Now, although every process like that starts with a reason, the 
fact is that the more that we looked at it and the more we 
observed it, it seemed far better to treat them all as one 
group.
    There are different rules, and that is what Secretary Marsh 
was referring to earlier, in terms of how they are treated when 
they return to their organizations.
    So there is a great concern there and we have pointed to it 
in our report and our belief is, for one thing, as Secretary 
Marsh said, that it is simply something that everyone has to 
look at more closely. There is great concern in the reserve 
components.
    Do you want to say anything further?
    Secretary Marsh. I might comment that the support 
structures for the active force and for reserve components are 
quite different. When a unit is mobilized, say, at Fort Bragg, 
the support structure centers on Fort Bragg, the dispensary, 
the post exchange (PX), and all these things.
    When a reserve or guard unit is activated, that network of 
support does not exist like you have on an active duty force. 
So it must be implemented and you must develop a separate 
support system for people who live in rural areas or who are 
far distant from other communities.
    Frequently, wives don't know other wives in the reserve 
components, but they might in the active.
    I think it is an area that we need to look to generally. I 
am not certain that we have fully utilized the capabilities of 
our reserve components, and I will give you an example in 
medical care.
    We are beginning to see some problems on getting qualified 
physicians into the guard and reserves. It is beginning to 
show. If we were to waive the requirement on the age above 50, 
and Joe can speak to this, and not require----
    Dr. Schwarz. I can speak to being above 50, for sure. 
[Laughter.]
    Secretary Marsh [continuing]. And not require an eight-year 
commitment, we could probably fill very quickly many of the 
vacancies that exist today in the Reserve community medical 
area.
    Joe, do you want to comment on that?
    Dr. Schwarz. Yes. There is an eight-year requirement now if 
someone decides to return to the military or enter the military 
for medical professionals. And the estimation is, and I believe 
it is probably quite correct, that there are numbers of older 
medical professionals who would serve and willingly and with 
great skill, but they are probably not of an age where eight 
years is practicable, but perhaps three years or five years 
would be practicable.
    And I believe that some of the positions, especially guard 
and reserve positions, where the individual could be at home, 
except for deployments, would help fill some of those vacant 
slots for physicians, for nurses, for physicians assistants 
(PA), for other medical professionals.
    So I think changing that requirement to a shorter term of 
duty would be a good thing and would allow a greater number of 
medical professionals to participate, especially in the guard 
and reserve.
    Ms. Shea-Porter. Thank you all.
    Major Holland. Ma'am, one additional point is the Army has 
taken and gone back to having one medical hold company, so both 
the guard and reserve fall into it.
    All I ask everyone to think of is those guard and reserve 
members are on active duty until the day they are discharged. 
They need to be considered that way, evaluated that way and 
handled that way, and their care needs to be the same.
    There need not be a priority or a stair-step system, and if 
we can do that, we would make lots of strides, ma'am.
    Ms. Shea-Porter. Thank you.
    Dr. Snyder. Thank you, Ms. Shea-Porter.
    I wanted to point out the Defense Bill that passed the 
House that will go to conference with the Senate when they pass 
the bill gives the Secretary of Defense permission to lower 
that eight-year obligation to two years, but it is at the 
discretion of the secretary.
    Ms. Sanchez.
    Ms. Sanchez. Thank you, Mr. Chairman.
    And thank you, gentlemen, for being before us today.
    In reading the report, one of the issues that came up was 
the challenges that were going on because of BRAC actions, A-76 
competitions and funding constraints over at Walter Reed. And I 
think that all the members of the subcommittee are concerned 
that Walter Reed not remain, as the report described it, in a 
state of limbo until the new facility is completed.
    And so my question is, how confident are you that Walter 
Reed will be able to run at optimal levels while the facility 
is, in fact, being closed down, until we get the new facility, 
et cetera?
    And more importantly, and this comes from a visit I made 
myself, as you know, if we pay money, Members of Congress can 
go over for some outpatient care there. I was over there 
talking to one of the doctors, being seen by a doctor and 
talking to her. And she was talking about movement and how 
doctors are leaving and how, for her own personal career, it 
probably would be better if she took a new position somewhere 
else. But she didn't want to look like she was jumping ship, 
because there was so much poor morale among the troops right 
now--the troops, meaning the people who work at Walter Reed--
not just over what had happened, but, in particular, because so 
many doctors and others are choosing to leave the facility.
    So the second question is, how are we going to be able to 
retain the best and the brightest to serve our service members 
during this time, when, just on a personal basis, people have 
talked to me about it?
    Secretary Marsh. I could mention several things, but I am 
not sure I have the whole answer, and Dr. Schwarz or others can 
contribute to that.
    You mentioned the competition and A-76, because Walter Reed 
could not control that. They were directed to do that.
    When the BRAC came out and Walter Reed began to have 
problems on maintenance that related to the old hospital, a 
memo was directed from the Department of the Army, as I recall, 
that you could not request the appropriations to improve a 
facility that was being closed by BRAC.
    Now, I am sure that will be changed, because that is one of 
the problems. I think the way that we are going to handle the 
Walter Reed thing to achieve the goals that you are talking 
about is going to require, one, a commitment to build a new 
hospital in a timely way and currently fund the operation at 
Walter Reed at full tempo up until you come to the time that 
you want to close its doors.
    And I think others may want to add to that.
    Mr. Fisher. I have never understood how you would sell a 
house before you bought a new one, and we are talking about 
people leaving Walter Reed because there is no future. There is 
no date of a new hospital. There is no reason, no reason at 
all, why the second and a new hospital is not being started 
right this minute.
    It has been three years since the BRAC Commission came out. 
Where are the plans? Where is the date of starting the new 
hospital? I am a developer. When I am ready to build something, 
we get started on it. We are talking--I have heard dates of 
2012 before the new hospital is built. I just don't understand 
this.
    The reason people are leaving, they have no future. If the 
date was established, this hospital is being started, maybe 
then the people working in the hospital know that they will 
leave this hospital and go to the new one. But to leave this 
thing up in the air for so long, to me, is unconscionable.
    Six-hundred-thousand Americans paid to have a center for 
the Intrepid in San Antonio that DOD had promised to build for 
four years. American people put together $50 million and, in 14 
months, built that center for the Intrepid in San Antonio.
    There is no reason why the government can't start this new 
hospital now. Maybe that would alleviate a lot of the problems 
of people leaving and people not knowing what is going on next.
    I think that is Congress's duty, to start this process now.
    Ms. Sanchez. Anybody else have a comment on the panel?
    Dr. Schwarz. Yes, I do.
    Ms. Sanchez. I see that the light is red.
    Dr. Schwarz. I have a very short comment, if I may, Mr. 
Chairman.
    I agree with Mr. Fisher. Walter Reed Army Medical Center 
was built 30 years ago. Thirty years in chronological age is 
not much; 30 years in medical advancement is an eon. A 
replacement hospital needs to be built as soon as possible.
    The concept of marrying Walter Reed with the National Naval 
Medical Center in Bethesda, perhaps a consummation devoutly to 
be wished, but I know that there are at least two and perhaps 
three members on the panel who are very aware of the 
differences in culture between the Army on one side and the 
Navy and the Marine Corps on the other. And I believe that is 
the reason that things have not progressed as rapidly as they 
should. And I guess there are several others of us down here 
who understand that difference, as well.
    So they need a new hospital. They need the new hospital 
yesterday. And if the Army needs simply to build a hospital on 
its own for whatever that hospital might cost, perhaps $2 
billion, I would remind all that we are spending $8 billion a 
month in Iraq and Afghanistan right now. It does not seem to be 
too high a price to pay to get going on a new hospital for 25 
percent of what we pay on a monthly basis to carry on the 
military activities we are involved in overseas now.
    Build the hospital, build it now, and a lot of these 
problems will be solved. Otherwise, the personnel problems will 
go on forever and the facility itself will continue to 
superannuate to the point where it is not anything any of us 
will be proud of.
    There is no malign intent on the part of any member of the 
uniformed services, especially the Army. The staff, the 
physicians, the nurses, and the ancillaries at Walter Reed are 
the best in the world. The trauma care, as we have noted, is 
the best in the world.
    These people are thorough professionals, but they need a 
facility and I believe that that facility should be built as 
soon as possible. And I think there are quite a few people on 
this side who would support me on that, although the BRAC is 
the BRAC and, as all of you know, the BRAC is a pretty 
difficult thing to get around.
    I am sorry I took so long, Mr. Chairman----
    Ms. Sanchez. Thank you, Mr. Chairman.
    Dr. Schwarz [continuing]. But I wanted to say that.
    Ms. Sanchez. Thank you, Mr. Chairman, for your indulgence.
    Dr. Snyder. Mr. Murphy, for five minutes.
    Mr. Murphy. Thank you, Mr. Chairman. And we are sorry to 
see you go, as well.
    Gentlemen, thank you for being part of the panel.
    I have made personal visits to wounded soldiers at the 
Malone House, and, as you know, the Malone House helps soldiers 
with their mental, medical or psychological problems.
    And when I was there, I always met with soldiers that had 
undergone serious surgeries. And one nice young solder in 
particular had one of his legs amputated--one of those 
signature injuries, Mr. West, Secretary West, that you 
mentioned in your testimony.
    He was going back under the knife for an operation on one 
of his eyes--again, injuries, sir, that resulted from his 
service in Iraq. And although he was in good spirits, he 
imparted to me that he was dissatisfied with the level of care 
he was receiving.
    And soldiers like him, as you know, are the future of our 
country and of our military.
    And the question I have for the panel there is, how can 
this Congress prioritize the Independent Review Group's 
recommendations to have the greatest impact to improve our 
system for such service members?
    I would like your comments on that. Thank you.
    General Jumper. Well, I will start, and I think everybody 
has an opinion on that, but I think that we have heard from 
distinguished members of this panel today the importance of the 
traumatic brain injury as a signature injury of this conflict.
    And to be able to prioritize that properly, to be able to 
create a center of excellence that can go back and research the 
history of this, do the case studies on those that probably 
date back to the Korean War or Vietnam War, to be able to 
distribute and identify the cutting-edge diagnostics as they 
emerge, be able to distribute those system-wide, and then be 
able to come up with the cutting-edge treatments and distribute 
those treatments system-wide would be a great service to this 
nation, and also be able to reach back to previous conflicts 
for those who we all know suffer from these diseases from the 
past.
    That, in my mind, would be the greatest service that we 
could provide.
    But second and close on its heels is to be able to attack 
this bureaucracy associated with the evaluation business. And 
Mr. Kline pointed out that we do have advocates that the United 
States Army have put with each of the injured members, and they 
are doing a magnificent job. But it doesn't keep the system 
from being adversarial, and it doesn't keep that soldier from 
being impacted morale-wise, seeing this system appear to turn 
against him or her as they progress through the process.
    So to be able to attack this process, to be able to do one 
physical examination, the data of which is acknowledged and 
used by all, to be able to have a code of identifying tables 
within the literature that does the best it can to categorize 
the TBI and the PTSD injuries, to be able to proceed with the 
leadership at the policy level, to, in good faith, wrestle 
these bureaucratic problems to the ground, to have the Congress 
give them times and dates certain for results that wrestle 
these problems to the ground would be, Mr. Chairman, sir, would 
be a great contribution to this nation, I believe.
    Secretary Marsh. Mr. Congressman, one of the things that 
came up as we began this effort was a recognition that we were 
only dealing with a piece of the pie, and the piece that we had 
was defined specifically to Walter Reed and, to a lesser 
extent, to Bethesda.
    I was of the view then, and I am of the view now, that some 
of the things that we are discussing that apply to Walter Reed 
apply to other military hospitals in the United States, and I 
think the Command Sergeant Major would confirm that.
    The other thing that we realize, dealing here with some 
mammoth bureaucracies, we cannot solve this solely in the 
Department of Defense. We are dealing in an inter-Cabinet 
thing.
    If you are getting into A-76, you get into a whole 
different field. You are getting into OMB. But we also know 
there is a consideration that relates to veterans and veterans 
affairs and the group that is being chaired by former Senator 
Dole and also Mrs. Shalala. So that is another shoe that has to 
drop.
    But I am telling you this is a mammoth sort of task that 
you are looking at. I think the Army is seeking to address a 
number of things, the military hospitals, but you would do well 
to inquire what the statuses are in Fort Bragg and Fort Gordon 
and Fort Lewis and other places.
    Secretary West. I don't want to drag this out, Congressman 
and Mr. Chairman, but I have to offer an alternative viewpoint. 
I think the priorities are pretty clear.
    One of the things that we are helped with is that some of 
the things that provoked this investigation have now been moved 
out on by Department of Defense and Department of the Army.
    The question of facilities is very carefully being looked 
at. The question of getting some people there, the brigade and 
the people who can help our service members and their families 
get through the process is being acted on.
    But PTSD and TBI, Walter Reed, in its new format, and the 
bureaucratic process for physical disability evaluation are 
three big issues that need a lot of attention right now.
    Each one of them is a long-range effort and a long impact, 
but we have to start it. And if you ask me where we would put 
priorities and where the emphasis seems to be, it is right 
there in our report.
    Mr. Murphy. Thanks, gentlemen.
    Thank you, Chairman.
    Dr. Snyder. Ms. Boyda for five minutes. Then we will go to 
Mr. Wilson.
    Mrs. Boyda. Thank you, Mr. Chairman, and thank you so much 
for the leadership. We will miss you on this committee, and 
looking forward to the leadership of Mrs. Davis.
    I just wanted to state one thing for the record. We kind of 
spoke about it a little bit earlier, but I have a guard that 
was just injured this weekend, and I would just like to go on 
the record as saying that his wife would certainly appreciate 
the ability to choose where he and his family go.
    She is going to have to pay to get herself down to Fort 
Bliss, and I would just like to go on the record as saying we 
certainly can do better. Give them a choice. We don't want them 
to feel like they are being pushed out. Give them some control 
of their lives, and it would mean a lot. And I heard you speak 
about that earlier.
    But I would like to just address the whole A-76 process. 
And I apologize that I was a little late, so if I have, in 
fact, missed this discussion, I apologize for that. But the 
statement was made that the A-76 directive was really placed on 
Walter Reed.
    Could you describe what that is and just, again, the whole 
A-76 process as a whole and what it is meaning certainly----
    Secretary Marsh. General Jumper has probably dealt with A-
76 more than any of us.
    Do you want to respond to that, General?
    Mrs. Boyda. Its ins, its outs, its goods, its bad, are we 
overseeing it? What is happening?
    General Jumper. Well, there are varied and wide opinions on 
A-76. And, of course, I tell you, as a guy who came out of 
uniform, I am one of the biased ones.
    I think that we have over-outsourced in many ways, and the 
direction to over-outsource was done with criteria that 
probably didn't always work to the best interest of the people 
in uniform.
    At Walter Reed, again, the A-76 process required 
outsourcing that put certain critical functions into the hands 
of--it took them out of the hands of very experienced people 
that were used to working with a very old infrastructure at 
Walter Reed and put them into the hands of lowest bidders that 
cut the services, cut the number of people attending the 
facilities in ways----
    Mrs. Boyda. In your mind, why do you think that was done?
    General Jumper. Because of savings. You saved money by 
outsourcing those----
    Mrs. Boyda. Short-term savings anyway.
    General Jumper. Yes. Well, many of us would believe it is 
only short-term savings. The process of A-76 believes it is 
long-term savings. But to those of us who experience it, we 
believe that the savings are only short-term, if at all, and 
certainly not long-term.
    Secretary West. The A-76 process is never one that an 
organization chooses for itself. It is almost always told by a 
higher headquarters or a higher authority during the budget 
process or the resourcing process, as part of putting together 
your plan for the future, go through the A-76 process, which is 
simply another way of saying, ``Compute all your functions.'' 
That is, compute your cost as a government function versus the 
cost of contracting it out.
    Mrs. Boyda. What do you think that the A-76 process does to 
morale, in addition to not knowing where the building is going 
to be on a given day or just the physical timing of the move? 
What does the A-76 process do on top of that for morale?
    Secretary West. In the several positions I have had in the 
Department of Defense and others elsewhere, I have never seen 
an organization or its people welcome the onset of the A-76 
process.
    Mrs. Boyda. Do you think it affects morale negatively?
    Secretary West. I am sorry?
    Mrs. Boyda. Do you think it affects morale negatively?
    Secretary West. Oh, surely, surely.
    Mrs. Boyda. So it is not just that it is not welcomed; it 
has a negative affect on morale.
    As you might guess, I am a little concerned about A-76.
    Secretary West. I don't want to be unfair to those who 
conceived of the process. But from the point of view of one who 
has actually been part of organizations going through it, it 
proceeds from the assumption that there is a good chance that 
someone other than the people we have recruited for the 
government in civilian positions could do the job just as 
effectively and cheaper.
    It proceeds from that assumption. That is not a good 
morale----
    Mrs. Boyda. Do you have any recommendations to this 
committee as we move forward?
    I will say that the--who are the top medical people? 
Surgeon generals of all three branches basically have suggested 
that A-76s may not be having a positive impact, and I will put 
that politely.
    Do you have any recommendations for this panel as it 
regards A-76 and our health-care system?
    Secretary West. That the medical centers and the health 
care in the department, those institutions, be exempted from 
the process.
    Mrs. Boyda. Thank you.
    Dr. Snyder. Mr. Wilson.
    Secretary Marsh. A-76 is quite old. A-76 was begun in the 
1960's, and it applies to many areas of government, and there 
is a lot of controversy about it.
    Dr. Snyder. Mr. Wilson, for five minutes.
    Mr. Wilson. Thank you, Mr. Chairman.
    And thank you, Secretary West, for being here with 
Secretary Marsh, your colleagues. We appreciate your service.
    I am particular happy to see my fellow Washington and Lee 
(W&L) University graduate, Secretary Marsh. You are certainly a 
distinguished graduate, and those of us of W&L appreciate your 
service and success.
    Additionally, I want you to know how honored I was to serve 
with Congressman Schwarz, who is sitting right next to you. 
What a fine gentleman and a great patriot for our country.
    As we look at this issue--and you all have really looked 
out for the soldiers and sailors and Marines of our country, 
and I appreciate that very much--the Defense Health Board has 
recommended that a specific individual be tasked with carrying 
out the recommendations of the Independent Review Group.
    Would you support that recommendation? And who would you 
recommend within the Department of Defense be tasked to carry 
out the recommendations?
    Secretary West. Our recommendation, of course, in our 
report was that the important thing was that there be some 
entity, whether it was an individual or a committee, 
responsible directly to the Secretary of Defense, whose 
position it was or responsibility it was to monitor compliance 
with our recommendations and action taken.
    The Secretary of Defense informed us in our exit interview 
with him that he had designated a committee consisting of 
senior people to meet each week and to carry out that function.
    And so, from my point of view, we thought that he had acted 
immediately in response to our recommendations.
    Your question is about an individual, and I am going to let 
any of my colleagues who want to address that speak to it. I 
think that he has acted in a way which we think is responsible.
    Mr. Fisher. I had originally suggested that a, for want of 
a better word, czar be appointed to make sure that this is the 
second or third committee that has come up with these 
suggestions. There is a committee following us. That is the 
Presidential committee. That we have had enough investigation. 
We need to get it implemented.
    And whether it takes a czar or a committee or whatever it 
takes, it should get started right away.
    Mr. Wilson. And then, Secretary West, could the committee, 
in fact, have the function of the czar?
    Secretary West. That is certainly I think the intent of the 
Secretary of Defense, and it would, we hope, be the way it 
would work.
    Mr. Wilson. Thank you very much.
    And, additionally, Secretary Marsh and Secretary West, the 
Army Medical Action Plan (AMAP) appears to be a systematic 
approach to addressing the problems regarding the care of 
covering wounded combat veterans identified at Walter Reed.
    What are your thoughts on this plan? And, in particular, do 
you think successful implementation of the plan will 
significantly improve the quality of life for recovering 
service members and their families?
    Secretary Marsh. I think it will be helpful.
    When this effort began several months ago, we learned that 
the Army, about a year ago, had begun an inspector general's 
(IG) report that looked at some of the same issues that we had. 
It was a very comprehensive thing.
    We received a briefing this morning, and the Army is taking 
steps to address the issues that are raised in our report and, 
also, the issues that were raised in its own IG report.
    They have not completely addressed all of them. Some of 
them go beyond their capabilities to remedy, for example, the 
evaluations under the disability systems.
    Incidentally, there is incompatibility in the evaluation 
systems in the Army, inside the Army, and there are differences 
between the Army and the Department of Defense and between the 
Department of Defense and the Navy and the Department of 
Defense and the Air Force.
    So they are not going to resolve that in that regard. One, 
it is beyond their capabilities. It is going to have to be done 
by law, in my view.
    But I think you are going to get a report here just very 
shortly that gives you a summary of the actions taken under the 
IG report, which is sometimes called the Army action plan.
    Mr. Wilson. And, again, I would like to thank you. I want 
to thank all of you.
    I have the perspective of being a veteran myself, 31 years 
in the Army Guard and Reserves, and I have four sons serving in 
the military, including one who is a doctor in the Navy, three 
in the Army National Guard.
    Thank you very much for your service.
    Dr. Snyder. Gentlemen, you have teed us up well for the 
second panel.
    Members may have questions for the record. If they do, I 
hope you will get those back to us in a timely fashion.
    I also want to give members any chance, if they have a 
question that they want to ask.
    Mr. Kline, anything further?
    Mr. Kline. No.
    Dr. Snyder. Ms. Drake.
    Mr. Wilson.
    Ms. Davis.
    Ms. Shea-Porter.
    I wanted to hold up the report. The title, I think, is 
great, ``Rebuilding the Trust,'' and you have the Purple Heart 
on here.
    I just want to make one point. We sometimes make mistakes 
referring to wounded warriors. And, obviously, everything in 
here applies to people who become ill or injured through non-
combat means. We care about them all.
    As somebody who got the sickest I have ever been in my life 
was when I was working in a refugee camp in Sudan, I appreciate 
the kinds of things that can happen overseas.
    I also appreciate the comment, a couple things that didn't 
come up in the discussion, you specifically are critical of the 
so-called efficiency wedges and the military-to-civilian 
conversion amongst medical services, which this committee has 
been very concerned about. And I appreciate your calling 
attention to that and, also, your vocal commitment in the 
report to medical research.
    Secretary Marsh. Mr. Chairman, in that regard, the funding 
streams inside the Department of Defense on the medical budgets 
was changed and no longer comes from the service secretaries of 
the three services, but has been moved up into the Department 
of Defense. And it, in my view, is not as effective or as 
efficient, and it needs to be reviewed.
    And I am very pleased to learn that you all are going to 
look at that, because it is one of the sources, in our view, or 
certainly in my view, of the problems that we have on 
financing.
    Dr. Snyder. And the surgeon generals have been very candid 
about that.
    Gentlemen, we appreciate you for being here, appreciate 
your service, appreciate this report, which was put together 
very, very quickly. I think you did a very thorough job.
    We will be in recess for about three minutes while we are 
changing name tags, and anybody who wants to run to the 
restroom can.
    Thank you. Thank you, gentlemen.
    [Recess.]
    Dr. Snyder. Mr. Kline and I want you to realize we are 
talking about Marine Corps three minutes, not congressional 
three minutes. [Laughter.]
    So we are about ready to start here. I am going to go 
ahead.
    I wanted to formally welcome you all and formally introduce 
you all.
    I don't know if you were able to watch this or not, but Mr. 
McHugh has been called to the floor to do an amendment on the 
floor. That is why he is not here with us.
    We are pleased to have with us on our second panel General 
Richard Cody, vice chief of staff of the Department of the 
Army; Major General Gale S. Pollock, acting surgeon general for 
the Department of the Army; Major General Eric Schoomaker, 
commander, North Atlantic Regional Medical Command and Walter 
Reed Army Medical Center; Brigadier General Michael Tucker, 
deputy commanding general, North Atlantic Regional Medical 
Command and Walter Reed Army Medical Center; and Colonel 
Terrence McKenrick, commander of the Warrior Transition Brigade 
at the Walter Reed Army Medical Center.
    General Cody, you have an opening statement.
    Does anyone else have an opening statement you want to 
present? General Pollock.
    General Cody, if you would begin.

