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


 
                         [H.A.S.C. No. 110-45] 

              THE STATE OF THE MILITARY HEALTH CARE SYSTEM 

                               __________

                                HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             MARCH 27, 2007

                                     
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                    MILITARY PERSONNEL SUBCOMMITTEE

                     VIC SNYDER, Arkansas, Chairman
MARTY MEEHAN, Massachusetts          JOHN M. McHUGH, New York
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
                                  2007

                                                                   Page

Hearing:

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

Appendix:

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

                        TUESDAY, MARCH 27, 2007
              THE STATE OF THE MILITARY HEALTH CARE SYSTEM
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

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

                               WITNESSES

Arthur, Vice Adm. Donald C., Surgeon General, Department of the 
  Navy, U.S. Navy................................................     6
Baker, David J., President and CEO, Humana Military Healthcare 
  Services, Inc..................................................    41
McIntyre, David J., Jr., President and CEO, TriWest Healthcare 
  Alliance.......................................................    38
Pollock, Maj. Gen. Gale S., Acting Surgeon General, Department of 
  the Army, U.S. Army............................................     3
Roudebush, Lt. Gen. (Dr.) James G., Surgeon General, Department 
  of the Air Force, U.S. Air Force...............................     9
Tough, Steven D., President, Health Net Federal Services.........    42

                                APPENDIX

Prepared Statements:

    Arthur, Vice Adm. Donald C...................................    84
    Baker, David J...............................................   137
    McHugh, Hon. John M..........................................    65
    McIntyre, David J., Jr.......................................   118
    Pollock, Maj. Gen. Gale S....................................    68
    Roudebush, Lt. Gen. (Dr.) James G............................   103
    Tough, Steven D..............................................   156

Documents Submitted for the Record:

    Addendum from New York Times Website to March 18, 2007, New 
      York Times Article on The Women's War by Sara Corbett......   206
    March 18, 2007, New York Times Article on The Women's War by 
      Sara Corbett...............................................   185

Questions and Answers Submitted for the Record:

    Mrs. Boyda...................................................   218
    Mrs. Davis of California.....................................   218
    Mr. McHugh...................................................   211
    Dr. Snyder...................................................   209
              THE STATE OF THE MILITARY HEALTH CARE SYSTEM

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                           Washington, DC, Tuesday, March 27, 2007.
    The subcommittee met, pursuant to call, at 9:05 a.m., in 
room 2212, Rayburn House Office Building, Hon. Vic Snyder 
(chairman of the subcommittee) presiding.

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

    Dr. Snyder. The hearing will come to order.
    I want to welcome our guests today and folks attending. We 
obviously have Major General Pollock, the Acting Surgeon 
General of the Army, Vice Admiral Arthur, Surgeon General of 
the Navy, and Lieutenant General--I need you to pronounce your 
last name for me.
    General Roudebush. Yes, sir, Roudebush.
    Dr. Snyder. Roudebush. I thought that is what it was.
    General Roudebush. Yes, sir.
    Dr. Snyder. But you and I had been friends long enough, I 
thought I didn't want to mess it up here.
    General Roudebush. Thank you, sir.
    Dr. Snyder. Lieutenant General Roudebush, Surgeon General 
of the Air Force.
    We appreciate you all being here.
    This is General Pollock's first appearance before this 
committee in this role. And we appreciate you being here today, 
General.
    And this may be Admiral Arthur's last time, although the 
full committee not long ago bid goodbye to General Schoomaker, 
and he returned, like, two weeks later.
    So this may be your last time here. We certainly appreciate 
your years of service to your country and to the Navy.
    And, of course, we can't discuss the current state of the 
military health care system without acknowledging the events of 
the last few weeks. The stories that have come, the reports out 
of Walter Reed Army Medical Center showed our failure to 
properly care for all of our wounded warriors in the way that 
we all want. And when I say ``our,'' it is a joint problem for 
this country. It is all of our issue and all of our 
responsibility.
    In order to have an open and honest dialogue, we need to 
understand both the challenges the system faces and the 
solutions the Department of Defense (DOD) and the services have 
proposed. Our military medics face growing requirements as far 
into the future as we can see. They will continue to support 
operations in Iraq, Afghanistan, and the global war on terror. 
They will also need to support the expansion of the Army and 
Marine Corps.
    While they are doing all of these things, however, the 
military medical departments are being required to cut costs. 
They are being tasked to find ``efficiencies'' in the system to 
the tune of $248 million in fiscal year 2008. They are further 
required to convert military medical positions to civilian 
ones, frequently reducing the overall number of medical 
professionals in the process.
    We have no doubt that our dedicated military personnel will 
devote all of their efforts to accomplish their assigned 
missions. But there is concern that they are not being given 
the resources they need, not want, but need to fully support 
our Nation's military forces.
    And we appreciate you being here. You are the first of two 
panels today.
    I also want to introduce David Kildee, who this is his 
first time in this staff position sitting here.
    And please prepare to fire off red flares, Mr. McHugh, if 
you and I get in trouble and he doesn't know what to do. So 
Jeanette will come racing over here to----
    Mr. McHugh. I hope you have got a lot of them. [Laughter.]
    Dr. Snyder. A lot of them.
    And with that, I would like to yield to Mr. McHugh for any 
comments he would like to make.

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

    Mr. McHugh. Thank you, Mr. Chairman. And I would ask my 
entire statement be entered into the record in its entirety.
    Dr. Snyder. Without objection.
    Mr. McHugh. I certainly want to add my words of welcome to 
our distinguished guests.
    I think, Mr. Chairman, you said an appropriate potential 
farewell to the good admiral. But whether it is his last or 
not, I will certainly add to your comments about our deep 
appreciation for all that he has done.
    And a word of special welcome to General Pollock, who not 
only joins us in her first hearing as the new surgeon general 
for the United States Army, but also comes, I am told by 
Jeanette James, who was the general's successor as the Medical 
Department Activity (MEDAC) medical commander up at Fort Drum 
for the 10th Mountain Division, she is also the first nurse to 
work her way and earn her way into this esteemed position.
    Although, general, very challenging times, we certainly 
congratulate you on your appointment and look forward to your 
progress and cooperation and participation in this partnership, 
as the chairman said, in the days ahead.
    Mr. Chairman, I would echo as well your comments about the 
broad range of challenges we face. You mentioned efficiency 
wedges, a fine phrase, if you will, for cuts. And it is really 
just the proverbial tip of the iceberg. If you look at the 
expected or anticipated savings placed against other costs in 
the medical system, we are looking at over $2 billion in 
efficiency wedges and cuts and savings that all mean we have 
got a great uphill battle to meet the demands of the budget.
    Civilian conversions from military positions--there are 
funds for an additional 2,700-plus positions for conversion at 
a time when we have already converted over 5,500. And I think 
it is appropriate, we begin to wonder what effect this is going 
to have on our ability to continue to provide a robust military 
health system carry out its mission. And certainly given our 
witnesses' expertise in their medical professions, we look 
forward to their perspective on those kinds of things.
    And last, Mr. Chairman, you are absolutely right. We need 
to focus all of our abilities and resources on Walter Reed and 
the larger medical hold, medical holdover system in the medical 
care system for all of our wounded warriors. None of us, no 
American, wants to see these brave heroes who have given all of 
us so much to get anything less than the quality care that we 
expect them to be treated with.
    So with that, we look forward to the panels here today. 
And, Mr. Chairman, I would yield back.
    [The prepared statement of Mr. McHugh can be found in the 
Appendix on page 65.]
    Dr. Snyder. Thank you, Mr. McHugh.
    What we will do, I am going to have David put the five-
minute clock on. But that is just to give you an idea where you 
are at. When you see that red light go on, if you have still 
got more things that you think we need to know, you go ahead 
and continue.
    We will begin with General Pollock and then go to Admiral 
Arthur and then to General Roudebush.
    So, General Pollock, the floor is yours.

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

    General Pollock. Mr. Chairman, Congressman McHugh, and 
distinguished members of the subcommittee, thank you for the 
opportunity to discuss the current posture of the Army Medical 
Department.
    Our investments in medical training, equipment, facilities, 
and research, which you have strongly supported, have paid 
tremendous dividends in terms of safeguarding soldiers from the 
medical threats of the modern battlefield, restoring their 
health and functionality to the maximum extent possible, and 
reassuring them that the health of their families is also 
secure.
    Army medicine is an integral part of Army readiness. Army 
medics are deployed around the world supporting our Army in 
combat, participating in humanitarian assistance missions, and 
training throughout the world. Like the rest of the Army, this 
operations tempo is beginning to take its toll on the people 
and equipment who are vital to its success.
    The toll has been high in terms of cost and human 
sacrifice. Army medics have earned 220 awards for valor and 
more than 400 Purple Hearts. One hundred and two Army Medical 
Department (AMEDD) personnel have given their lives in Iraq or 
Afghanistan. These men and women are truly the best our Nation 
has to offer and will make any sacrifice in defense of their 
nation and most importantly, for the care of their patients.
    We recently hosted a human capital strategy symposium to 
address growing concerns within Army medicine about accessions, 
retention, and including well-being issues, which have a direct 
impact on morale. We have established a 180-day deployment 
policy for select specialties, established a physician 
assistant critical skills retention bonus, increased the 
incentive special pay for certified registered nurse 
anesthetists, and expanded the use of the health professions 
loan repayment program.
    Fiscal year 2006 presented Army medicine with challenges in 
recruiting health care providers. The Army fell short of its 
goals for awarding health profession scholarships in both the 
medical corps and dental corps. These scholarships are by far 
the most important source of accessions for physicians and 
dentists. And this presents a long-term manning challenge 
beginning in fiscal year 2009.
    The Reserve Office Training Corps, or ROTC, is a primary 
accession source for the Army Nurse Corps. In recent years, 
ROTC has had challenges in meeting the required number of nurse 
corps accessions. And as a consequence, the U.S. Army 
Recruiting Command was asked to recruit a larger number of 
direct accession nurses to fill the gap. This has been 
extremely difficult in a difficult and competitive market. In 
fiscal year 2006, recruiting command achieved only 84 percent 
of its mission for Army Nurse Corps officers.
    The reserve components provide over 60 percent of Army 
medicine's force structure. And we have relied heavily on these 
citizen soldiers during the last four years. And they have 
performed superbly.
    But accessions and retention in the Army National Guard and 
Reserve continue to be a challenge. Working with the chief of 
the Army Reserve and director of the Army National Guard, we 
continue to explore ways to improve reserve component 
accessions and retention for this important group.
    We seek to quickly integrate lessons learned from the 
battlefield into health care training and doctrine, not only in 
military medicine, but throughout civilian facilities as well. 
Army medicine continues to lead the Nation in adopting new 
trauma casualty management techniques. Since 2003, we have 
provided rapid fielding of improved tourniquets, new pressure 
dressings, and the use of hemostatic bandages that promote 
clotting.
    I know you are aware that traumatic brain injury (TBI) has 
emerged as a common blast-related injury. TBI is a broad 
grouping of injuries that range from mild concussions to 
penetrating head wounds. An overwhelming majority of TBI 
patients have mild and moderate concussion syndromes with 
symptoms not different from those experienced by athletes with 
a history of concussion. Many of these symptoms are similar to 
post-traumatic stress symptoms (PTSD), especially the 
difficulty concentrating and irritability.
    Through your continued support, we will quickly develop a 
better understanding of TBI from scientific research, including 
acute diagnosis, treatment, and long-term rehabilitation. You 
are well-aware of the challenges involved in managing this 
health care delivery system, as highlighted in the recent 
Washington Post articles about conditions at Walter Reed Army 
Medical Center.
    The Post series highlighted brick-and-mortar problems that 
should have been identified and fixed by our leaders at Walter 
Reed. But more challenging, the Post series articulated 
soldiers' frustration with a bureaucratic disability evaluation 
system that truly needs an overhaul.
    We have not waited to correct the problems identified at 
Walter Reed. I have a tiger team out assessing all of our 
facilities to ensure that there is not another Building 18 out 
there and that any other concerns are identified and quickly 
resolved.
    Within two weeks of the Washington Post series, every 
soldier who had been living in Building 18 had been moved out. 
And the Corps of Engineers was awarded a contract to replace 
the roof on the building. We will evaluate future uses of the 
building before we decide to invest on additional renovations.
    We are improving the transition from in-patient care to 
out-patient care for our warriors at Walter Reed and across 
Army medicine. We quickly established a wounded warrior 
transition brigade led by experienced combat veterans to focus 
on the unique command and control requirements of patient 
management as opposed to the day-to-day command of soldiers 
assigned to the staff at Walter Reed. The leadership of this 
brigade down to the platoon sergeant level is supported by the 
line Army so that now the medics at Walter Reed can focus on 
patient care responsibilities they were assigned to Walter Reed 
to perform.
    We took the painful lessons learned at Walter Reed and 
implemented an Army-wide action plan for improvement. This plan 
includes a wounded soldier and family hotline, an 800 number 
which began operations last Monday on the 19th. As of the 25th, 
we had received 315 calls detailing 179 issues ranging from 
medical care to personnel to finance.
    We have already researched and resolved 29 of the 56 
complaints received about Army Medical Command areas of 
responsibility. Seven of those calls were for information only. 
But these issues are quickly elevated to the Army leaders. And 
calls are returned by an expert in the topic area within 24 
hours.
    We are also implementing a one-stop soldier and family 
assistance center at Walter Reed. This center combines case 
managers, family coordinators, personnel and finance experts, 
and representatives from key support and advocacy organizations 
such as the Army Wounded Warrior Program, the Red Cross, Army 
Community Services, the Army Relief Fund, and the Department of 
Veterans Affairs. We are also hiring patient advocates across 
the AMED and establishing an ombudsmen program, first at Walter 
Reed and then across the Army.
    We are revamping the administrative processes of evaluating 
and adjudicating our soldiers' disabilities. Our goal is to 
streamline the process to eliminate confusion among soldiers 
and families. As we make these changes, we must not compromise 
the quality of medical care received or the soldiers' right to 
a full and thorough medical evaluation.
    We will need Congress's support to make some of the 
necessary changes. As we identify those areas that need 
legislative change, we will bring them forward for your 
consideration. We will ensure that soldiers no longer feel that 
when they leave the resources and attention of our health care 
system behind, when they are discharged from the hospital, that 
people don't care.
    I am grateful to the Congress for the concern and attention 
paid to soldiers and their families. And I will keep Congress 
informed as we improve these processes.
    In closing, let me emphasize that the service and sacrifice 
of our soldiers and their families cannot be measured with 
dollars and cents. The truth is we owe far more than we can 
ever pay to those who have been wounded and to those who have 
suffered loss.
    Thanks to your support, we have been very successful in 
developing and sustaining a health care delivery system that 
honors the commitment our soldiers, retirees, and their 
families make to our Nation.
    Thank you again for inviting me to participate in the 
discussion today. I look forward to your questions.
    [The prepared statement of General Pollock can be found in 
the Appendix on page 68.]
    Dr. Snyder. Thank you, General Pollock.
    Admiral Arthur.