    STATEMENT OF GEN. RICHARD A. CODY, VICE CHIEF OF STAFF, 
               DEPARTMENT OF THE ARMY, U.S. ARMY

    General Cody. Thank you, Chairman, distinguished members of 
the subcommittee. I appreciate this opportunity to discuss with 
you our continuing efforts to improve the outpatient care and 
the administrative support of our wounded soldiers and their 
families.
    In February of this year, I made a commitment to our 
soldiers, our families, the American people and to you that I 
would personally oversee the needed fixes to the care and 
support we provided our wounded soldiers. We are here today as 
a group to provide you, our soldiers, the American people an 
update on our progress to date on that continued way forward.
    In the last several months, we have done much to improve 
the outpatient care conditions and support for our warriors-in-
transition and their families both at Walter Reed Army Medical 
Center and across our Army. In my written statement, I describe 
a number of the immediate fixes we have taken, but would like 
to highlight two of the most critical for you now.
    First, to provide the caring, purpose-driven leadership our 
soldiers and families deserve, we have transformed and formed 
up 37 warrior transition units to replace the medical hold and 
medical holdover companies. Established at locations with 
significant warriors-in-transition populations, we are working 
aggressively to man these units with the right leaders in the 
right numbers with the right training down to the squad level.
    Second, we have established the transition triad, 
consisting of the squad leader, nurse care manager and the 
primary care manager, all linked with each warrior-in-
transition. This triad will work closely together to ensure the 
medical, the administrative, and the outpatient support 
requirements of our warriors-in-transition and their families, 
so that we ensure a positive, timely and fair manner of medical 
care.
    Of the initiatives we have implemented to date, I consider 
these two to be the most important and most critical. They 
provide the focused leadership and personalized care that our 
soldiers require to expedite their rehabilitation and return to 
duty or timely and fair disposition as they work through the 
physical disability evaluation process.
    While we have done much already, there is still much to do. 
Our way ahead is captured in the Army Medical Action Plan. 
Several weeks ago, I sent out a Department of the Army 
operations order to all of our subordinate commands and 
supporting agencies directing specific actions required to 
address 120 issues identified in our action plan.
    This order was received and acknowledged by our three-and 
four-star commanders, our assistant chiefs of staff, and our 
hospital commanders. The order specifies tasks, timelines and 
reporting requirements to ensure full implementation and 
enduring implementation of our Army Medical Action Plan and to 
sustain the momentum we have already gained.
    Warrior-in-transition care is truly, at its heart, an issue 
of leadership, from squad leader all the way up to the chief of 
staff and secretary of the Army. I assure you that nothing is 
more important to the Army's leadership than ensuring quality 
care for our soldiers and families, and we are fully engaged to 
achieving that end.
    Our acting secretary, Pete Geren, and I are principal 
participants in the senior oversight committee, chaired by the 
Deputy Secretary of Defense, that meets weekly to coordinate 
the Department of Defense efforts to improve medical care 
processes, disability processing and transition activities with 
the Department of Veteran Affairs.
    Over the last several months, I have chaired several video 
teleconferences with our hospital commanders to receive direct 
feedback from them on the progress and challenges they are 
having out there in our medical treatment facilities. These 
monthly video teleconferences have proven crucial to developing 
and disseminating and implementing the Army Medical Action Plan 
and have been invaluable to focusing and synchronizing our 
efforts across the Army.
    Our senior mission commanders, our two-star and three-star 
commanders of our posts, camps and stations participated during 
the most recent teleconference and provided their respective 
insights as to how we are doing in taking care of their 
soldiers.
    I can't emphasize enough how important the care of our 
soldiers and our families are to this Army, an all-volunteer 
force that is making incredible sacrifices every day during 
this time of war.
    Our nation could not ask our soldiers and their families to 
make these sacrifices and not ensure that their medical care 
and overall quality of life is at least equal to the quality of 
their service and their sacrifice. We cannot ask our soldiers 
to ensure the rigors of combat and then endure an under-
resourced or bureaucratic system when they come home.
    This Army is many things, but ultimately it is about people 
and it is about our soldiers. The entire Army leadership is 
committed to getting this right for them and their families.
    And I look forward to your questions.
    [The prepared statement of General Cody can be found in the 
Appendix on page 76.]
    Dr. Snyder. General Pollock, we will go to you.
    And then, General Schoomaker, you have an opening statement 
also.
    General Pollock, for as long as you need.