   STATEMENT OF VICE ADM. DONALD C. ARTHUR, SURGEON GENERAL, 
               DEPARTMENT OF THE NAVY, U.S. NAVY

    Admiral Arthur. Yes, good morning.
    Dr. Snyder. Good morning.
    Admiral Arthur. And, Dr. Snyder, Ranking Member McHugh, 
other distinguished members of the panel, thank you very much 
for your kind wishes on my announced retirement in August. It 
has been an honor to serve for these 33 years and to come and 
represent the Navy in this committee.
    I joined the Navy in the 1970's when we had some 
significant problems with health care quality. We had a draft 
service. We had the Berry plan. We had other plans that brought 
into our service the top health care providers that we have 
today.
    We suffered through some of those problems in the 1980's. 
The best of our people stayed and made what I think is the best 
health care enterprise in the world today. Both Army, Navy, and 
Air Force systems, I think, have the highest quality we can 
have.
    In our Medical Treatment Facility (MTF), you can get 
quality care that is focused on the patient. I like to say that 
we never ask our patients how sick they can afford to be 
because we give the right care every single time. And what a 
pleasure it has been to have a patient population that is 
composed of 100 percent patriots.
    We have some of the greatest graduate medical, dental, and 
nursing education programs in the United States ranking in the 
top ten for many of our programs. The quality of the care, the 
quality of the education is extraordinarily high.
    We also deliver the best care in the world where it counts 
the most, in combat service support. We have the lowest disease 
and non-battle injury rate in history. That is the rate of 
illnesses and injury in a combat zone that are not due to 
combat but to other illnesses and injuries. We are also 
resuscitating people from injuries that in prior wars would 
have been fatal. The average stay for a casualty who comes back 
to Bethesda in the intensive care unit is 7.5 days. The average 
time in a hospital is 109 days.
    How people that badly injured are able to get off a 
battlefield and survive their injuries is nothing short of 
miraculous. It is due to many factors: the quality of care that 
we have, the surgeons far up front, the nursing staff that are 
right there on the battlefield.
    But I would say the overwhelming reason why we have the 
resuscitation rate that we do is the Navy, corpsmen and by 
extension, the Air Force and Army's medics who are on the field 
and give the first level of care. They have either seen a 
Marine or soldier who has been injured or they have trained 
another Marine or soldier to deliver that combat care.
    Unless a wounded veteran gets to a surgeon with a 
heartbeat, he will not survive. And it is our corpsmen and by 
extension the medics who ensure that. They are the best they 
have ever been.
    I want to say a special warm thanks to the Air Force's 
critical care air transport teams that make it possible to get 
all of these critically injured patients from the battlefield 
to Landstuhl and then Landstuhl back to the states. And a 
special thank you to the Army's wonderful facility at 
Landstuhl, which we are proud to have one-quarter of the staff 
as Navy personnel. This was a recent addition to their 
armamentarium.
    I want to especially recognize Landstuhl because unlike 
Walter Reed, Bethesda, and all of our other facilities back at 
Continental United States (CONUS), the folks at Landstuhl get 
to see all of the casualties in their newly injured states. 
They don't have the advantage of seeing them walk out, see 
their families reunited, and to see the wonderful cures. They 
day after day see injured sailors, Marines, airmen and soldiers 
and, I think, have extraordinary challenges. My hat is off to 
the staff of the Landstuhl Army Regional Medical Center.
    We do have special challenges, as General Pollock 
mentioned, especially in traumatic brain injury, post-traumatic 
stress. When I first took this job, someone gave me a brief 
that said 15 percent of people who go into combat are 
significantly affected by the experience. And I said, ``That is 
wrong. One hundred percent of people who are in combat are 
significantly affected by the experience.''
    The closer you are to combat, the closer you are to the 
actual fighting, the breaking in of the doors at Fallujah, the 
more affected you are. And we have to recognize that this is a 
debt that all of these young men and women are gaining in 
combat that we need to repay by paying attention to their needs 
as they come home.
    Traumatic brain injury is an especially difficult entity 
for us to define right now. We are just coming to the 
realization that blast injuries, the concussive injuries, 
especially multiple concussive injuries, have an affect on the 
brain, on cognitive function that we had not anticipated before 
and that we have to now define what that is. It is similar to, 
but not exactly like, the concussive injury in sports players 
and other people who have a direct blow to the head. These 
concussive injuries can give you very subtle symptoms that 
often are not amenable to diagnosis with standard tests.
    They can be difficulty with memory, difficulty with mood, 
inability to make a decision on a menu. And we have veterans 
who get lost in supermarkets from their traumatic brain injury 
effects. We need to do a better job of defining it, to 
following these people, to being able to give them the right 
treatment based on their symptoms.
    As good as we are today, we can be better. I think a 
unified or joint approach to health care would benefit us all 
so that we have common financial systems, common logistics, 
common communication, common doctrine. And we are working 
toward that, but I think we have a long way to go. And we could 
certainly do better.
    Another area where we are working very hard and I think we 
are making great strides is with DOD and the Department of 
Veterans Affairs (VA) interface for our veterans. And one of 
the examples I would give is the facility at Great Lakes. The 
Naval Hospital and the VA facility at Great Lakes have 
combined. They have combined their leadership, their clinical 
staffs, their laboratory, their X-ray. And we now have as close 
as we can get at the moment a joint facility with the Veterans 
Administration.
    We do have some challenges that I would be happy to 
discuss.
    Dr. Snyder, you mentioned the efficiency wedges. We have 
other wedges and reductions. And by what other name you want to 
call them, they are reductions in our funding. For us in fiscal 
year 2008 is $343 million out of a $2.7 billion budget.
    We have challenges in personnel. We have program budget 
decision 712 that you know well, that has asked us to make 
military to civilian conversions. We are only able to make 
about 83 percent of those conversions at the moment, despite an 
intense effort to do so.
    We also have the program decision memorandum number 4 that 
mandated 901 additional cuts, not conversions. And this year, 
we will have 489 people that we will cut from our roles 
beginning October 1, 2007. In addition to those cuts, the 
budget wedges, efficiencies, reductions will necessarily result 
in a decrease in our contracting funds, further adding to our 
challenges with providing the right personnel to staff our 
facilities and be ready to support combat operations.
    We have gone through the quadrennial defense review and its 
medical readiness requirements review. And in that process, 
many of our future requirements were minimized, especially in 
areas of homeland defense and humanitarian assistance. That 
concerns me.
    We also addressed fatigue of our deployers. We have a great 
number of our corpsmen, doctors, nurses, dentists who are 
deploying and not just once or twice, but three, four times. 
And this operational tempo for a very combat trauma 
resuscitative, intensive war does cause fatigue in our 
providers.
    Mr. Chairman, thank you very much for the honor of being 
here today. It has been a pleasure to serve. And I thank you 
for allowing me to give my statement.
    [The prepared statement of Admiral Arthur can be found in 
the Appendix on page 84.]
    Dr. Snyder. Thank you, Admiral Arthur.
    General Roudebush.

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

    General Roudebush. Mr. Chairman, Congressman McHugh, 
distinguished members of the committee, it is really a 
privilege and honor for me to be here today to tell you about 
Air Force medicine on the battlefield and at home station.
    Up front, I would like to note that Air Force medicine is 
not simply about support. And it is not simply about reacting 
to illness and injury. Air Force medicine is a highly adaptive 
capability tightly integrated into Air Force expeditionary 
capability and culture.
    We build a healthy, fit force fully prepared to execute the 
mission from each of our bases whether deployed or here in the 
states because every Air Force base is, in fact, an operational 
platform.
    Whether launching bombers from Whiteman Air Force Base or 
sitting alert in a missile control facility at F.E. Warren Air 
Force Base, or providing close air support from Balad Air Base 
in Iraq, we protect our power for our joint forces and provide 
sovereign options for our national leadership from our bases. 
Air Force medicine supports that warfighting capability at each 
of our bases and is, in fact, designed to prevent casualties 
and sustain our fighting strength. The result is the lowest 
disease non-battle injury rate in the history of warfare.
    But when there are casualties, whether they be airmen, 
soldiers, sailors or Marines, your Air Force medics are there 
with worldclass care. In the deployed arena, our medical teams 
operate closer to the front than ever before allowing us to 
provide our warfighters advanced medical care within minutes. 
Underpinning this worldclass health care for our joint 
warfighters is our system of joint en route care.
    It begins with a Navy corpsman or an Army medic providing 
life-saving first aid at that point of injury. The casualty is 
then moved to the next level of care for us at our theater 
hospital at Balad Air Base, the hub of the joint theater trauma 
system where life-saving damage control surgery is performed by 
Air Force surgeons and on occasion, teaming with Army surgeons. 
The casualty is then prepared for safe and rapid movement in 
our Air Force air medical evaluation system to Landstuhl, an 
Army hospital manned by Army, Navy, and Air Force medics.
    Re-triage and restabilization is accomplished. And the 
casualty is prepared for air evacuation back to definitive care 
at Walter Reed, Bethesda, Wolford Hall, Book Army, Navy Balboa, 
or perhaps a VA hospital. These capabilities combined to create 
an average patient movement time of three days from battlefield 
to stateside care.
    That is truly remarkable when compared to the 10 to 14 days 
required during the Gulf War or an average of 45 days it took 
in Vietnam. And it is especially remarkable when you consider 
the severity and complexity of the wounds that our forces are 
sustaining.
    In short, Air Force medicine is a key and central player in 
the most effective joint casualty care and management system in 
military history. Having just returned from Afghanistan and 
Iraq, I have personally observed this capability from that far 
forward care all the way home to the states. And it is truly 
life-saving care.
    As our casualties move back through Landstuhl and on to our 
stateside military medical centers, our Air Force casualties 
are followed closely by their unit through an assigned family 
liaison officer, a member of their unit, to ensure that the 
needs of the casualty and their family are met. And if going 
through the disability evaluation process is the next step for 
our wounded airmen, the Air Force HEART program ensures the 
commander, the medics and the family liaison officer continue, 
eyes on and hands on, throughout the disability process.
    Our Air Force medical capabilities go beyond home station 
care and support of our warfighters. Our medics are globally 
engaged in training our allies, in supporting humanitarian 
missions, responding to disasters, and winning the hearts and 
minds in key areas around the globe.
    And as we focus on care for our warfighters, I believe it 
is also very important to note that caring for the families of 
our airmen is a mission critical factor. Knowing that their 
loved ones are well-cared for back at home gives our airmen the 
peace of mind to do a critical job in a stressful and dangerous 
environment.
    The care we provide is a very important factor in building 
that trust that is fundamental to attracting and retraining an 
all-volunteer force. This demanding operations tempo at home 
and deployed also means that we have to take care of our Air 
Force medics. This requires finding a balance between these 
extraordinarily demanding duties, time for personal recovery 
and growth, and time for family.
    And it means developing the next generation of Air Force 
medics. My charge is to ensure that we recruit the best and 
brightest, prepare them to expertly execute our mission, and 
sustain and retain them to support and lead these important 
efforts in the months and years to come.
    In summary, the talent and dedication of our military 
medics ensure an incredible 97 percent of the casualties that 
we see in our deployed and joint theater hospitals will survive 
today. For our part in this extraordinary system, Air Force 
medics have treated and safety evacuated more than 40,000 
patients since the beginning of Operations Iraqi Freedom and 
Enduring Freedom.
    Globally, we have provided compassionate care to 1.5 
million people on humanitarian missions over the past six 
years. And at home station we continue to provide high-quality 
health care for three million patients every year.
    It is clear that we have challenges. But these challenges 
represent an opportunity. And we have the responsibility to 
step up to that opportunity to assure that our processes and 
our capabilities are precisely what those who go in harm's way 
both need and deserve and that we take care of their families 
as well.
    Thank you for your support and assistance in meeting this 
incredibly demanding and critically important mission. I assure 
you that we will continue to work hard with you in the months 
and years to come to sustain and improve our medical 
capabilities for this fight and for the next.
    Thank you.
    [The prepared statement of General Roudebush can be found 
in the Appendix on page 103.]
    Dr. Snyder. Thank you, General Roudebush.
    What we will do now is David is going to put the five-
minute clock on us, and Mr. McHugh and I follow it pretty 
closely. And we will just go down the line here. But I suspect 
we will go at least two, if not a third round. So when we get 
to Ms. Shea-Porter, your day is not over. We will come back and 
start over again.
    I would like to start.
    We appreciate your testimony.
    Admiral, you brought up this issue of efficiencies. You had 
such an artful sentence in your written statement on page two, 
in which you state, ``Fiscal year 2008''--you need to put the 
clock on now, David--``Fiscal year 2008 provides funding 
challenges in that the efficiency wedge increases in certain 
assumptions regarding savings opportunities may not be borne 
out in execution.''
    I thought that was a very artfully crafted sentence that I 
think if I am an enlisted guy or a junior officer and I read 
that, I think we are going to get screwed. Something bad is 
going to happen. And you brought that up. And I appreciate you 
acknowledging it is a problem this committee, as Mr. McHugh 
articulated very well, has been very concerned about.
    The question for us is, what do we do? You know, we usually 
say we are here to help you do your job. But you all are 
receiving some mandates, not from us, but from others that are 
making your mission difficult.
    So, I mean, we are here on this committee heading into the 
defense bill. This is a great committee. We are short some 
Republican members. They are having a conference, a very 
important meeting today. But we are all unified in our efforts 
to help you. So what is our response?
    I mean, what do you suggest for us, Admiral Arthur, in 
terms of how do we deal with this? In fact, you upped the ante. 
We thought it was $248 million. And you said it is $343 million 
that we are looking at. That is a lot of pressure on the folks 
at the lower end of the chores that you want to get done.
    Admiral Arthur. Yes, sir. My figure is we have $147 million 
in what is called an efficiency wedge, which has no granularity 
to it. It is a rough figure that health affairs has given us. 
We have----
    Dr. Snyder. I don't know what you mean by no granularity. 
Do you mean it is not any detail, nobody has come and just said 
do this?
    Admiral Arthur. No, no. Correct. There is a requirement to 
fund the private-sector care. And funds are being removed from 
the direct care system to fund the private-sector care. Now, 
the law was created by this forum to prohibit money from going 
from direct care to private-sector care during the year of 
execution. However, this is a creative way to do it in the 
Program Objective Memorandum (POM).
    So in the POM this year we have $147 million in an 
efficiency wedge. And it is interesting that whenever we 
highlight efficiencies, they are taken off and the efficiency 
wedge still remains in its $147 million form. We have a 
reduction in pharmacy services of $127 million, facility 
renovation and upkeep reductions of $422 million, and a 
reduction in our end strength, which results in a 900-person 
cut in our staffing over the next few years. This year will be 
$47 million.
    So the total for us is $343 million out of our $2.7 billion 
budget this year. We cannot maintain the present level of 
services with a funding cut that is about 16 percent of our 
total budget.
    Dr. Snyder. But, I mean, you are heading out the door. Who 
is going to get you? But you are being told that you can. 
Correct? I mean, somebody must think--I mean, I have no doubt 
that there are patriots all the way up and down the line in the 
Pentagon. But somebody thinks that you can do this without that 
money. Is that a fair statement?
    Admiral Arthur. Well, somebody thinks we can be a whole lot 
smaller than we are today and get the job done.
    Dr. Snyder. Yes.
    Admiral Arthur. And if we are going to make these kinds of 
cuts, we will be delivering care to active-duty only. We will 
be having pharmacy services that are provided not in our 
military treatment facilities, but in the private-sector care. 
And this, in my opinion, will increase the bill overall.
    Dr. Snyder. Right.
    Admiral Arthur. Because it will force more care out into 
the private sector where on the margin it is more costly to 
provide. And the only mechanism that the Pentagon has to 
influence private-sector care is a bill because there aren't 
the kind of programs and efficiencies that we can enact within 
the MTFs that we can display in the private-sector care.
    Dr. Snyder. The point you just made concerns me because on 
your list was some maintenance monies. Is that correct?