STATEMENT OF MAJ. GEN. GALE S. POLLOCK, ACTING SURGEON GENERAL, 
               DEPARTMENT OF THE ARMY, U.S. ARMY

    General Pollock. Mr. Chairman and distinguished members of 
the subcommittee, thank you for the opportunity to update you 
on the Walter Reed Army Medical Center and the noteworthy 
achievements of the Army Medical Action Plan.
    In the last four months, the Army and the Army Medical 
Department have taken significant actions improving the 
management and care of soldiers in an outpatient status. We are 
committed to getting this right and providing a level of care 
and support to our warriors and their families equal to the 
quality of their service.
    As you have heard, the Vice Chief of Staff, General Cody, 
the G-1, Lieutenant General Rochelle, and the commander-
Installation Management Command, Lieutenant General Wilson, 
have been personally invested in finding solutions.
    Shortly after publication of the media reports, General 
Cody reached out to the Armor School at Fort Knox and tapped 
Brigadier General Mike Tucker to be our bureaucracy buster and 
to serve as the deputy commanding general of North Atlantic 
Regional Medical Command.
    We have put Mike in charge of the Army Medical Action Plan, 
the AMAP, and he has been diligently pursuing a comprehensive 
plan to improve outpatient management at Walter Reed and across 
our Army.
    At the same time, Medical Command (MEDCOM) established a 
tiger team composed of ten subject-matter experts, led by 
Colonel Ben DeKoning, and charged them to determine if any of 
our other medical facilities were experiencing issues similar 
to those at Walter Reed.
    This multidisciplinary team spent a month on the road 
visiting 11 different installations, inspecting soldier 
welfare, infrastructure quality, medical administrative 
processes, and soldier and family information sharing.
    The team identified some concerns similar to those at 
Walter Reed, but also found best practices that could be shared 
across the Army Medical Command. The tiger team's findings and 
recommendations became one of nine different source documents 
used by the AMAP team to develop a detailed and comprehensive 
action plan.
    In its 90 days of existence, the AMAP team conducted an 
initial analysis, developed lines of operations, codified the 
requirements, conducted personal reconnaissance and 
assessments, hosted a synchronization conference, and 
established a bevy of quick wins, short-range goals, and long-
term goals.
    Although the team has ``medical'' in its title, its 
composition and focus is much broader. Permanent team members 
came from Manpower and Reserve Affairs, the Installation 
Management Command, the Army G-1, the Army G-3, and Medical 
Command. Other participants include the Army Corps of 
Engineers, the TRICARE Management Activity, Veterans Affairs, 
and other Federal agencies.
    The team has already provided several updates to Acting 
Secretary Geren and received clear senior Army direction and 
leadership. Everyone is working toward the same goal, and we 
are all working with urgency.
    The AMAP succeeded in meeting all of its quick wins, many 
of which I detail in my written testimony. I would like to 
highlight and elaborate on just two of them now.
    We have been very focused on family support. As we analyze 
each aspect of the soldier support, we ask ourselves, ``But 
what about the family?''
    First, we heard concerns about how loved ones were 
supported upon arrival at the airport. In response to those 
concerns, we implemented a program of family escorts whose 
mission is to greet the families at the airport, transport them 
to the hospital, and bring them to the soldier family 
assistance center. There they meet with counselors or chaplains 
and relax a bit before they go to the ward to see their loved 
one for the first time.
    It sounds like a simple thing, but to pull it off required 
some serious bureaucracy-busting. It is absolutely the right 
thing to do, and the families deserve this special treatment.
    Another quick win that seems rather simple but that we 
expect to be of enormous benefit to our families is the trained 
ombudsmen we have assigned to each facility.
    Although all of our facilities have had patient 
representatives for years, they were seen by some of the 
stakeholders as inadequate. We evaluated and agreed it was time 
for a transformation.
    We combined the ombudsman with a patient representative, 
developing an empowered patient advocacy office with a direct 
line to the hospital commander and to me. They no longer sit in 
their offices waiting for a distressed person to find them. 
They are required to get out and meet every warrior-in-
transition and proactively engage family members. They are 
further charged as local bureaucracy busters to implement 
immediate fixes and work every problem through to resolution.
    We will maintain a central database of their case work so 
we can spot trends early and take responsive action. Patient 
advocacy will not be a buzzword in the Army Medical Command. It 
is a required mindset and an ever-present attitude. We are here 
for our patients.
    I want to ensure the Congress that the Army Medical 
Department (AMED) places high priority on caring for these 
warriors-in-transition and their families. I am proud of the 
AMED's efforts over the last four months, and I am convinced 
that, in addition to our quick wins, we are setting the stage 
for long-term solutions that will significantly enhance the 
rehabilitative care and support of our warriors and their 
families.
    Thank you for allowing me to be present at the hearing, and 
thank you for your continued interest and support of the 
warriors and families that we in the Army Medical Department 
are honored to serve.
    I look forward to your questions.
    [The prepared statement of General Pollock can be found in 
the Appendix on page 81.]
    Dr. Snyder. Thank you, General Pollock.
    And this committee likes having Schoomakers around. So, 
General Schoomaker, go ahead.

  STATEMENT OF MAJ. GEN. ERIC B. SCHOOMAKER, COMMANDER, NORTH 
ATLANTIC REGIONAL MEDICAL COMMAND AND WALTER REED ARMY MEDICAL 
                       CENTER, U.S. ARMY