    Admiral Arthur. $22 million in facility maintenance.
    Dr. Snyder. I think the Air Force was doing this a few 
years ago overall. And it is shortsighted budgeting because 
things that you ignore in maintenance bites you sometime down 
the line. And, I mean, any home owner knows that. You ignore 
the small leak, and pretty soon you are replastering walls. So 
that seems pretty shortsighted.
    With regard of the personnel cuts or conversions, is it 
also fair to say--I mean, General Roudebush doesn't submit an 
invoice for the overtime hours he has worked last month. A 
civilian employee is obligated. I mean, you are obligated to 
pay those kinds of fees. It does not become a one to one 
conversion. Is that a fair statement?
    Admiral Arthur. That is fair. And at Bethesda this week I 
was told of the problem with overtime pay given to the 
civilians that we have had on conversion because they are----
    Dr. Snyder. So it is already an issue?
    Admiral Arthur. They are no nights, no weekends, 40 hours a 
week, no deployments.
    Dr. Snyder. Yes.
    Admiral Arthur. And they take the place and sit right 
beside a lesser-paid active-duty member who is doing the same 
job.
    This year in fiscal year 2008 we will convert 1,036 
billets, positions. And if we keep the 83 percent rate that we 
are able to fill them currently, that means a decrease of 176 
more people.
    Dr. Snyder. Mr. McHugh.
    Mr. McHugh. Thank you, Mr. Chairman.
    I think it is fair to say what happens on capital costs and 
maintenance costs is Walter Reed. There were contract problems 
there and continuity of contracts, I understand. But certainly, 
if you don't have dollars to maintain facilities, including 
those places where the soldiers are housed while under care, 
those are the kinds of problems you have.
    The good admiral kind of highlighted the concerns he has 
about the beginning of the military to civilian conversion 
plan. I want to broaden that a little bit. You know, as I 
mentioned in my opening comments, we have already converted 
thousands of these positions, including at this point 152 
physicians, 349 nurses, and 208 dental positions. And at the 
same time, this Congress is actively enhancing the recruiting 
and retention through the medical health care professional 
program to try to bring more of these people in.
    It just seems kind of at odds to me that we are having 
trouble, as General Pollock said, finding some health care 
specialties and yet we are cutting them out. I don't know.
    Do either General Pollock or General Roudebush want to 
comment a little bit about the concerns you may or may not have 
with respect to the military to civilian transition program on 
the medical health care professions, particularly nurses and 
physicians?
    General? Either general?
    General Roudebush. Yes, sir, it is a concern. As we attempt 
to find the right balance within our capabilities--and there 
are opportunities where we can, in fact, use some civilian 
physicians in order to provide the capabilities both for our 
active-duty and our family members. That is not a bad thing in 
and of itself. It is the extent to which we are being asked to 
go in terms of making those conversions that causes us great 
concern.
    In the Air Force, we have done a thorough review of our 
deployable requirements and our active-duty requirements, 
identified a body of positions that we thought could make sense 
to convert and then did a business case analysis on it to see 
if, in fact, those capabilities were present, were they cost-
effective and could we acquire them.
    We can go that far. But we are concerned about going any 
further than that because it very quickly gets into the issues 
that Admiral Arthur describes where we can, in fact, or cannot, 
in fact, meet the mission in some regard. So we do have 
concerns in that area.
    Mr. McHugh. I appreciate it.
    And if I may add before we will have comments from General 
Pollock, beyond, I would argue--and I would like your feedback 
on this--what the chairman said. And I agree with him totally.
    I mean, you have an overtime situation in the civilian 
sector you don't have under normal circumstances, at least in 
the military sector. You have also got a deployability, 
availability to deployability issue, which I think would be a 
big issue for all of you, certainly, but particularly for the 
Navy and the--well, no, all of you, all of you, General, across 
the board.
    So, you know, it is kind of a two-edged sword that cuts you 
both ways, it seems to me.
    General.
    General Roudebush. Yes, sir. In fairness, though, I could 
say we have tried to convert those billets that are not 
deploying billets such as radiation therapists for cancer. We 
don't have any deploying billets for them, so we will convert 
them to civilian positions.
    Mr. McHugh. Yes, I understand that. And I appreciate that. 
And I understand what you are trying to do. But you can only 
try to do so much.
    General Roudebush. Yes, sir.
    Mr. McHugh. And you noted you are able to fill 83 percent. 
So try as you might, you have got some real problems there.
    General Roudebush. Yes, sir.
    Mr. McHugh. That is my point. Thank you.
    General.
    General Pollock. Sir, when the original plans were made, we 
did not take into consideration that we could truly be in a 
long war. And some of the eliminations that we have done are 
for staff now that we realize are absolutely critical. You 
addressed the physician and nurse issues. I am also concerned 
about our enlisted soldiers that have been converted to 
civilians.
    Mr. McHugh. Yes.
    General Pollock. We are unable to get the mental health 
specialists that we are able to train and use as part of that 
care team. We have not been able to do the hiring--even those 
positions were eliminated--for a number of the nursing 
positions because of the national nursing shortage and the 
challenges that we have in hiring because of the Office of 
Personnel Management (OPM) restrictions on how we can hire a 
nurse.
    Very, very difficult for us to bring professional nurses 
back into our organization. And then when we add the 
significant pay difference between what a civilian would 
receive and then the overtime compensation compared to the 
enlisted or junior officer salaries that are available to them, 
that is definitely a morale buster.
    Mr. McHugh. Yes. I appreciate your expanding on that. And 
you are absolutely right. It is a critical issue beyond just 
the health care professionals. There are other positions that 
are staffed that are equally important. So thank you for 
filling that in.
    And, Mr. Chairman, I appreciate it. I yield back.
    Dr. Snyder. Thank you.
    I think this line of questions is going to continue here 
through the day, I think.
    Ms. Davis.
    Mrs. Davis of California. Thank you, Mr. Chairman.
    And thank you all for being here. You obviously are here at 
such a critical time in this discussion.
    On the conversion issue, if I can just continue with my 
colleagues, are we at really a critical point in this? Should 
we be rethinking what we are doing?
    General Pollock. We have asked the Army and the Department 
of Defense to hold on any additional conversions so that we can 
do a renewed look because of the issues that we hadn't taken 
into consideration when we made the original suggestions back 
in 2003 and 2004 for who we thought we could convert. Because 
the reality is although we selected specialties that we thought 
we would be able to hire in the civilian world, we are 
discovering that we really can't.
    Mrs. Davis of California. Yes.
    General Pollock. And we would like to have that reassessed 
so that we are making better decisions and not breaking health 
care as a result of a personnel change.
    Mrs. Davis of California. Do you see impacts as well in 
terms of individuals who might be in a pool, so to speak, to be 
moving into military health provider positions who perhaps 
would see the conversions and not consider those positions for 
the future? Is it impacting folks in that way?
    General Pollock. Ma'am, would you be so kind as to ask me 
the question again? I am not sure I followed you.
    Mrs. Davis of California. I am just wondering by virtue of 
a lot of the conversions that we have made--I am wondering. You 
mentioned some of the corpsmen, the tremendous role that they 
are playing, the skills that they have developed. I am just 
wondering whether in some ways we are not cutting off those 
opportunities for them in the future by virtue of what we have 
done in these conversions, whether that somehow somebody 
looking at that would say, ``Well, why would I bother?''
    General Pollock. Well, we certainly have concerns with that 
because as we decrease the number of our junior enlisted in 
different specialties, then that also decreases the number of 
non-commissioned officers (NCO). And as you then become top 
heavy in those NCO ranks, they stop being promoted.
    So then again there is one of those second and third order 
effects that people hadn't anticipated that then people who are 
then mid-term, you know, mid-career NCOs are going, ``Well, if 
I can't get promoted and I have to go start at the bottom of a 
new specialty, should I stay in the Army?'' And that is a 
concern for us.
    I have been working since I took over the position to start 
to address these concerns.
    Mrs. Davis of California. Yes. I want to turn for a second 
to the mental health area because of one of great concern to me 
personally, but obviously to all of us. And I know that we are 
going to have testimony in the second panel from TRICARE.
    But I wonder if you have concerns we are cutting--there is 
a 5.8 percent decrease in behavioral health provider 
reimbursements. And do you see that as having an impact?
    Obviously, as you are saying, we are not able to even find 
the people that we need. And now we are going to be cutting 
back and in some ways, discouraging people from treating those 
who really need it right now. Can you comment on that?
    General Roudebush. Ma'am, in the Air Force, we have paid 
close attention to that. First, training our providers in terms 
of PTSD, what to look for, how to identify it, how to support 
that individual and treat them as they go through.
    And in addition, we have brought on 32 additional mental 
health providers to put in those areas where we have the most 
returning Air Force airmen that have been deployed that could 
potentially require that capability. So we are paying close 
attention to that in order to maintain the capacity that we 
need.
    Mrs. Davis of California. You are not necessarily seeing 
any negative impacts of that decrease at this time?
    General Roudebush. Because of the steps that we have taken, 
we have not seen any impacts.
    Mrs. Davis of California. You are not seeing any.
    General Roudebush. However, we continue to watch that very 
closely because as we get into this sustained conflict--and I 
think we are going to be in this conflict for a very long 
time--I think the likelihood and the necessity for continuing 
to both maintain and perhaps increase our capabilities will be 
very real.
    Mrs. Davis of California. Yes.
    Admiral Arthur. Ma'am, there is a military health--a mental 
health task force that is looking at this in a very 
comprehensive way from start to finish, involving the service 
members and their families, military and civilian mental health 
services. It should report out to the Secretary of Defense on 
the 15th of May.
    Last week I was made the military chairman of that effort 
after General Kiley's retirement. He was the co-chair before 
me. So we are going to look at this.
    I have read the material that they have collected so far. 
And they are looking at a very broad-based approach to mental 
health, not just starting at the time when we identify people 
who need treatment, but before that and building resilience in 
our service members and their families anticipating some of the 
stresses of combat and other stresses of military life.
    Mrs. Davis of California. Yes.
    General Pollock. The concern I would have, ma'am, is we 
have forward deployed many more members of the behavioral 
health team to assist the folks who are deployed. And then as 
we have requirements for the soldiers as they have returned or 
their families, we are dependent on the civilian sector for 
that support. Mental health has not been a robust practice 
arena in the United States.
    Although there is demand, we have certainly are under-
resourced across the country. And many of us could speak to the 
challenges that we have for a child or adolescent behavioral 
health care around the Nation and how difficult it is.
    I remember when I was up at Fort Drum how difficult it 
could be to move a child perhaps to another state before we 
were able to get in-patient care if he needed it. This is 
certainly an area that is a national issue, not just one for 
the military.
    Mrs. Davis of California. Yes. Thank you.
    Thank you, Mr. Chairman. I know I certainly want to address 
the women in the military issue as well with PTSD. Thank you.
    Dr. Snyder. General Pollock, I need to have you clarify 
your first answer to Ms. Davis in which you--I forgot how you 
phrased it, but you have asked your senior folks to revisit a 
certain decision on their military conversion. Did I understand 
correctly? Would you repeat what you said?
    General Pollock. Yes, yes.
    Dr. Snyder. I thought you had an October 1, 2008, timeline 
that you have to meet.
    General Pollock. Yes, sir, we have the 2008 conversions 
broken into different phases. And I have gone back and asked if 
we could please relook those to see whether or not we are 
actually going to be able to hire the folks that we had 
anticipated that we could when we did that original assessment.
    Dr. Snyder. And specifically, whose decision is that?
    General Pollock. That goes up through the Army G-1. And 
then it also goes to the Tricare Management Activity (TMA) up 
to Department of Defense.
    Mr. McHugh. Mr. Chairman, if I may?
    Dr. Snyder. Yes, Mr. McHugh?
    General Pollock. Thank you. Admiral Arthur reminded me it 
is for the under secretary for personnel and readiness.
    Mr. McHugh. Yes. When Dr. Winkenwerder appeared before this 
subcommittee in response to a question I had posed, he had said 
that they are certainly willing. I don't think he made a hard 
commitment they were. But he said they certainly were willing 
to reevaluate both the efficiency wedges and the military to 
civilian conversions. But I don't think a decision has been 
made on that. And until a decision is unmade, it remains, it 
seems to me.
    Dr. Snyder. Ms. Boyda.
    Mrs. Boyda. Thank you, Mr. Chairman.
    Let me just say my dad was a medic on a submarine in World 
War II. So I have always had good medical care at home where he 
thought was he still was, you know, still from 60 years ago. 
And thank you very, very much for your service.
    May I just ask a question? Did you say you have lost 102 of 
your medics? Did I hear you say that?
    General Pollock. Yes, 102. It is across the health care 
professions. It is medics. It is physicians. It is physician 
assistants. It is medical service corps officers.
    Mrs. Boyda. That was in the Army or it was in the armed 
services?
    General Pollock. That is within the Army. That is the Army 
medical department.
    Mrs. Boyda. I had no idea. I am sure all of our condolences 
on behalf of everyone here.
    After the Walter Reed, I went to both of the VA hospitals 
in my district and then to Irwin Army Hospital there at Fort 
Riley, came back and reported that there is some really ugly 
green tile in our VAs, but they are clean and they are safe, 
which is not surprising.
    When I went to Irwin, the guy--and I am going to tear up. 
The staff virtually teared up at how much they take care of 
their soldiers, how much of a team they are and the concept 
that we are just turning these into civilian, you know, jobs 
just alarms me like no other.
    And I am a freshman here. Can you explain how we got here, 
how the decision was made, when it was made? I really don't 
have the background. When was this decision made?
    Admiral Arthur. For the military to civilian conversion?
    Mrs. Boyda. Yes.
    Admiral Arthur. Every four years we have a quadrennial 
defense review. And that review takes into consideration all of 
the policies and all of the plans that we have to conduct 
operations in DOD. And part of that is a medical readiness 
requirements review where the Department says these will be the 
requirements over the next foreseeable future for combat 
operations and here is how the medical piece will fit into that 
support.
    They calculate what operations they will have, what number 
of casualties, what kind of casualties. And then they plot what 
the support will have to be to ensure that those casualties are 
well-trained. They take into consideration the garrison care, 
that is the corpsmen, the doctors on the submarines, the ships 
and with the Marines every day. And they roll it all into a 
figure, and they tell us that this is what we require of your 
medical department.
    Mrs. Boyda. Who is ``they''?
    Admiral Arthur. The Under Secretary of Defense for 
Personnel and Readiness through his plans, analysis and 
evaluations program, the PA&E, as we call it.
    Mrs. Boyda. Does that come back through Congress then for 
any kind of funding or any kind of--again, I am trying to 
figure out--and it doesn't sound like--it is just----
    Admiral Arthur. No, it does not.
    Mrs. Boyda. And when was this one done then?
    Admiral Arthur. This one was done just within the last 
year. They have taken minimal casualty requirements for future 
warfighting scenarios, minimal deployment and redeployment, 
almost no humanitarian assistance, disaster relief or homeland 
security.
    Mrs. Boyda. So this conversion--I hate to interrupt, but 
this conversion that we are talking about that is going to be 
finished on October of 2008 was actually directed in what year?
    Admiral Arthur. Yes. This past year. Well, actually, there 
are two components. There is the program budget decision 712. 
And that was several years ago. And we are on the track to 
convert that number of billets that we had in many ways agreed 
to.
    Mrs. Boyda. So this conversion started when, again, if you 
would?
    Admiral Arthur. In fiscal year 2006 and will continue to 
fiscal year 2011.
    Mrs. Boyda. I guess what I am trying to ask is--and I just 
sometimes continue to be appalled at some of the decisions that 
we are making. This move to convert actually happened while we 
were at war?
    Admiral Arthur. Yes, ma'am.
    Mrs. Boyda. Well, did they start looking at doing this 
maybe a few years back?
    Admiral Arthur. No, this was in the last two or three 
years.
    Mrs. Boyda. And I am going to have to go to an Ag hearing 
meeting. So I am going to go to a different subject right now.
    And, you know, we hear that funding for TBI research has 
been cut back. Can you address that? Do you know anything about 
that? Is that true? And is there something that Congress can do 
to--sometimes what you read in the paper doesn't actually 
reflect reality. I know that shocks us all.
    General Pollock. I am glad that someone else thinks that, 
ma'am. What I would like to do is provide you a written 
response to that question. I am new enough in the job that I 
can't remember all of those numbers for the research. And I 
would like to make sure that what I provide you is correct.
    [The information referred to can be found in the Appendix 
beginning on page 218.]
    Mrs. Boyda. Are you concerned that funding has been cut? Is 
that something that is on your list of things to worry about? 
Or if you would like to get back, that is fine.
    General Pollock. Yes, I am concerned about it because with 
the fact that TBI and PTSD are seeming to be connected in some 
analyses, I think it is very important that we continue that 
research so we know exactly how to provide the care so we can 
return these men and women to their absolute highest level of 
functioning.
    Admiral Arthur. This is a newly emerging entity, a new 
realization for us. And unless we get the research correct, we 
are not going to get the longitudinal studies that tell us 
whether we are doing the right thing or not, we are not going 
to be able to follow the members and their families.
    Mrs. Boyda. Data are good.
    Admiral Arthur. Yes, ma'am, data are plural.
    Mrs. Boyda. Thank you very much. And thank you for your 
service, Admiral.
    Admiral Arthur. Yes, ma'am. It is an honor.
    Mrs. Boyda. And, General, congratulations and good luck 
with your challenges ahead.
    General Pollock. Thank you.
    Mrs. Boyda. Thank you.
    Dr. Snyder. Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you, Mr. Chairman.
    I would like to pursue that direction that my colleague was 
going in. My husband was stationed at Fitzsimons Army Medical 
Center in Colorado when it was a major medical center. And I 
was there as well. And I saw the incredible work they were 
doing through a lot of casualties from Vietnam.
    And I am sitting here today. And I, too, am trying to 
figure out how we got to this point where we decide to gut the 
system as I knew it and wind up with this other system that we 
are using.
    And what I would like to know when they made the decision 
to privatize these jobs, was there much input from all of you. 
Were you asked to give your opinion about all this? Or was it a 
unilateral decision?
    Admiral Arthur. Yes, we were. And, yes, it was a unilateral 
decision. We made many inputs. And they were carefully 
considered and rejected. Some of our inputs had to do with the 
cost of the civilian conversions, the cost of the people and 
the overtime, as Dr. Snyder was saying. Some of it was the 
culture of the military. And that is a difficult thing to 
quantify.
    But as I said in my opening statement, I was here in the 
1970's and saw a very different culture. Every single one of 