    General Schoomaker. Thank you, sir.
    Mr. Chairman, distinguished members of the subcommittee, 
thank you for this opportunity to address the committee. I am 
speaking today as the commanding general of the North Atlantic 
Regional Medical Command (NARMC), commander of eight hospitals 
and eight clinics in the North Atlantic, to include our premier 
medical center in the North Atlantic, Walter Reed Army Medical 
Center.
    Approximately three months ago, my command sergeant major 
and I stepped into what you have heard described as a perfect 
storm that had affected Walter Reed and really all of Army 
medicine in the Army. My arrival really was the one part of a 
very aggressive plan on the part of the Army and the Army 
Medical Department to track that storm and to wrestle it to the 
ground.
    Since that time, we have been unremitting with the 
incredible support of the Army, the Department of Defense and 
this Congress to solve those problems. We have used Walter Reed 
and its campus to harvest problems really and to seek across 
the Army solutions and best practices and, where those weren't 
available, to create new solutions with the leadership and 
assistance, of course, of my deputy commanding general, Mike 
Tucker, our bureaucracy buster that you have heard described by 
General Pollock.
    Rather than to enumerate all of what is written in my 
statement, I will just highlight a few things that we have 
worked on.
    First of all, almost immediately we moved all of the 
patients that were in Building 18 out of Building 18. No 
patients have been put back in Building 18. I dare say we might 
not have any other patients, soldiers or civilians in Building 
18 until the campus is BRAC'ed and we turn the facility over.
    We have roofed the Building 18 so that our equity is 
conserved, but we have elected not to use that as a domiciliary 
or administrative building.
    Second of all, as you have heard General Pollock describe, 
we have a plan of receiving families at the airport. So just as 
we receive their warrior, sons, daughters, husbands, wives, 
grandchildren, through the Air Force's assistance at Andrews, 
we receive them and bring them to Walter Reed.
    We have a program of sending letters to each of the units 
that these warriors have left back behind. There is a hole 
left, literally and figuratively, in that warfighting unit and 
those commanders and first sergeants. And the squad leaders and 
squad members lose track of where these soldiers are, and they 
need some sense that the system is working for them and that 
their teammate, their comrade has not been lost.
    And so Colonel Terry McKenrick and his staff in the Warrior 
Transition Brigade have already started with the outpatient 
group, and we are moving toward the inpatient population, as 
well, to immediately alert the unit to where their soldier is.
    We have created the Warrior Transition Brigade. This is the 
commander of the first Warrior Transition Brigade at Walter 
Reed, Colonel Terry McKenrick, a combat veteran. And he has 
done a superb job with his command sergeant major, Jeff 
Hartless, in standing up that brigade and really breaking down 
all the boundaries between med hold, med holdover and building 
that triad that you have heard described by the vice and the 
acting surgeon general.
    We have many other things--ombudsmen, patient advocacy, the 
creation of a soldier and family assistance center in the 
hospital--that will be duplicated across the Army.
    Let me focus this on one soldier, though, that some of you 
have heard about before, a soldier that was featured in an 
article on the sixth of April, when he wrote about the problems 
that he had. And I raise him because we have used soldiers like 
him and others to go back and ask the question today: If we had 
what we have going now, would we have the problems or would 
they have encountered the problems that they encountered then?
    This soldier was a mobilized national guardsman from 
Mississippi, a great kid, slow-talking, plain-speaking 
Mississippian who joined the Army because he wanted to do 
something meaningful with his life, became a military police 
(MP), was deployed.
    On one of his trips on the main supply route (MSR) into 
Baghdad, he was hit by an improvised explosive device (IED). It 
took the legs off his driver. He was in the turret as a gunner. 
He was knocked back. It broke his leg, the upper thigh. He also 
had a laceration of one of the major arteries in an arm, and he 
had a traumatic brain injury, a mild form of traumatic brain 
injury.
    He complained about the problems, not with his care--his 
care was excellent, and, as many of our patients, and you have 
heard from families and service members alike, the care he 
received in the hospital was excellent. He got a rod put in his 
leg. He got a repair to his arm.
    But what he had problems with is when he transitioned to 
the outpatient arena in a facility on a campus that has no 
primary care, no robust care for folks like that.
    And we now have the Warrior Transition Brigade, with a 
squad leader, primary care manager and nurse case manager.
    He had problems with a wheelchair. He had a mechanical 
wheelchair, with a broken leg and a bum arm, and we gave him a 
mechanical wheelchair. I am embarrassed. I was humiliated, 
talking to this soldier with my sergeant major, about how we 
could have done something like that. But we didn't have squad 
leaders who could look out for the soldiers. We didn't have a 
case manager who would have identified a big hole in our plan 
for that soldier.
    He complained about the fact that he had mild traumatic 
brain injury, and so he was putting Post-It notes all over his 
room in the Malone House, a great place to live. And he was 
well-supported, but he didn't have a mother with him. His mom, 
a nurse, was down in Mississippi taking care of a husband who 
was dying of Lou Gehrig's disease. So he was alone in a room, 
with mild traumatic brain injury.
    We now have a squad leader and a case manager and primary 
care manager who tracks our soldiers and who is going to be 
able to keep up with their problems, and a primary care manager 
who is going to be trained in managing mild traumatic brain 
injury. So we are not going to have problems unrecognized and 
untreated.
    And he had problems with the personnel system. How could he 
get promoted? How could he get an invitational travel for his 
mom to come and visit when she could? Again, we have a soldier 
and family assistance center in the hospital that handles all 
of those issues, a one-stop shop that is focused on the 
soldier.
    So I like to believe that we have solved his problems. And, 
frankly, Colonel McKenrick and his people have identified 
problems that we never knew existed.
    A soldier who has a large number of boxes and baggage that 
he has to get back home, who is going to pay for his own 
shipment of goods back home? His squad leader jumps on it, 
figures out a way to get the Army to pick that up 
appropriately, and the soldier is on the plane and his boxes 
aren't, and you don't hear about it, and we don't have a 
disgruntled soldier and family on our hands.
    You know, 107 years ago today, an Army major physician 
named Walter Reed started his experiments in Cuba, the 26th of 
June, 1900, to find the cause and transmission of Yellow Fever. 
His studies, which are landmark studies, changed the face of 
America and changed the face of global health.
    His name is associated with military health care of the 
highest order and caring for soldiers and the world population. 
We feel very strongly that we are restoring his name to the 
place it should be in history and that we are here to restore 
the confidence of the American people, the Army, and you in 
what we are doing at Walter Reed.
    Thanks, sir, for the opportunity to speak today.
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 91.]
    Dr. Snyder. Thank you all for being here.
    General Cody, we will start with you, but I would like to 
just briefly go to each one of your team there. You five people 
are remarkable folks. You have risen to high levels of 
leadership within the Army. But like all good people in the 
military, somebody is going to replace you at some point and 
you will be moving on.
    And one of the concerns we have is what is being built into 
this system, that, one or two or three years from now, your 
successors won't somehow be lured off to other topics and that 
the concerns that you are dealing with, very energetically 
dealing with, may not be the same focus of those that come 
after you.
    What are you all and what are your successors going to be 
following to be sure that we don't repeat some of the problems 
that you all are correcting?
    If we could start with you, General Cody, then I would just 
like to hear from each of the four people.
    General Cody. Thank you, Chairman. That is a great question 
and one that, when I started this, you know, my expertise is 
not in this area, but I learn pretty quick.
    When we looked at this, that was the first thing that the 
Secretary and I discussed, as well as when I brought Eric 
Schoomaker in and Gale Pollock. We all sat down.
    The one question--we knew how to fix it very fast, some of 
these things, but our real concern was, how do we make this 
stick and how do we make it enduring? Because we believe that, 
one, it is the right thing to do, but more importantly, we are 
going to be with this all-volunteer force--I believe we are 
going to be in a prolonged struggle for some time.
    That is why we did an executive order and an operations 
order. I can't remember when we have ever sent out a 
headquarters Department of the Army operations order. It has 
been a long time. I will go back and find out when. In fact, we 
can give you one for the record.
    But in doing that, and it was signed by a four-star, this 
thing becomes a requirement for all our two-star generals, our 
three-star, our four-star generals, the Department of the Army 
staff, and it is enduring and it lays out the plan.
    The second piece of it--and so as the G-1 changes out, he 
still has to comply with this. As the new vice chief comes in 
or a new commanding general at Eisenhower or some other place, 
this thing, with 120 of the tasks and purpose, is very 
directive in nature.
    The second piece--and you know this oh-so-well--if you 
don't put money against it, it doesn't become enduring. And so, 
as we laid this out, some of the money clearly up front has 
been done with global war on terror (GWOT) supplemental 
dollars. But in the 2009-2013 Program Objective Memo (POM), we 
are putting in an average--and I have to look on my cards so I 
get it right for the record--an average of $370 million each 
year in the 2009-2013 POM.
    And this will cover the things at different installations 
that we build up for the warrior transition units, the 
operations tempo (OPTEMPO) dollars required, the operations & 
maintenance Army (OMA) dollars required, to cover the salaries 
of the behavioral people that we are contracting out for, as 
well as to take care of the operations of these warrior-in-
transition units and the additional piece that the Army is 
providing for our hospitals and our garrisons.
    In part of that is $168 million right now that we need to 
do in military construction to become Americans with 
Disabilities Act (ADA)-compliant for the warrior-in-transition 
barracks, as well as some other construction that we need to 
put in.
    So that has been our way, Chairman, to make sure that this 
becomes enduring.
    The last thing I will say is the warrior-in-transition 
units have been documented in the Army's personnel structure. 
And so we have a brigade at Walter Reed. Most of the other 
warrior-in-transition units are battalion level and then in the 
smaller posts, camps and stations, they are company level. But 
they are now in our personnel documents and in our Army unit 
documentation. And so, that is another way of doing it to make 
sure it is enduring.
    Dr. Snyder. Does anyone else have any comment on that 
issue? General Tucker or General Pollock?
    General Pollock. Yes, please.
    Dr. Snyder. General Pollock.
    General Pollock. I think that it is very, very important to 
the Army Medical Department to get this right and to sustain it 
because of the concerns that we have for setting the bar for 
the nation, particularly in rehabilitative care.
    Because what we are dealing with now is something that the 
rest of the Nation has never needed to. And should we have to 
deal with any kind of large terrorist events in the United 
States, the same struggles that we had at Walter Reed could be 
repeated anywhere in the country. So if we have figured out the 
best way to manage these men and women and their families, we 
will be able to serve as a resource for the nation.
    The other reason that I believe that we will sustain the 
focus on this is the morale of the Army Medical Department was 
very badly affected by all of this media presentation and the 
awareness that we had let a single soldier down.
    We can't recruit and retain if we are not proud of what we 
do. So it is absolutely essential that we recover from this so 
that we can continue to do what we have an obligation to do in 
support of the warfighter.
    So there is no question, in my mind, that the professionals 
that I work with in the Army Medical Department want to have 
this corrected for the long term.
    Dr. Snyder. Any comment, General Tucker?
    General Tucker. Sir, I will just say that at my level in 
the Army Medical Action Plan, I do a lot of fixing out there in 
terms of people who have been subjected to the former system. 
And every time we fix and we do that very quickly, we 
automatically go into, was that a problem of policy, was it a 
problem of regulation or law, because we need to fix that so we 
don't have this gap that someone else could fall into.
    So I think that is part of the bridging strategy, as well, 
sir, to sustain.
    Dr. Snyder. General Schoomaker.
    Colonel McKenrick.
    General Schoomaker. I think Colonel McKenrick would like to 
describe some of the things that we are doing in the way of 
developing doctrine that is going to be a part of the Army and 
enduring legacy of this work.
    Dr. Snyder. Go ahead, Colonel.
    Colonel McKenrick. Sir, one of the initial charters from 
General Cody was for us to not only stand up this new 
organization and brigade here at Walter Reed, which would be 
the pilot across the Army, but also to write the doctrine, what 
we do, what our mission is, the tasks that we have to 
accomplish on a daily basis for the squad leader, the case 
manager, and then to describe in detail how we do that, put 
those systems, those procedures in a document.
    We have just finished that. Today we are hosting a warrior 
transition unit conference for 150 warrior transition unit 
commanders. First sergeants, battalion commanders, command 
sergeants major from across the Army are here at Walter Reed, 
and we are running them through two days of training on those 
systems and procedures, talking to them about PTSD, TBI, much 
of the training that we did for our own cadre over the last 
three months.
    Now, those are the kind of things make this system 
enduring. The TDA, the table of distribution and allowances, 
the manning document that General Cody referred to, for us, is 
an enduring document. It requires that we have four companies' 
worth of troops on the document. We are only manned and 
authorized for manning for three of those companies. That gives 
us the flexibility to increase capacity for our cadre if that 
is required. And, of course, our goal is that, before I leave 
command, to be able to deactivate, to be able to take that down 
to two companies.
    But that table of distribution and allowances, that 
doctrine, those are the enduring systems that we have in place 
for Walter Reed and for across the Army.
    Dr. Snyder. Mr. Kline, for five minutes.
    Mr. Kline. Thank you, Mr. Chairman.
    Thank you, gentlemen and lady, for being here today.
    Speaking to the morale of the personnel at Walter Reed, 
that was immediately raised to me as a concern when the 
Building 18 issue came up. And I really hated that that 
happened, because nowhere in this process has anyone really 
questioned the extraordinary professionalism and care that 
those professionals, doctors and nurses and medics and 
technicians have provided to the soldiers at Walter Reed, and 
not only the soldiers, the active-duty soldiers, but some of my 
close friends. I am at the age now where a lot of my retiree 
friends are going to Walter Reed for care and getting 
outstanding care.
    And so I think it is important that we remind ourselves and 
those professionals at Walter Reed that they really are world-
class and some would say the best in the world.
    The issue has been around transition, evaluation boards, 
outpatient and all of those sorts of things. And so I have a 
question, and I think it is going to be for Colonel McKenrick 
maybe more, because I am a little bit confused.
    I am very anxious that we do this right, but I have 
listened to the testimony and I have heard words like triad, 
soldier and family transition office, trained, ombudsmen, 
patient representatives, advocacy office, a care manager, a 
Warrior Transition Brigade with subordinate warrior transition 
units. And I am trying to decide or understand what fits where.
    What, Colonel, or to anybody who wants to answer, what is 
the relation of all of this stuff that I just listed? It all 
sounds important and sounds like it is taking care of soldiers, 
but is it all coordinated? Is it all you, Colonel? What is 
that?
    Colonel McKenrick. Sir, I will take the first stab at that, 
and what I don't answer I am sure someone else will help me out 
with.
    It is a coordinated effort, and it starts with that triad 
of warrior support: the squad leader, the case manager, the 
primary care physician. Those three individuals form a network 
that take care of that warrior, their family, any of the needs 
that they have.
    In addition to those are a variety of other systems at 
Walter Reed, around the Army.
    Mr. Kline. Excuse me. Hang onto that thought.
    They do not all work for the Warrior Transition Brigade, 
though, right? You have a physician, he is doing something, and 
you have--who is in charge?
    Colonel McKenrick. Sir, I am in charge, but in my brigade, 
down in my company, I will have a company commander. In his 
company, he will have 12 case managers taking care of his 200 
warriors. He will have 18 squad leaders and 6 platoon sergeants 
all taking care of those warriors. And then he will also have a 
primary care physician that is part of our warrior care clinic.
    So you have got that teamwork down at the company level, 
and that will be throughout the Army, where you have the 
primary care physician, the doctor, working with the nurse case 
manager, working with the squad leader, all there to make sure 
that this soldier, whatever problems they have, they get to 
their appointments, the care plan is set, everybody understands 
the warrior, the family member understands that care plan, have 
a say in it, a vote in it, and we help them through the 
process.
    Mr. Kline. That sounds good. Do they all work for one 
person?
    Colonel McKenrick. Sir, at the company level, those case 
managers work for the company commander. The squad leaders----
    Mr. Kline. And the physician and the nurses, they work for 
somebody else.
    Colonel McKenrick. Sir, they are all in my brigade. They 
all work for me. Ultimately, they work for me. But down at the 
company level, that doctor is working for that company 
commander. All those warriors in that company, that doctor is 
there to take care of them.
    Mr. Kline. Super. And so the advocacy for the patient, for 
the wounded warrior, comes through you.
    Colonel McKenrick. Yes, sir.
    Mr. Kline. If the wounded warrior now enters this morass 
that we discussed with the previous panel of evaluation boards, 
are you the advocate or your organization the advocate?
    What was described in the last panel and which we have 
heard a lot about and I think all of you are very familiar with 
is you have an adversarial relationship between the soldier and 
the evaluators in this board process. And we don't want that 
soldier, Marine, airman, sailor to be out there sort of adrift 
and feel like the system is working against him.
    So it has been my belief that we ought to have a Warrior 
Transition Brigade, or the Marines call it a wounded warrior 
regiment, or somebody who understands that soldier and is the 
advocate and who the soldier knows is their advocate. So when 
they run up against a problem, they are turning to somebody.
    Is that you?
    Colonel McKenrick. Yes, sir, that is us. That is our 
brigade. When the warrior first comes in the hospital and is an 
inpatient, that squad leader and case manager go over and 
introduce themselves. Now, they have a social worker and they 
have doctors and nurses taking care of them in the hospital, 
but our cadre come over and introduce themselves.
    When they become an outpatient, that squad leader is 
interacting daily with that warrior and their family. The case 
manager is meeting them at least weekly to review their care 
plan. The doctor is seeing them for all their needs, referring 
them to specialists.
    When that warrior is going through rehab treatment, that 
squad leader is going up there with them to their appointments, 
motivating them through their rehab.
    When that warrior goes to the review board, their medical 
evaluation board or their physical evaluation board, that squad 
leader goes there with them and talks to them, understands 
their issues and concerns. And that squad leader's job is to 
answer all their questions; if they can't answer them, to go 
find the answer and bring that back to them.
    The same with the family, to help them understand all the 
issues, understand all the questions, and be able to answer 
everything.
    General Schoomaker. I would say, sir, that you have 
identified one of the problems we have had all along, which is 
these are fundamentally, in the private sector, what you would 
call, or the academic sector, what you would call 
multidisciplinary teams, and we would call them combined arms 
teams in our business.
    But we are trying to exercise unity of command and control 
whenever possible to ensure that the soldier, warrior and his 
family, his or her family, are under the care of an accountable 
commander.
    And when those teams are multiple in number that have to 
interact with an individual patient--I mean, you are going to 
have physicians and occupational therapists and physical 
therapists, you are going to have a psychiatrist, 
psychologist--those department chiefs who supervise those 
individual practitioners all fall under the hospital commander, 
and that hospital commander falls under me.
    So ultimately there is unity of command that is going to 
pull all these together. And what we focus upon is what the 
individual warrior-in-transition requires.
    Mr. Kline. Thank you.
    Thank you, Mr. Chairman.
    Dr. Snyder. Ms. Drake, for five minutes.
    Mrs. Drake. Thank you, Mr. Chairman.
    First of all, thank you all for being here, and it is quite 
impressive what you have just described.
    And I have got two questions, but, first, I want to 
comment. Kind of maybe a model is what we hear in Special Ops 
with Navy SEALS, how they assign someone to stay with that 
person for their team member. And yours is kind of a little 
different process, but probably along the same thoughts.
    But from listening to what you have just described to 
Congressman Kline, my first question would be, do we have the 
resources and the manpower to do what you are talking about? Do 
you need more from us? Do you need more from DOD? And how we 
are going to do all of this?
    And then, second, for you, General Cody, is there built 
into all of this a feedback mechanism so someone at your level, 
at the four-star level, would know if there is a problem, that 
our soldiers would be willing to go up that chain of command 
somehow and let you know there is a problem?
    Because typically we see our military members don't want to 
complain, it is not part of who they are. And so I want to make 
sure there is a feedback mechanism, how that would work not 
only for the military member, but also for their families, 
because often they are the ones that see that something is 
going on and they don't know how to get that information to 
you.
    So the two questions on the feedback and on do we have the 
resources and the manpower to do what you have just described.
    General Cody. Thank you for those questions, because I 
think it is important for us to discuss them.
    First, on the resources, this Congress and Office of the 
Secretary of Defense (OSD) has allowed the Army now to, after 
the temporary growth of 30,000, to make it a permanent growth 
of 65,000 to the active-duty force.
    I am taking some of that 65,000 and redirecting it. We were 
taking at a high prior to it and over 2,000 personnel spaces. 
The other piece of the resourcing--and that is just for these 
warrior-in-transition units and I believe they are enduring.
    You heard Colonel McKenrick say that we have got them on 
the tables of distribution and allowances, and that means we 
can resource to it. When we don't have to resource to it based 
upon demand at different places, we can ratchet it back. But we 
always have the authorization document, which means that we put 
on the personnel system that requirement. So we have enough 
resources now with the 65,000 Army to be able to do that.
    The resources in terms of the operational maintenance 
dollars and the Military Personnel (MILPER) dollars we are 
doing with GWOT dollars this year and next year and I am 
putting it into the budget as we build the 2009-2013 program. 
And I believe that, one, with the help of Congress and OSD, we 
will be able to put that much money in. It is about $368 
million to $370 million a year to be able to run at the level 
we are operating at right now, with about 5,000 warriors-in-
transition across our Army on any given day.
    So I believe that we have got the right resources right 
now, and I am watching it closely.
    Now, the feedback mechanism is one that we have established 
with the executive order that we sent out from the Department 
of the Army, with the tasks that I have given to the Department 
of the Army IG to go back and to look at everything that the 
panel before you went out and looked at, as well as what we are 
executing here.
    They have scheduled looks. The medical community have their 
scheduled looks. But at the same time, we have put in these 
soldier and family hotlines, 1-800 number, and we get--those 
command 24/7, being manned, and that is part of the resourcing 
that we did. And so we are getting feedback there.
    We also are training ombudsmen so that they can bring 
forward those issues to us.
    But I firmly believe that the best feedback we are going to 
get is the investment we are making in the training of the 
squad leaders, platoon sergeants and these company commanders 
and first sergeants who are part of that triad of care with the 
case manager, and that is where we are going to get the 
feedback.
    And I am convinced that with the right training that we are 
putting in right now, the selection process of who we are 
putting in these warrior-in-transition units to take care of 
these soldiers, that is where we are going to get most of our 
feedback from.
    Mrs. Drake. Thank you very much.
    Thank you, Mr. Chairman. I yield back.
    Dr. Snyder. Ms. Davis.
    Ms. Davis. Thank you, Mr. Chairman.
    And thank you all very much for tackling what are some very 
difficult issues, and we appreciate that.
    I wanted to go a little further along with the combat 
support arms personnel that you are working with. And my first 
question really was, when I had a better understanding of how 
this triad was coming together, is there something that is not 
being done, because these folks are being recruited and 
actively involved in this way?
    What roles were they performing before and how do you 
recruit them? Some criticism might be that, in that position, 
they might not be as sympathetic perhaps as someone might be. 
And how does the culture that they bring with them from the 
military, how does that interface with the hospital culture?
    General Pollock. I will take that for starters, because we 
tasked from across the Army Medical Department to bring in 
nurse case managers to Walter Reed, which did cause us to 
abruptly take nurses out of other facilities. So we have been 
doing local hires there, and we are looking at how we need to 
assign.
    So the fact that we brought medical/surgical (MED/SURG) 
nurses in from other facilities, they were accustomed to 
dealing with patients and their families. They know how to 
coordinate all of those pieces.
    But it is a challenge for us because we do have a shortage 
of nurses in the Army nurse corps, and so when you need to move 
them, you have second-and third-order effects on other places.
    We are actively recruiting, but with the national nursing 
shortage, we aren't always able to rapidly fill.
    Ms. Davis. I appreciate that, and that is a great concern, 
because we know that that is true in the general sector, as 
well.
    How is that working?
    Colonel McKenrick. Ma'am, I will add to the portion that 
deals with our cadre. They have come in to be the squad leaders 
and platoon sergeants. Many of them are combat veterans. Most 
of them have led in combat. They are used to taking care of 
soldiers, taking care of their fellow comrades. They are 
honored to be selected for this mission to take care of our 
fallen comrades.
    They have all been through training that we conducted when 
they first came on board that taught them how to deal with TBI 
and PTSD and the medications that the warriors are on.
    They are used to training their soldiers to high standards 
of performance in preparation for combat. They have changed 
that focus for this mission to take care at the highest 
standards of care for their warriors and their family members.
    So it is the same energy, the same high level of 
professionalism and competence, but directed in a different way 
toward taking care of those warriors and all their needs.
    Ms. Davis. And they are tapped to do this. Is there a call 
for volunteers, essentially, among the group of people that 
would be eligible?
    Colonel McKenrick. I don't think that most of our cadre 
were--they were assigned this duty, but if you had asked them 
if they could volunteer for this duty, they would have. It is 
an honorable mission.
    Like I said, most of them have been deployed and they enjoy 
the opportunity to provide energy and effort into taking care 
of those who desperately need their help.
    General Schoomaker. Let me put a very resounding 
exclamation point on what Colonel McKenrick is saying.
    Physicians and nurses and administrators in the hospital 
business do not have a corner on the market of caring for 
soldiers. It starts with the young non-commissioned officer 
(NCO) who is caring for his or her soldiers and the officer 
corps that cares for them, as well.
    And I am very impressed with what this Warrior Transition 
Brigade has brought to us and how they have applied their NCO 
and soldier-leading skills to this task. It is part of the 
warrior ethos that we not leave a fallen comrade, and that is 
very clear in Walter Reed today.
    In fact, this might be the best place to insert this. It 
derives from what Congressman Kline said, as well. You list all 
the people who now are lined up to give support to these 
warriors-in-transition. I have now the concern that we have too 
many folks, all, in many respects, beginning to take 
responsibility and accountability for things across all these 
disciplines.
    I would make the very strong plea that we not be 
micromanaged on the individual ratios of folks, so that we have 
some latitude to take experiences and take lessons learned from 
this new enterprise and apply them logically.
    Ms. Davis. I know you certainly recognize the perfect storm 
that our last panel talked about. Just very quickly, and you 
can perhaps answer this at another time, do you think that we 
are truly prepared for that next perfect storm as we see large 
deployments coming back, perhaps not with physical injuries so 
much but certainly with mental health issues and TBI? Do we 
have that transition in place?
    General Cody. I think we do from a leadership aspect. The 
medical piece, I think that there is work to be done research-
wise on PTSD and TBI. And we are aggressively moving forward, 
and with the help of Congress, with the inject of the money for 
TBI research and PTSD, it is very helpful.
    We are going out and chain-teaching right now in the whole 
Army, starting in July, how to look at PTSD and TBI. It was 
started with our AMED and with our other experts. We have got 
it vetted now.
    And, again, reinforcing what General Schoomaker said, this 
is about first sergeants and company commanders teaching their 
leadership and their soldiers what to look for in terms of the 
stressors of combat, how to take care of each other, how to 
recognize whether you have the symptoms of PTSD or TBI, and 
educating our force.
    We are also going to take it to the family members.
    So if we don't do that, I think there is a real part of the 
perfect storm that we would have to catch up on very quickly. 
So we are moving out on that in July.
    The further piece about will we have enough case managers 
and enough behavioral clinicians and some of the other people 
that are my doctors on my left and right are worried about 
hiring, because there is a national shortage of them, I think 
it is something that we are all going to have to work toward.
    And I would defer to General Pollock and General Schoomaker 
to talk to you about that piece.
    General Schoomaker. Well, I would just say real quickly I 
think that one of--I can't answer your question, because I 
don't have that crystal ball. I will tell you, as General 
Pollock has alluded to and General Tucker and the Vice, that we 
are putting in place processes that will be there, that will be 
enduring and that are addressing the right questions and the 
right needs once they do arise.
    One important one that we haven't talked about, but the 
first panel did, was our interagency handoffs between the DOD 
and the VA, for example. We have a very large capacity in this 
nation to respond to health threats and health requirements. 
And I think one thing that we are beginning to do far better 
than we have ever done in my career in the Army is to begin 
this discussion in battle handoff with the VA and with other 
elements of the private sector, for example, in rehabilitative 
medicine.
    Those are the things that we need to do, and do far better 
than we have done historically, and I think those processes are 
being established.
    Dr. Snyder. Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you very much.
    Major General Pollock, I would like to start with you, 
please. I remember in March you came before us and had a 
discussion about efficiency wedges, and I would appreciate if 
you would give us an update, the impact that these were having 
and what you see as problems that are fixable versus we are 
stuck in for the while.
    General Pollock. Thank you.
    Congress did come back and support us. So the Department of 
Defense received $200 million to refund the efficiency wedge, 
for which I am very grateful, because in fiscal year 2008, my 
efficiency wedge was $142 million, which is equivalent to a 
large facility like Fort Hood.
    So in the short term, because Congress has basically funded 
what we hadn't had funded, we are okay in the short term. But 
it is something that we need to stay attuned to as we move 
forward.
    So thank you very much for that support.
    Ms. Shea-Porter. Thank you.
    But could you tell us what will happen, what you 
anticipate? Because we are going to continue to see more 
soldiers, as you know, coming and requiring these services and 
more problems inside the personnel system. What do you forecast 
for us, if you want to just tell us what we need to know in 
four years, in six years?
    General Pollock. I think one of our shortage areas that 
will be a challenge for us to fill will be behavioral health.
    The good news, when we look at behavioral health, though, 
is we know so much more now than we did immediately after 
Vietnam. Now, we know that there are certain symptoms that are 
very, very normal for people to display after being in the 
stress of combat, being stressed by a traumatic event, where 
they potentially could have lost their lives or they saw others 
lose their lives. Those symptoms are very normal for us as 
human beings and the majority of us will work through them, but 
we almost need permission to know that the thoughts and the 
emotions that we are having are normal.
    Then, as we give people permission to have those 
experiences, to admit those experiences, it increases the 
likelihood that they will work through the symptoms and it will 
not develop into a full-blown disorder like we have seen so 
many people from Vietnam suffer.
    So we are very hopeful that with the changes in therapy, 
with a recognition of symptoms, we will be able to prevent that 
onslaught of all of these disabled people that we keep hearing 
about, because we think that we know enough now that we are 
going to be able to reduce a significant amount of that.
    We won't prevent it all, because we don't all have the 
resiliency and the coping mechanisms that we need sometimes to 
get through things, but I think that, with what we know, we are 
going to really make a lot of progress in that.
    And then, again, as I mentioned before, there are certain 
areas that we will step out and lead the nation. And I think as 
we start to destroy the stigma that is associated with asking 
for and receiving behavioral health, we are going to make 
inroads into the concerns for depression, which are now 
predicted to be the leading cause of illness and lost time by 
2010 for our nation.
    Ms. Shea-Porter. Thank you very much.
    And, Major General Schoomaker, could you please tell me, 
what are the records like at this point and the communication 
records between the VA and the active-duty military, DOD?
    My understanding is that they still have some problems, 
soldiers accessing their records and the different people 
involved in the case being able to have instant access to 
records. How are we doing there?
    General Schoomaker. Well, I mean, for the movement of 
patients into the four polytrauma centers for the VA--in Tampa, 
in Richmond, in Palo Alto and in Minneapolis--that is going 
extremely well. In fact, I think the latest is to try to move 
very large digital records of scans and the like. But routine 
records I think has been moving now fairly easily.
    There has been a project in place to move bidirectional 
flow of digital information from the VA into the DOD's 
electronic health record. We have a system called Armed Forces 
Health Longitudinal Technology Application (AHLTA), they have a 
system called Vista, and there is a bidirectional flow.
    I believe by the end of summer, ma'am, is that correct?
    General Pollock. The TMA, the TRICARE Management Activity, 
is telling us that by the first of October, all of our 
facilities will have access to the bidirectional health 
information exchange.
    Ms. Shea-Porter. Thank you very much. I am happy to hear 
that.
    Dr. Snyder. Mr. Wilson.
    Mr. Wilson. Thank you, Mr. Chairman.
    And I would like to thank all of you for your service, 