the senior providers in the military now are here because they 
are volunteers. And they do not work for money alone.
    It is not a reimbursement system. They work to give the 
right care to each of our veterans and their families every 
day. That keeps the best of our people in.
    And I am concerned about people who will come in for a 
contracted fee and look at the bottom line, the money, work 40 
hours, no nights, no weekends and they will sit right next to 
someone who makes half as much and the morale impact on that. 
We have the kind of quality health care we have today because 
the system has evolved over the last 2 or 3 decades.
    And I am afraid that some of these conversions, while we 
will get some very good people, we will also get people who are 
not invested in our military families but in the paycheck that 
comes from their contracted services.
    Ms. Shea-Porter. I share your concern about that. And it is 
especially poignant to me today because a couple of days ago I 
got a call from a relative I am very close to. She lives in 
North Carolina. And she told me she was in South Carolina 
because she had been diagnosed with breast cancer. They use 
TRICARE, and they couldn't find physicians who would provide 
appropriate care for the funding.
    And I want to pay tribute to all who have worked in the 
military health care system. I remember how dedicated they 
were, and they are to this day. And I find it deeply 
disturbing. And I thank you for your candor about that. And I 
think as a Nation it is ironic that we talk about supporting 
our troops, and then we sit here and we find out what that 
translates to if they need medical care.
    I did want to talk about the mental health issue for 
another moment. We have known for a long time that when 
soldiers go into combat or have any kind of adverse situations 
there will be some mental illness and post-traumatic stress 
syndrome. What has happened in the past couple of years as we 
have been receiving these troops with these brain injuries and 
post-traumatic stress syndrome that kept us from addressing it 
at such a heightened level until now?
    In other words, if you could talk to me about two years 
ago. Was this an issue that you were addressing? Were you 
looking at these troops and their families and saying this is a 
crisis? And if you did, who did you talk to in terms of, you 
know, what department, and what was the response?
    Admiral Arthur. Well, yes, ma'am, we did address that. I 
think all three services addressed it several years ago. And I 
think we are actually doing pretty well. For the Navy and the 
Marine Corps, which we serve in the Navy, we have embedded 
people in our OSCAR program.
    We have mental health providers, technicians, 
psychiatrists, psychologists embedded into the units that go 
into combat. They go into combat with them. And instead of 
being sent for evaluation to some other unit or location, they 
are treated in theater with personnel that are assigned to 
their battalions.
    So I think that is a very effective way to do it. When they 
come back, there are debriefings. There are debriefings before 
they go. The senior leadership is involved. And I think we are 
seeing a low rate of PTSD compared to what it could be if we 
weren't paying attention to it.
    We also have the reassessment six months after they come 
back. And it is not because we want to wait six months. It is 
because that six months is required to get some of the 
manifestations of post-traumatic stress and the decompression 
that they need to really manifest some of the post-traumatic 
stress symptoms.
    So we see them. We evaluate all of those assessments. We 
get them to see mental health providers whenever it is needed. 
And they can self-refer as well.
    So I think we are doing a pretty good job. Are we hitting 
everyone? I am not sure you can always say that we will hit 
everyone because it may take a long time for some of these 
symptoms to manifest.
    General Roudebush. And, ma'am, it is broader than just the 
PTSD. The PTSD is a critically important piece of this. But as 
we look at what that means to the family caring for an 
individual and to the broader community looking across all the 
behavioral health issues with suicide, for example, being a 
critical concern always as well as family stress, deployment 
stress, those sorts of things, and the fact that TBI and PTSD 
have some overlap.
    And as Admiral Arthur pointed out, there are areas where we 
do not have all the information and the data that we need to 
fully elucidate that. So I think we are moving in that 
direction. But I think the on-going research that is required 
and the attention and the focus on this is a very good thing to 
help us move that forward and be sure that we do cover this and 
the whole spectrum of stress, if you will, across the force and 
the families that we are able to address.
    Dr. Snyder. Mr. Jones.
    Mr. Jones. Mr. Chairman, thank you.
    And I am going to be very brief. I am sorry I was late 
getting here because I am very, very interested in this issue 
and wanted to hear you, the first panel, and look forward to 
hearing the second panel.
    I guess most of the questions since I have been here have 
been asked that I might would have pursued. But something just 
came to my mind, in talking about family stress.
    And I want to give you an example, Admiral Arthur and only 
because this touched me so greatly and so dearly. Four or five 
weeks ago, I was invited to go to Camp Lejeune, which is in my 
district, and read a book to six-year-old children at the 
Johnson Elementary School. And they had 10 little children 
there in front of me.
    I am sitting in a rocking chair, probably where I deserve 
to be anyway, and reading Dr. Seuss, quite an interesting book 
because I couldn't pronounce half the words. But the teacher 
told me not to worry about it. The children wouldn't know if I 
was right or wrong with what I said. [Laughter.]
    So anyway at the end, I let the little children make 
statements or ask me questions. And, of course, everything 
from, ``Have you seen the zoo in Washington?'' to ``Do you know 
the President?'' to, you know, ``Where do you work?''
    But one thing that really bothered me, toward the end two 
or three children mentioned that their father or their mom was 
in Iraq. And again, these are six-year-old children. But the 
last child said to me--and I never will forget it--``My daddy 
is not dead yet.'' A six-year-old child, ``My daddy is not dead 
yet.''
    And, Admiral, I guess my question to you: How far down does 
the Navy and the Marine Corps, Army, Air Force--how far down do 
you go to try to figure out what services you can offer to the 
family?
    I am not saying that child has a problem. But that was such 
a deep statement that I heard, ``My daddy is not dead yet.'' 
You cannot go into every family. You cannot evaluate every 
child. But where in the world, if this is a problem--not saying 
this is an emotional problem. But this is a six-year-old child 
that is thinking that, ``My daddy is not dead yet.''
    How do you reach the family? I mean, does the family in 
that kind of situation--and not saying there is a problem. I 
don't know how to evaluate what I am trying to ask you. And I 
am sure you can't make any sense out of what I am trying to 
say.
    Admiral Arthur. Well, Congressman Jones, it is good to see 
you again.
    Mr. Jones. Yes, sir, my pleasure.
    Admiral Arthur. I think that six-year-old does have a 
problem. There is nothing more fundamental to a young person's 
life than the knowledge that the family unit will be there. The 
insecurity about the death of a parent is fundamental to the 
development of this young man or woman.
    We have all sorts of family services. And they go right 
down to the children. We involve the teachers in the schools in 
classes about what is post-traumatic stress, what should they 
look for in the children, how should they help the children 
cope, especially on Camp Lejeune, whereas DOD schools--all of 
or the majority of the children there of active-duty Marines 
are cared for on the base, especially with those brand-new 
schools that are beautiful.
    Mr. Jones. Yes, sir.
    Admiral Arthur. And they pay particular attention because 
all of their mothers and fathers are subject to deployment. We 
have in the Marine Corps the key volunteers that I think you 
know very well. They are the spouses of men and women who are 
deployed. And they are very, very active working with the 
family unit. So I think they are well-supported.
    But that said, you can never get away from the fact that 
everyone in that school is going to know someone whose mother 
or father was either very seriously injured or killed in this 
combat. And you can't get away from that.
    Mr. Jones. Sure.
    Admiral Arthur. So I think the key is to be proactive. That 
said, we are having a lot of our staff of our military 
treatment facilities deployed.
    I went to Cherry Point last month. The commander of the 
base said, ``You know, we have got longer lines in the pharmacy 
and longer waits for clinics.'' And I said, ``Yes, sir. Twenty 
percent of your hospital staff is deployed today.''
    And they are not on vacation. They are deployed in direct 
combat service support for their Marines in theater. And saying 
you can go 40 minutes for an obstetrical appointment to Craven 
Medical Center is not the kind of service that I think our 
Marine families deserve.
    Mr. Jones. Mr. Chairman, before I close--my time is about 
up--I could not say enough about the services provided at Camp 
Lejeune and Cherry Point at the hospital. It is outstanding. I 
would agree with you that the family support is excellent, I am 
sure across every base, Army, Navy, Marine Corps, and Air 
Force.
    And I would also say that the DOD schools as long as there 
is a military in this country I hope that the Congresses of the 
future when I will not be here will always remember that those 
schools are an integral part of the quality of life because I 
have seen so much good at those schools and at Camp Lejeune and 
the one I visited.
    Admiral Arthur. Yes, sir.
    Mr. Jones. So I appreciate your comments.
    Admiral Arthur. If I could say one more thing.
    Mr. Jones. Yes, sir.
    Admiral Arthur. My daughters went to those schools at Camp 
Lejeune. And they could ride their bicycles to school and leave 
them in a bike rack unlocked in front of that school and know 
that they would be there in the afternoon when they returned.
    Mr. Jones. That is very important.
    Admiral Arthur. It is a wonderful culture.
    Mr. Jones. Thank you, sir.
    Admiral Arthur. Yes, sir.
    Dr. Snyder. Congressman Jones, I have been talking with the 
staff. And at some point this year I hope that we will have a 
hearing of this subcommittee on the specific issue of childcare 
and DOD schools, both domestically and internationally because 
it is so important.
    Mr. Jones. Thank you, Mr. Chairman.
    Dr. Snyder. We are going to start our--let's see, I think 
everybody has been around once. We are going to start our 