Generals and Colonel, here today.
    The reason I stayed in the National Guard of South Carolina 
for 31 years, and the Army Reserves too, is because the people 
that I served with I felt were the most competent, capable and 
patriotic people I know.
    And so I just want to thank you for your service and I know 
your passion and commitment for our wounded warriors and for 
their families.
    I have the perspective, I have visited the field hospital 
in Baghdad. I have been to Landstuhl, I have been to Bethesda, 
I have been to Walter Reed. The people that you have working 
with you I believe are just extraordinarily capable. And with 
your leadership, the changes that needed to be made after 
identifying Building 18 I think can be made.
    I also have the perspective and appreciation for what you 
are doing because I have three sons in the Army National Guard 
who could be in your care, and I have faith that in your care 
they would do well.
    I also have the perspective of another son who is a 
Uniformed Services University of Health Sciences (USUHS) 
graduate, who is currently a doctor in the Navy. And so I learn 
firsthand from him of the commitment and dedication of the 
military medical professionals.
    General Cody, could you explain how the Army will evaluate 
the success or failure of the Army Medical Action Plan?
    General Cody. As I said earlier, Congressman, one of the 
things that we have set in place with the executive order that 
went out, we also put in an inspection program with the 
Department of the Army IG, as well as internal to each one of 
the military medical treatment facilities. They have their own 
internal inspections. All of this is reportable back up to the 
Department of the Army.
    And what we are going to do right now, because we just put 
it out--and it is a five-page program. In January of 2008 is 
when we hit phase five. In stride with that, the teams will go 
back out to look at each one of the medical treatment 
facilities.
    I am personally going out and looking at 18 of the largest 
ones. I start here next week. I have had General Tucker out. 
And I carry with me the action plan. And then each place--and I 
am hesitant to say which ones I am going to, because three of 
them are surprises, and they will sit down and tell me where 
they are.
    And so we have a pretty aggressive feedback and inspection 
program. Clearly, we have to change the inspection program of 
the Department of the Army IG, as well as General Pollock's 
leadership in the AMED, they have to change their inspection, 
because we have 120 items that we are looking across the board 
at.
    So that is how we are tackling it, and I feel pretty 
confident that we will get it right.
    Mr. Wilson. And, General Tucker, I appreciate that General 
Pollock has identified you as the bureaucracy buster. I can't 
imagine a more difficult job. And indeed I know it was with 
great intent the Med hold units, but it didn't seem to work. 
And so I am very hopeful that your efforts, according to the 
Army Medical Action Plan, that you have been appointed by 
General Cody, that has been identified as the action officer.
    And in this position, do you feel that you have the 
necessary resources and manpower to get the job done 
successfully? Are there changes to the Army or DOD policies or 
legislative authority that may help you succeed in your 
mission?
    General Tucker. Sir, without question, I have all those 
things. I have been given enormous authority by the Army 
leadership.
    And I can tell you that in my travels--I have gone to eight 
different installations, and I have briefed all over the 
Pentagon--I foresee no pushback from any person at all. They 
welcome all these changes, as dynamic as they are. We are 
bending some pretty thick metal here in the Army.
    I think it is just testimony to the warrior transition 
company itself, the baseline organization.
    Just to give you a comparison, sir, before, this 
organization was manned with nine members in its cadre. Today 
that is 39. So that gives you an appreciation that a 75 percent 
increase in leader-to-led ratio.
    And when the Army commits to something, we put boots on the 
ground. And, sir, this is putting boots on the ground in a big 
way across our entire Army, and I think it is going to serve us 
well.
    Mr. Wilson. As I conclude, again, I want to thank you for 
your service and as a Member of Congress, as a parent, as a 
fellow veteran, just thank you for what you have done and what 
you will be doing in the future for our wounded warriors.
    Thank you. God bless you.
    General Tucker. Thank you, sir.
    General Cody. Thank you, sir. And, by the way, you know, at 
least three of your sons got it right. And we are just as proud 
of Hunter, who just joined Reserve Office Training Corps 
(ROTC). So we look forward to getting him in our ranks.
    Dr. Snyder. I have a 13-month-old son, but he has not 
expressed any interest yet, General Cody. [Laughter.]
    General Cody. I still may be around, so I might be able to 
influence him. [Laughter.]
    Dr. Snyder. General Clark lives just down the street from 
us, so he has been trying to indoctrinate him in West Point. 
[Laughter.]
    I don't know if other members will have many questions, but 
we are going to go ahead and start a second round.
    A quick question, Colonel McKenrick, for you, before I go 
back to General Cody. Your unit is an integrated unit of both 
reserve component and active component and both guard and 
reserve.
    Have you had any issues dealing with the fact that you have 
got a bunch of people that are working under different 
personnel policies and promotion policies? Has that been an 
issue for you or has that all gone very smoothly?
    Colonel McKenrick. Sir, that has been a challenge for us. 
We recognized early on the need, when we integrated those, to 
make sure that we had expertise in each one of our units, each 
one of our warrior transition companies.
    Dr. Snyder. Personnel expertise?
    Colonel McKenrick. Yes, sir. Personnel, promotions 
policies, pay policies, all those issues that are different 
between the different components of the service.
    So we currently have one expert that we have got working in 
a cell that we are going to establish at brigade, put down in 
amongst those companies. We have got, at Human Resources 
Command (HRC), some paperwork to pull in a second person. And 
we are working an initiative to get a third, so that we have 
three personnel that are national guard-reserve experts that 
focus on the very difficult orders process that deals with 
national guard and reservists and the pay and promotions and 
other personnel issues.
    So it is a challenge for us that we currently have one 
person. We need to get two more, and we are working that 
aggressively.
    Dr. Snyder. General Cody, I am not a big one for rehashing 
old history, but I wanted to ask a lessons-learned question, if 
I might, because I know when you first heard about this, you 
were very concerned about it.
    I guess when I first read The Washington Post story, I 
first heard about all the details that were in the story, I 
thought back. If I was Ike Skelton, I would be able to tell you 
the name of the general, but it was one of Ulysses Grant's 
predecessors, in his capacity, who was quite an old man at the 
time, but they would find him in the middle of the night, when 
all the troops were sleeping, going tent to tent, opening 
flaps, making sure people actually were on dry ground, that 
they had their clothes dried out. He was kind of old-timey, ``I 
am going to take care of my troops, even if they don't want to 
be taken care of'' kind of soldier.
    And it seemed to me that--my question is in terms of 
lessons learned. It seemed to me that somebody wasn't doing 
that, that somebody should have been going, at a high level of 
rank, door to door, room to room, talking to people, looking in 
the showers and that kind of thing.
    Has this created any apprehension amongst you in other 
areas other than medical that maybe there is not that kind of 
attitude about leadership? I mean, do we have people out there 
sticking their head in the boiler room, sticking their head in 
the air conditioning rooms at all these different facilities?
    What have been your thoughts about that? Because I know you 
were very concerned when you first heard about this in terms of 
the leadership.
    General Cody. Clearly, my biggest angst was the fact that 
this should not have happened. It was a failure of leadership, 
and, as you know, we relieved a lot of people and we moved 
people out, and we quickly--my assessment up front was we 
didn't have people going to each one of those rooms.
    I went through each one of those rooms at Building 18, but, 
quite frankly, there should have been lieutenant colonels and 
majors and captains and sergeant majors and other people 
checking those things out.
    We have asked that question, is this indicative of an Army 
that is stretched pretty thin by repetitive combat tours and 
everything else? What I am seeing outside of that in our combat 
units is not the same. We have got very, very good, engaged 
leadership.
    The decision that we made four years ago that company, 
battalion and brigade and division commanders and their 
sergeant majors and first sergeants would train a unit up 
during the reset period, build the team, deploy with that team 
to combat and stay in command positions and bring them home was 
a pretty smart thing that we did, unlike what we did during 
Vietnam, where you could have three company commanders in one 
tour or three battalion commanders in one tour.
    And so when the units come back, you have got a well-rested 
first sergeant--well, maybe not first sergeant, but a well-
rested new company commander getting ready to take command, a 
battalion commander and a brigade commander. And the handoff 
between those commanders and the lessons learned are being 
passed very, very aggressively.
    Plus, our two-star commanders I have great trust and 
confidence in, and our two-star sergeant majors. They all know 
that they have to pay very, very close attention and walk 
around into the barracks, walk around into the motor pools, 
because they only have 12 months to reset that outfit, assess 
their leaders, build the team, get the training done, and then 
they are going right into combat.
    So that is happening.
    The failure at Walter Reed at Building 18 was just an 
unfortunate failure of people being--I don't want to say out of 
sight, out of mind, but they were across the street.
    We did not resource the AMED at Walter Reed with the ratios 
that you just heard Mike Tucker talk about. They were forced to 
take it out of clinics. They were taking medical NCOs and other 
people. So they were doing double jobs, and, quite frankly, it 
caught up to us. They went from 300 to 400 to 500 to 600 
outpatients. But some leader should have caught it, and it is 
unfortunate.
    But the net result of all of this is we have revamped 
everything, and I feel very, very confident that the young men 
and women that we have asked to go, over 2,000 of them that we 
will build into these warrior transition units, the care that 
our soldiers and the families get is going to be wonderful. And 
it is going to be what you and I would want for our son or 
daughter, and America will be proud of it.
    It is unfortunate that it took Building 18 for us to get 
there, but I see something good coming out of this. And so I am 
committed, as all the other people here.
    But more importantly, the question you asked, are our 
commanders below us cognizant, and the answer is yes. And I 
feel pretty good about it, but we will continue to check.
    Dr. Snyder. Mr. Kline.
    Mr. Kline. Thank you, Mr. Chairman.
    Colonel McKenrick, I want to echo some of the thoughts and 
comments that the chairman made, having to do with personnel 
issues. That seems to be at the heart of the problem. What are 
the policies? Not only for guard and reserve and active, but 
you have to somebody who really knows that. So I would 
encourage the Army and you to work hard to make sure you have 
got people with the requisite skills.
    A quick question for you: Who signs your Officer Evaluation 
Report (OER)?
    Colonel McKenrick. Sir, I work for General Tucker as the 
deputy commanding general for North Atlantic Regional Medical 
Command (NARMC), and my senior rater is General Schoomaker.
    Mr. Kline. Okay, great, good idea. Thanks. It is amazing. 
That was the right answer to the question.
    I want to go back to something that I raised very briefly 
with the earlier panel, and realized I was probably talking to 
the wrong people, but there was a finding in their report that 
says, ``Walter Reed Army Medical Center and National Naval 
Medical Center staff members, especially those in the nursing 
field, are showing signs of compassion fatigue.''
    And so I want to ask you probably, General Pollock, General 
Schoomaker, and perhaps Colonel Horoho, hiding in the back 
there, if you agree with that, and if so, what you are doing 
about it.
    General Pollock. I will change hats here and put on the 
chief of the Army nurse corps hat.
    And, yes, they are absolutely struggling. Unfortunately, 
the Army has not made mission for the Army nurse corps since 
1999, and each year our junior officers are fewer and fewer. As 
a result, we are asking them, as the junior officers, to do 
more and more work.
    And, unfortunately, when there is a civilian nursing 
shortage and you either can't fill your general schedule (GS) 
positions or the contractors don't come to work, and the 
civilians have the option of refusing over time, who do you 
turn to to provide care? It is the military nurse.
    They are also the same nurses that deploy. So we put them 
in a combat environment for a year, and then we come back and 
we work them perhaps harder than they were working in a combat 
theater.
    Mr. Kline. So, if I can interrupt, this isn't just a 
matter, as the recommendation and the findings say, a formal 
study of stress, immediate action, provide stress reduction 
programs for all personnel, that is maybe a decent idea, but 
that is not at the heart of the problem.
    You have got a resource and personnel problem, is that 
right?
    General Pollock. Correct, sir. And Colonel Horoho has done 
a fabulous job working with some compassion fatigue and stress 
management initiatives at Walter Reed, but the cause of the 
problem is the nursing shortage and our inability right now to 
bring those nurses into the military.
    Mr. Kline. Well, as I have said before, we are doing our 
part in our family. My niece is an Army nurse down in San 
Antonio right now. My wife is a retired Army nurse. I try to 
keep this information from her, because she is going to have 
this desire to run back and put the uniform back on again. So 
don't even go there. [Laughter.]
    General Pollock. Well, we would welcome that, sir.
    Mr. Kline. I am afraid that would be the case. So we will 
keep this little secret.
    General Pollock. Because if we could each attract one, sir, 
we wouldn't have a nursing shortage.
    General Schoomaker. Sir, if I could make one comment.
    Mr. Kline. Yes, General?
    General Schoomaker. Because like General Pollock, I served 
as the chief of the Army Medical Corps until last October for 
four years. And I have thought about that phrase and that 
notion that we are suffering from compassion fatigue for some 
time, and I have asked people to help me understand better what 
that means. Because, frankly, most people, as you know from 
your wife, go into medicine and nursing knowing that they are 
going to see a lot of human misery and they are going to see 
suffering.
    Frankly, we also get reports from people who have even 
deployed to the theater of operation that this is some of the 
most rewarding work they have ever performed in uniform, and 
they seek opportunities to go out again and take care of these 
soldiers.
    So what exactly are we talking about when we talk about 
compassion fatigue?
    I think what I hear most people talk about is the fatigue 
not of taking care of the most severely injured and most 
challenging patients, it is the fatigue of a system that 
doesn't allow us to transfer records to the VA very 
successfully, a system that puts a physician or a nurse in a 
position of being an adversary of a patient they are trying to 
take care of. Because why? The patient is frustrated with a 
physical disability and evaluation system that the physician or 
the nurse has no control over.
    Mr. Kline. So you don't see a lack of compassion as the----
    General Schoomaker. Absolutely.
    Mr. Kline. What I found striking, I guess that is what had 
me going down this road, is I was just struck that they said 
there is compassion fatigue. I can understand where fatigue 
would wear on you and perhaps you would be a little bit sharper 
in your response or something, but I was having difficulty 
understanding how they concluded that this was compassion 
fatigue.
    General Schoomaker. I think it is bureaucracy fatigue.
    General Cody. Absolutely. That is why we took on the 
bureaucracy first. I echo what General Schoomaker said. I have 
gone out and talked to these doctors at the caches that had 
second tours or third tours. I have talked to them up on the 
intensive care units (ICU), the nurses.
    I agree with General Pollock that we have a nurse shortage. 
We need to fix it. But everywhere I go, it is not one of not 
wanting to take care of and not wanting to do the best in terms 
of compassionate care of our soldiers. The frustration is with 
our bureaucracy, our system, and, in some cases, our personnel 
assignments, and, in some cases, it is the OPTEMPO.
    But when you put a nurse or when you put a doctor with a 
patient or a family, you don't see that. What frustrates them 
has been the bureaucracy and that is, quite frankly, what we 
have tackled.
    Mr. Kline. Thank you.
    Colonel Horoho, I didn't mean to single you out back there, 
but congratulations on the command, as well. Did you have 
something?
    Colonel Horoho. Thank you, sir, very much.
    All of our clinicians, I would say, remain extremely 
compassionate when they are providing care. And they are 
providing care 24/7 to all of our warriors and their 
beneficiaries. We as a command have worked very, very hard.
    We just got approval to be able to put in a retention bonus 
so that we can retain those quality nurses that have been 
providing care for the last several years at Walter Reed.
    We have also been working very aggressively with the 
intercardiac health promotion program, to work with a stress-
reduction program, to provide not only for our nurses but all 
of our health-care providers, because it is not just taking 
care of our warriors, but there are multiple stresses in 
people's daily lives. So we want to keep them all very, very 
healthy.
    We have also gotten approval to be able to fund the 100 
unfilled positions that we had, so that we can recruit and be 
much more competitive as we are competing with all the 
hospitals in the Washington, D.C. area.
    Mr. Kline. Thank you.
    And thank you for your indulgence, Mr. Chairman. I do think 
that is something that we as a Congress and we as a committee 
need to continue to look at, those items like retention bonuses 
and things to fill that shortage, because we have heard it 
continually in this vein.
    I yield back.
    Dr. Snyder. Mr. Kildee tells me it was General Winfield 
Scott. It was a Civil War general that I knew you all wanted to 
know that I couldn't remember.
    Ms. Davis.
    Ms. Davis. Thank you, Mr. Chairman.
    And I certainly look forward to working with all of you.
    What is a fair amount of time for us to try and go back and 
evaluate the system that has now been put in place?
    General Cody. I think, ma'am, I will take it first.
    We are in phase two of our five-phase plan. I think you 
ought to ask us back probably October-November timeframe, and 
then we ought to be called back probably in February, right 
after the State of the Union and other things get out of the 
way. We will be pretty much closure on execution of phase five. 
Those are the timelines.
    So I think somewhere in the fall, and then bring us back in 
here right after the first of the year.
    Ms. Davis. Thank you.
    General Cody. Because we are going to continue to go out 
and measure. There will be some changes. If we have any drastic 
changes, we go out there and find something that we had not 
been able--or we didn't anticipate, clearly, we will transmit 
that to you all. But I think those two timeframes.
    Mike, what do you think?
    General Tucker. Yes, sir, I agree 100 percent. We have got 
a good glide path. We are being resourced as we should be to 
facilitate and set the conditions for this plan to be 
successful and, like General Cody said, along those timelines 
October and then again in February. February, we see ourselves 
as wheels up, air speed and altitude, gaining momentum.
    General Pollock. The other piece that I will add to that is 
each of the tasks that we have identified for the AMAP is 
actually listed on a scoreboard for me so that I can constantly 
monitor it. So once a week, they do an update for me that 
identifies whether anything has changed. So if there is a 
change, say, an amber has gone to green, then I get a little 
thumbs-up next to it so I know that it is a recent change.
    But we are monitoring that very carefully, because I want 
to make sure that because we fix this piece, that one doesn't 
then break. So we have oversight of the entire process.
    So I am comfortable saying that we can move forward.
    Ms. Davis. Thank you.
    While you are all here, I know we are trying to get a 
handle on the evaluation systems so that people are fairly 
compensated for their injuries, for their disabilities, as they 
transition.
    And I know, General, that you have asked the judge 
advocates to help with some of that transition. Is that a large 
enough effort that we would be able to see some suggestions, I 
guess, coming out of that?
    What I am trying to determine is, is this a system that 
really needs a whole overhaul? Is it built on the idea that 
somehow people are going to try and fraud the system, as 
opposed to seeking reasonable compensation from it? And can we 
learn from the judge advocates, if they are working?
    Is there a way out there, is there a mechanism that we can 
begin to perhaps have good information and move forward with 
this over the next, I would hope, two years?
    General Cody. I think, one, we understand now where the 
friction points are. We are talking about the physical 
disability evaluation system.
    Before the war started, ma'am, we averaged about 6,000 
cases a year. I think we are averaging now about 12,000, which 
tells you that we need to--we should have been a little bit 
quicker in responding to that case load, that plus the amount 
of wounded that we have had in this war.
    We have gone back and looked at the MEB and the PEB 
process. We have identified the liaison officer (LNO) as the 
clutching mechanism and a crucial part of that for the soldier, 
and we are training those people.
    We also looked at extensively the legislative changes that 
we needed to pass through Congress and say we and the OSD--now, 
I am part of the steering committee at OSD that meets once a 
week with the Veterans Administration, led by Secretary Gordon 
England and the deputy of the VA. We have put five or six now 
recommended changes that will help eliminate that friction 
point and, to your point, the issue of having a soldier almost 
have to ask for something that we should give them as a country 
anyways.
    And right now, I think some of the laws are such that, with 
minor changes, we could eliminate that friction point, and the 
Physical Disability Evaluation System (PDES) and the movement 
through adjudication would be much, much smoother.
    But we have created a situation in some cases, especially 
with our national guard soldiers and our reserve soldiers, 
where, quite frankly, with a law change, this will all go away.
    Ms. Davis. I look forward to working with you on that. 
Thank you very much.
    Thank you, Mr. Chairman.
    Dr. Snyder. Mr. Wilson.
    Mr. Wilson. Thank you, Mr. Chairman.
    General Schoomaker, the Independent Review Group reported a 
finding that the philosophical and operational differences 
between Walter Reed Army Medical Center and the National Naval 
Medical Center are hampering the efforts to transition to the 
Walter Reed National Military Medical Center, as required by 
the BRAC decision.
    It is further reported that the leadership and personnel 
time devoted to planning the integration of clinical services 
have detracted from the time required to manage the medical 
center.
    How are you addressing these issues today? What are your 
views on the IRG's recommendation for a general or flag officer 
to be placed in charge of the transition team?
    General Schoomaker. Well, sir, first of all, I would have 
to concur with the group that there are within the national 
capital area, where you are talking about two medical centers 
operating in a somewhat coordinated fashion, but in two 
different locations, in two different somewhat distinct 
cultures, I would have to agree that that is occurring today.
    But I want to make clear that I am not trying to throw 
stones at the Navy here. The Navy has a different culture about 
how and a different process by which they manage severely 
injured Marines, largely Marines. They do it in a decentralized 
fashion. They do not keep them at the National Naval Medical 
Center Bethesda. They try to get them back to Camp Lejeune or 
Camp Pendleton, close to their units and close to civilian or 
the VA system, and they are much more rapid in moving that way.
    On the other hand, the Army, with a larger burden of these 
severely injured soldiers, especially amputees and more 
severely brain injured soldiers, tends to keep them at Walter 
Reed.
    We have created, for all intents and purposes, what we lost 
after Vietnam, which is a rehabilitative medicine capability. 
We have moved toward a civilian model of acute inpatient 
medicine and ambulatory care and no intermediate rehab service.
    We have now built, for all intents and purposes, de facto, 
a stepped-down rehab center, called the Malone House. It was 
never designed to be that, but that is what it effectively does 
for families and soldiers.
    And we keep them together because we in the Army have 
adopted a very aggressive ethos of maintaining and retaining as 
many of those soldiers as possible. We are now returning 20 
percent of our amputees to active duty. That is about five 
times higher than we have historically. We now have soldiers 
fighting--we have at least one soldier fighting with a 
prosthesis in Afghanistan today. That is a very strong part of 
our ethos and our ambition.
    Frankly, I think the future Warrior Transition Brigades and 
companies and battalions will contain as a part of their cadre 
soldiers who are severely injured and are fully recovered and 
returned to duty.
    So what we are trying to do is move these two cultures 
together in a way that involves also the VA system, so that we 
more rapidly and proactively identify who is going to return to 
duty and we ought to keep on campus and keep in active 
rehabilitative medicine programs and research, and who ought to 
be transitioned more rapidly to the VA system and to home care, 
and that has got to be a part of that blending.
    As far as the overarching command and control, I think our 
vice has worked out with the vice chief of staff of the Navy a 
method by which that transition will take place.
    Mr. Wilson. And, indeed, I am glad you brought up about 
assisting persons to return to duty.
    Last week, I had the extraordinary opportunity--a hero of 
mine is Major David Roselle, and so I had the great privilege 
and opportunity to host them for a tour of the Capitol. What a 
wonderful young fellow he is and his wife, Kim, and their 
children, two little guys, Jackson and Forrest. What a role 
model that he has been. It was just chilling to see, again, the 
quality of the young people serving in the military of the 
United States.
    General Cody, as a former member of the national guard, I 
was interested as you pointed out that the wounded warriors, 
say, who return to a base, as General Schoomaker mentioned, the 
Marines returning to their bases--and I appreciate that there 
is not being a difference between serving guard members and 
active duty.
    But what type of coordination is there of Guard members who 
return home with their adjutant general, their state adjutant 
general? Are they kept informed of their release, of their 
return to home state? How is that handled?
    General Cody. First off, they stay on active duty. Clearly, 
their unit, as I think General Schoomaker may have said, or 
Colonel McKenrick, when a soldier arrives into a warrior 
training unit, they have an aggressive program to notify the 
unit that your warrior is here.
    In the case of national guard units, the The Adjutant 
General (TAG) is notified. But that soldier is still on active 
duty as he goes through that care. And then when you talk about 
transitioning back either in a still active-duty status while 
he is rehabilitating, he could go to a civilian health-care 
organization. At that time, the handoff, he still has that 
triad of care of a squad leader who is assigned and a case 
manager and his unit is notified.
    Now, if his unit is deployed, like with the Minnesota Guard 
right now, they have their own rear detachment that takes care 
of that. So it is a little bit different, but the concept is 
the same.
    But the most important thing is we don't discharge them 
from active duty until we are assured that we have got that 
young soldier on the right path, either returned to full duty; 
if he has to be medically retired, he is so or she is so. But 
we make sure of that handoff, or go through a handoff to the 
veterans hospital.
    So it is a little different, but the safety nets are still 
there.
    And I would ask General Tucker, he just went through this 
going out there, he could probably give you a couple anecdotes 
of how it is working.
    General Tucker. Sir, we have LNOs from the national guard 
at our medical treatment facilities, and they immediately hook 
up arm-in-arm with these warriors as they come back. And so 
they are with them as one of their national guard brothers to 
help them through that process and link them back to their unit 
and all their needs and specific requirements that they have, 
sir.
    Mr. Wilson. Again, thank you for what you are doing for our 
troops and their families.
    Dr. Snyder. I had two final questions I wanted to ask.
    General Tucker, you mentioned earlier this afternoon that 
when you have a soldier that has a specific problem, that you 
get together with the soldier, your folks do, and get the 
problem resolved fairly quickly.
    In the course of doing that, do you run across things that 
you think, ``You know, that really ought to be a statutory 
change. I need to let somebody know in the Armed Services 
Committee that we have got a problem with statute?'' Is that 
something that you all have your feelers out for?
    Because we are certainly aware that we can be part of the 
problem.
    General Tucker. Sir, absolutely. The Army has provided me--
when I said they give me pretty good latitude, they allow me to 
build a team. So I have a team of about 22 personnel that work 
up here at Skyline up at Falls Church. And, sir, I have 
expertise in there from all the branches of the Army and some 
of the levels within the VA.
    And so when we see those things, we quickly begin to crack 
the nut as to, at what level does this problem reside? Can we 
fix it within the MEDCOM, or is it an Army problem, or is it a 
DOD problem or a VA problem or legislative problem?
    And we have got a pretty good battle drill that we get 
things channeled into the right venues, sir, so that they get 
addressed rapidly.
    Dr. Snyder. I hope all of you will feel free to let us know 
if you think that there are things that we need to do 
differently.
    My last question, General Pollock, we have had complaints 
at some point recently from M.D. types that are saying that 
there is variation from specialty to specialty in the length of 
deployments overseas, and it is creating some heartburn amongst 
folks, that they feel that they are not being treated fairly.
    Is that an issue that you are familiar with? Is that an 
accurate----
    General Pollock. Yes, it is, sir. It is an area I am 
familiar with, and it is an area that I am working with the 
Army now because the deployment strain on the Medical 
Department, because we are not as large as we need to be, in 
support of a long war, in support of a growing Army. The Army 
G-3 and the Army G-1 are working with me on both deployment 
issues and the size of the force.
    Dr. Snyder. But the specific issue that certain specialties 
of physicians are treated differently because of their--you 
have need for----
    General Pollock. Yes, sir. We currently have a group of 13 
specialties that do a 6-month deployment, and that had to do 
with how small and how intense the demand would be on that 
specialty.
    We would not have been able to provide them what is now 
called an adequate dwell time at all. So by decreasing the 
deployment period compared to the rest of the group, we were 
able to do a better job at retaining them so that it didn't get 
worse.
    But we are looking at some modifications so that there 
would be more equity across the system.
    Thank you.
    Dr. Snyder. Mr. Kline, anything further?
    Mr. Wilson, anything further?
    Yes, General Cody, did you have a final comment?
    General Cody. Chairman, to get to your point that you asked 
General Tucker, Congress has been very, very good here in the 
last year, two years, assisting us with any type of 
legislation. And Mike Tucker and General Pollock and General 
Schoomaker and the rest of the people working this have gotten 
with our legislative people and gotten with OSD, and we are 
putting some of those things forward.
    I would like to comment, though, that there are significant 
medical provisions in H.R. 1585. And I have scanned through it, 
I have had my staff look at it, and we think this is absolutely 
the right direction to go on many of the items in H.R. 1585.
    However, there are some things in there that would cause 
more bureaucracy for us. I will just be honest with you.
    One of them is prescribing ratios. You have heard Colonel 
McKenrick today and you have heard General Tucker talk about, 
listen, we know how to do this, and it would not be helpful if 
you prescribe ratios, and it may become bureaucratic as we 
wrestle through 37 warrior transition units to get them up to 
speed. Now you make it law, and that could be problematic for 
us.
    So I would ask your indulgence, if we could help by 
commenting on how that particular section should be written.
    Another one that may cause us problems is congressional 
notification. The phrase is in there for congressional 
notification. We clearly, as an Army, want to let every one of 
the elected officials know exactly when a wounded warrior is 
wounded, where he or she is going to be taken care of. But, 
again, making it law and making it very prescriptive may 
require us to have another bureaucracy, and I worry about some 
of the specificity there.
    And so I would ask your indulgence as we comment back on 
H.R. 1585. The rest of it is fine, and there is a lot of great 
things in there about the efficiency wedges and pre-and post-
deployment cognitive assessments, and all those things are all 
moving in the right direction. But I just worry sometimes about 
being too prescriptive and it becomes law.
    Dr. Snyder. I share your concerns. We in Congress, with 
good intention, can certainly create problems. We are very much 
aware of that.
    On the other hand, with regard to those two issues, if you 
and I had had a conversation a year ago about how do you think 
the ratios are at Walter Reed, you would have told me you 
thought they were about right, and it clearly turned out that 
they were not right.
    And so what you are seeing is, when we drafted that, and I 
had a role in drafting that legislation----
    General Cody. Unfortunately, I would have said two years 
ago I don't know, I will have to get back to you, because I 
didn't know, which is another problem.
    Dr. Snyder. I think things clearly are moving in the right 
direction.
    The issue of notification came about. That has been a 
frustration for Congress. And we had this discussion, both at 
the member and staff level, at length, because if the 
notification issue language had been different under law, so 
that we would actually know in a timely fashion when someone 
from our district ends up at one of these facilities or has a 
severe wound, I don't think we would be dealing with the kind 
of problems we had at Walter Reed.
    Now, why do I say that? Because just like General Tucker 
resolves problems when he runs into them, that is what our 
congressional offices do. Maybe we don't do it, but our staffs 
do. We get a call.
    If we had a notification that this person was wounded and 
is at this facility, our staff would check on him, we would be 
in touch with him, give us a call. And every congressional 
office in the country now has that frequently occur, where they 
get phone calls.
    I have had it--you make a courtesy call when someone has 
lost a loved one overseas, and it is almost pro forma to say, 
``If we can do anything, give us a call,'' and the next day 
they call back and say, without ever anticipating that they 
would need to get hold of them.
    So that is why that language was put in there, that we 
think we can be a part of the solution, that when we get a call 
from somebody, when we hear about somebody, if we can have us 
or a staff member go by and put a business card on their 
hospital table that says, ``If you have got any problems, if 
your family has got any problems, give us a call.''
    And at the time, they may think, ``Well, that congressman 
is the last person I am going to call,'' until something 
happens that frustrates them. And that is the kind of calls we 
get, and then we would be calling you, and then you would have 
known there was a problem, General Cody.
    And because what was happening, the staff was going over 
there, and every soldier they ran into with a problem, they 
were taking care of the problem. The issue was there were 
people that were lost, that had just left the campus that 
weren't running into staff members in the hallways, and we 
didn't know they were having problems.
    So that was the purpose of that language. It may not be the 
most artfully written, but that is the intent of it, is that we 
would be part of kind of having the feelers out there for where 
there are problems.
    But I appreciate your comment.
    General Cody. We want everybody on the team, Chairman, and, 
again, every one of these are helpful and we understand the 
purity of the intent. I would just say because we are going to 
make it law, I think we could have a good discussion to make 
sure that we get it right.
    Dr. Snyder. I share your concerns, and that was one of the 
questions I asked General Jumper earlier, from his perspective 
on being both sides of this thing. We are always willing to 
pass laws, but we all want to do stuff that is helpful and not 
become part of the problem down the line.
    We appreciate you all. And if I picked up future Chairwoman 
Davis's intent, we will probably see you somewhere around the 
October timeframe.
    Thank you.
    We are in recess.
    [Whereupon, at 4:11 p.m., the subcommittee was adjourned.]


=======================================================================




                           A P P E N D I X

                             June 26, 2007

=======================================================================



=======================================================================


              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             June 26, 2007

=======================================================================



    [GRAPHIC] [TIFF OMITTED] 37326.001
    
    [GRAPHIC] [TIFF OMITTED] 37326.002
    
    [GRAPHIC] [TIFF OMITTED] 37326.003
    
    [GRAPHIC] [TIFF OMITTED] 37326.004
    
    [GRAPHIC] [TIFF OMITTED] 37326.005
    
    [GRAPHIC] [TIFF OMITTED] 37326.006
    
    [GRAPHIC] [TIFF OMITTED] 37326.007
    
    [GRAPHIC] [TIFF OMITTED] 37326.008
    
    [GRAPHIC] [TIFF OMITTED] 37326.009
    
    [GRAPHIC] [TIFF OMITTED] 37326.010
    
    [GRAPHIC] [TIFF OMITTED] 37326.011
    
    [GRAPHIC] [TIFF OMITTED] 37326.012
    
    [GRAPHIC] [TIFF OMITTED] 37326.013
    
    [GRAPHIC] [TIFF OMITTED] 37326.014
    
    [GRAPHIC] [TIFF OMITTED] 37326.015
    
    [GRAPHIC] [TIFF OMITTED] 37326.016
    
    [GRAPHIC] [TIFF OMITTED] 37326.017
    
    [GRAPHIC] [TIFF OMITTED] 37326.018
    
    [GRAPHIC] [TIFF OMITTED] 37326.019
    
    [GRAPHIC] [TIFF OMITTED] 37326.020
    
    [GRAPHIC] [TIFF OMITTED] 37326.021
    
    [GRAPHIC] [TIFF OMITTED] 37326.022
    
    [GRAPHIC] [TIFF OMITTED] 37326.023
    
    [GRAPHIC] [TIFF OMITTED] 37326.024
    
    [GRAPHIC] [TIFF OMITTED] 37326.025
    
    [GRAPHIC] [TIFF OMITTED] 37326.026
    
    [GRAPHIC] [TIFF OMITTED] 37326.027
    
    [GRAPHIC] [TIFF OMITTED] 37326.028
    
    [GRAPHIC] [TIFF OMITTED] 37326.029
    
    [GRAPHIC] [TIFF OMITTED] 37326.030
    
    [GRAPHIC] [TIFF OMITTED] 37326.031
    
    [GRAPHIC] [TIFF OMITTED] 37326.032
    
    [GRAPHIC] [TIFF OMITTED] 37326.033
    
    [GRAPHIC] [TIFF OMITTED] 37326.034
    
    [GRAPHIC] [TIFF OMITTED] 37326.035
    
    [GRAPHIC] [TIFF OMITTED] 37326.036
    
    [GRAPHIC] [TIFF OMITTED] 37326.037
    
?

      
=======================================================================


                   DOCUMENTS SUBMITTED FOR THE RECORD

                             June 26, 2007

=======================================================================

      
      
    [GRAPHIC] [TIFF OMITTED] 37326.043
    
    [GRAPHIC] [TIFF OMITTED] 37326.044
    
    [GRAPHIC] [TIFF OMITTED] 37326.041
    
    [GRAPHIC] [TIFF OMITTED] 37326.042
    
    [GRAPHIC] [TIFF OMITTED] 37326.038
    
    [GRAPHIC] [TIFF OMITTED] 37326.039
    
    [GRAPHIC] [TIFF OMITTED] 37326.040
    
    [GRAPHIC] [TIFF OMITTED] 37326.045
    
    [GRAPHIC] [TIFF OMITTED] 37326.046
    
    [GRAPHIC] [TIFF OMITTED] 37326.047
    
    [GRAPHIC] [TIFF OMITTED] 37326.048
    
    [GRAPHIC] [TIFF OMITTED] 37326.049
    
    [GRAPHIC] [TIFF OMITTED] 37326.050
    
    [GRAPHIC] [TIFF OMITTED] 37326.051
    
    [GRAPHIC] [TIFF OMITTED] 37326.052
    


      
=======================================================================


             QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD

                             June 26, 2007

=======================================================================

      
                   QUESTIONS SUBMITTED BY MR. MCHUGH

    Mr. McHugh. The AMAP includes the requirement for a command and 
control structure along with primary care managers, nurse case managers 
and squad leaders for Warrior Transition Units with thirty-five or more 
soldiers. Given the present number of warriors in transition throughout 
the Army: How many of each of these required personnel will be needed 
to staff all of the Warrior Transition Units that will be established 
by the Army?
    General Cody, General Pollock and General Schoomaker. Given the 
projection of approximately 8,000 Warriors in Transition (WTs), the 
Army estimates a requirement for 2,408 personnel (1,498 military and 
910 civilians) to staff the Warrior Transition Units, to include 40 
primary care managers, 345 nurse case managers, and 680 squad leaders.
    Mr. McHugh. What are the planning factors for determining the 
number of personnel needed?
    General Cody, General Pollock and General Schoomaker. The following 
Army-approved staffing ratios were used to determine the personnel 
requirements for each Warrior Transition Unit.

        1 company for every 200 Warriors in Transition (WTs)

        1 company commander and first sergeant for every 
company

        1 executive officer for each company of at least 150 
WTs

        1 platoon sergeant for every 36 WTs

        1 squad leader for every 12 WTs

        1 nurse case manager for every 18 WTs (medical centers)

         1 nurse case manager for every 36 WTs (community 
hospitals or health centers)

        1 human resource sergeant for every 200 WTs

        3 human resource specialists for every 200 WTs

        1 finance sergeant for every 200 WTs

        1 supply sergeant for every 200 WTs

        1 supply specialist for every 200 WTs

        1 patient administration sergeant/specialist for every 
200 WTs

         1 medical evaluation board physician for every 200 
Soldiers in the MEB process

        1 primary care manager for every 200 WTs

         1 social worker (family therapist qualified) for every 
100 WTs (1 for every 50 at Walter Reed and Brooke Army Medical Centers)

        1 training specialist for every 200 WTs

        1 occupational therapist for every WT brigade or 
battalion

        1 occupational therapy technician/recreation specialist 
for every 200 WTs

         1 physical evaluation board liaison officer for every 
30 Soldiers in the MEB/PEB process

        Ombudsmen are ``earned'' as follows:

           >35 WTs-200 WTs = 1 Ombudsman

           201 WTs-400 WTs = 2 Ombudsman

           401 WTs-600 WTs = 3 Ombudsman

    Mr. McHugh. How will the Army obtain the personnel?
    General Cody, General Pollock and General Schoomaker. Department of 
the Army Execution Order (EXORD) 118-07, Healing Warriors, dated June 
2, 2007, directs the establishment of Warrior Transition Units (WTUs), 
to include primary care managers, nurse case managers, squad leaders, 
and command and support staff at 35 locations worldwide. The EXORD also 
calls for 55 ombudsmen at these locations, as well as 130 physical 
evaluation board liaison officers. This represents a total requirement 
of 2,408 personnel. A significant planning factor in enabling the Army 
Medical Department to attain 50% strength in all WTUs by September 3, 
2007, is the availability of mobilized Reserve Component personnel 
assigned to Medical Readiness Processing Units (also referred to as 
Medical Holdover Units) as a result of consolidation of these units and 
Medical Hold Units into WTUs. Additionally, positions will be filled 
from the available population of qualified personnel (those Soldiers 
already serving in Medical Holdover and Medical Hold units) to attain 
90% strength in WTUs by January 1, 2008. The Army intends to source 
these positions for the long term with the planned increases in Army 
end strength.
    Mr. McHugh. Will the increased requirement for these individuals 
affect future military to civilian conversions and if so, how?
    General Cody, General Pollock and General Schoomaker. Staffing 
Warrior Transition Units will result in increased military requirements 
but many of them are non-medical. An in depth review of military 
medical positions identified for conversion is on-going to determine 
the feasibility and advisability of continued conversions.
    Mr. McHugh. The House version of the National Defense Authorization 
Act for Fiscal Year 2008 mandates ratios for case managers, service 
member advocates and PEBLO personnel to service members undergoing 
outpatient treatment. How many additional personnel would the Army 
require for the Warrior Transition units if the conference report 
includes the ratios in the House version?
    General Cody, General Pollock and General Schoomaker. The House 
version of the National Defense Authorization Act for Fiscal Year 2008, 
HR 1585 would set the ratio of case managers to Wounded Warriors at 
1:17. The Army Medical Action Plan (AMAP) calls for nurse case managers 
at a ratio of 1:18 Warriors in Transition (WTs) at Army Medical Centers 
where the acuity of care required is high and to 1:36 at those Army 
treatment centers where the acuity is much lower. HR 1585 calls for 
service member advocates at a ratio of 1:30 WTs. The AMAP establishes 
that ratio at 1 ombudsman for every 200 WTs. The House version would 
establish the ratio for PEBLOs at 1:20, while the AMAP sets this ratio 
at 1:30. The difference in requirements between these two approaches is 
presented in Table 1 below.

                                 TABLE 1
------------------------------------------------------------------------
                                   HR 1585        AMAP
           Position              Requirement   Requirement      Delta
------------------------------------------------------------------------
Case Manager/Nurse Case                 500           345           155
      Manager
------------------------------------------------------------------------
PEBLO                                   195           130            65
------------------------------------------------------------------------
Advocate/Ombudsman                      240            55           185
------------------------------------------------------------------------
TOTAL                                   935           530           405
------------------------------------------------------------------------

    Table 1 summarizes these differences which are based on a current 
WT population of 3,903 undergoing a Medical Evaluation Board (MEB) to 
calculate the PEBLO requirement, 7,189 WTs currently in WTUs to 
determine the ombudsman requirement, and a projected total capacity of 
approximately 8,000 WTs to project the case manager/nurse case manager 
requirements.
    It should be noted that these numbers do not include the command 
and support positions required to staff all WTUs. The U.S. Army Medical 
Command established the number of medical unit personnel required 
according to the Army Medical Action Plan at 2408. It should be noted 
that this does not include the requirement to staff Community Based 
Health Care Organizations (CBHCOs) with nurse case managers (48) or 
other required CBHCO personnel.

                                  