second round here.
    I had said earlier facetiously that General Roudebush, when 
he submits his voucher for overtime--it turns out staff 
corrects me. He has submitted a voucher for overtime. We owe 
him $2,873,000. [Laughter.]
    I wanted to get into specifically this--that is not true. 
For the record, that is not true, General Roudebush. I made 
that up.
    General Pollock, I want to direct this question to you, 
General Pollock and Admiral Arthur. But when your predecessor 
was here March 8th, he specifically stated--it was before the 
full committee--``I am concerned about 2008 and 2009 we will 
have an efficiency wedge that, at least as I sit here now, I 
cannot see efficiencies gained to recover that. I have grave 
concern if we are going to be able to meet those budgetary cuts 
in those outyears.'' That is the end of his quote.
    And when I think about efficiencies, I think about, you 
know, energy efficiencies in the home. It turns out if you have 
a front-loading washer, that is much more efficient than a top-
loading washer. And yet the household doesn't notice anything 
different.
    I can also do energy efficiencies just by dropping the 
temperature down three degrees. But that is not an efficiency. 
That is just a cut in service. And I think the concern in this 
committee is not that you are going to end up with 
efficiencies. It is just going to be a cut in service, that 
somebody is going to see something different in their lives.
    So my specific question to you, General Pollock, and you, 
Admiral Arthur, is, as you look ahead for the next calendar 
year, from this day until one year from now, if nothing has 
changed from the mandates you have received from above, in 
terms of civilian conversions or these efficiencies, what 
specific services to our military families and our men and 
women in uniform do you foresee you will not be able to provide 
in the same way that you do now?
    General Pollock. Unfortunately, sir, that is an issue that 
my staff is already working with. The equivalent for us over 
the next calendar year is the budget equivalent for one of our 
large MEDACS. So basically it means we are going to take an 
entire MEDAC out of the ability to contribute to the health 
care of the men and women and their families in uniform. There 
is no way that I can salami slice that. So it will truly be we 
will need to make a decision about what we are going to stop 
doing.
    Dr. Snyder. So it is not an efficiency. It is a flat-out 
cut in service at a time our Nation is at war?
    General Pollock. Sir, it will be a cut in service.
    Dr. Snyder. Admiral Arthur.
    Admiral Arthur. I echo that. If you recall the words of 
Portia, the lawyer in the Merchant of Venice, she said, ``You 
may have your pound of flesh, but draw nary a drop of blood.'' 
There is no more flesh to be gained without drawing the blood 
of the services that our family members and our active-duty 
will have.
    Our cuts are equivalent to one of our large family practice 
hospitals like Camp Pendleton and Camp Lejeune, Pensacola, 
Jacksonville, Bremerton. And we will have to have a serious 
conversation about what services we can provide at 16 percent 
less funding than the year before.
    Dr. Snyder. As a follow-up to that, Admiral Arthur, you 
both equated it to the closing of a large unit. But it is not 
going to be the closing of a large unit. It is going to be 
sprinkled through the system in a way that this committee, this 
Congress, you all are going to have trouble following, I would 
think, in terms of what the cuts in services are. You know, 
every military family that has a delay in an appointment, 
instead of one week, it is a month or whatever it is.
    Instead of having a service at their normal military 
treatment facility, they are going to have to drive 25 miles at 
a civilian facility. That is very difficult to follow, is it 
not? How are you going to follow this impact?
    Admiral Arthur. Well, it is. And I would say we are--with 
the magnitude of these cuts, we are beyond the ability to take 
salami slices. We are going to have to, in my opinion, close 
significant service locations.
    General Roudebush. Sir, if I might add with that.
    Dr. Snyder. Sure.
    General Roudebush. There are several ways to get at that. 
One is the diminution or the loss of services. And actually, 
that requirement never goes away. So those services will be 
provided, but it will probably be in the private sector where 
it could be even more expensive in some regards. But the other 
way that we try and mitigate that and taking risk is with our 
sustainment accounts, our care of our facilities, our buying 
our equipment.
    Dr. Snyder. Through seed corn?
    General Roudebush. Yes, sir. And we push things downstream.
    Dr. Snyder. Yes.
    General Roudebush. And particularly now with Military 
Construction (MILCON), those dollars being in such short 
supply, we are taking care of older and older facilities. So it 
is a bow wave of obsolescence. It is a bow wave of risk because 
we all work as hard as we can to keep those services up to the 
last inch before we have to say okay, we are going to have to 
send that care downtown. So it drives us in a direction that 
has impact in a variety of ways.
    General Pollock. Sir?
    Dr. Snyder. Yes.
    General Pollock. If we cut services and have to send it out 
to the private-sector care, we also lose our ability to ensure 
the continuity of care. We lose our ability to evaluate the 
quality of care that our patients are receiving there. Whereas 
inside the Army now we are using measures which are national 
criteria to ensure that we are providing the absolute best that 
we can.
    And our goal is to not meet those measures, but to grossly 
exceed them so we can clearly demonstrate that our care is 
superior to that available in the private sector. But we are 
unable to even measure that right now in the private sector.
    Dr. Snyder. Of course, I will be a little bit of a devil's 
advocate. The military is always going to have some substantial 
amount of care done in the private sector.
    And if that is a problem, you need to figure out how it is 
not a problem because we are going to have to follow the 
quality and the continuity of care that is done in the out-
patient civilian sector, even care that sometimes is mandated 
on top of you that you just as soon not----
    General Roudebush. Well, sir, if I might speak to that. We 
have good allies in the private sector.
    Dr. Snyder. Right, right. That is right.
    General Roudebush. Our partnership with our TRICARE managed 
care support contractors is as good now as it has ever been.
    Dr. Snyder. Right.
    General Roudebush. And we need to continue to make that 
grow and get better.
    Dr. Snyder. And better.
    General Roudebush. But as that care goes into the private 
sector, there is also the issue of currency. Our providers need 
a caseload. They need the complexity. They need to take care of 
patients in order to stay current up on the step to be able to 
go do the deployed mission as well. So it is important that we 
keep that care in the direct care system for a variety of 
reasons.
    Dr. Snyder. We will go to Mr. McHugh. And then we will go 
to Mr. Kline, who has joined us.
    Mr. McHugh. I will be happy to pass to Mr. Kline.
    Dr. Snyder. Mr. Kline. And then we will go to Mr. McHugh.
    Mr. Kline. Thank you, Mr. Chairman. I understand we have 
already discussed the conflict this morning. I am very much 
disappointed that I couldn't be here for the first hour of this 
hearing because it is hard to imagine a more pressing issue 
right now. And because I did miss the first hour, I will try 
very hard not to trod on old territory.
    Admiral, I would like to go, if I could, to you. And I 
understand you discussed it very briefly. But let's talk about 
corpsmen. The Marine Corps is increasing its end strength 
significantly. And as I understand, as part of this process, 
the Navy is looking at reducing the number of corpsmen. Is that 
correct?
    Admiral Arthur. That is correct. We have the program budget 
decision that this year is going to reduce 283 corpsmen. They 
will be gone by October 1st. We are also looking at the Marine 
Corps' requirement to increase approximately 800 staff, which 
includes some corpsmen. So we are hoping those will balance. 
However, we are not including the Marines' families in that 
calculation. So I think we are still going to be left with----
    Mr. Kline. I am sorry. Explain the balance again. We are 
cutting?
    Admiral Arthur. Yes, sir. The program decision memorandum 
number 4 has required that we cut 901 staff over the next 
couple of years. The contribution in fiscal year 2008 starting 
October 1st will be 283 corpsmen. And this was calculated based 
on the Navy coming down about 30,000 people.
    At the same time, the Marine Corps is increasing 28,000 
people. And we are trying to work with the Marine Corps to 
offset this program decision memorandum so that we can properly 
fill the health service needs of those additional Marines, 
which turns out to be about 700 or 800. We have yet to have a 
firm figure on that.
    Mr. Kline. And what would the Marines do to make this 
offset? I mean, what do you mean you are working with the 
Marines? They don't have any corpsmen.
    Admiral Arthur. The program decision memorandum which took 
900 staff from us is done. It is in the budget. And those 
people, the money are gone. So we have to work with the Marine 
Corps as they increase their staffing by 28,000. The Marine 
Corps must put in a requirement back to the defense health plan 
to increase the staff. They are two separate entities, I am 
being told. One is a cut. It is done. The other is an increase, 
which we now must properly debt through the system and argue 
for the corpsmen and doctors, nurses, dentists to support the 
Marines and, I hope, also their family members who will come 
with them.
    Mr. Kline. Well, it is Washington. Thank you. I yield back.
    Dr. Snyder. Mr. McHugh.
    Mr. McHugh. Let us talk go back to the comments I was 
making about physician losses, 162 that have been lost in the 
military to civilian conversion but take it from a different 
perspective. Two of you noted that you are having trouble 
recruiting in the doctors and into the other health care 
professions. I mentioned what the Congress has done with 
respect to trying to make increases for the health profession 
scholarship program.
    We have increased the loan repayment program for officers 
from $22,000 to $60,000. We have increased the Health 
Professionals Scholarship Program (HPSP) scholarship grant from 
$15,000 to $45,000, increased the monthly stipend, which was at 
$579 a month to no more than $30,000 a year intended, of 
course, to try to facilitate those recruiting.
    Other than addressing the issue from the conversion part, 
which I think is an important component of that challenge, do 
you have any suggestions what this Congress can do to help you 
to be more effective in recruiting health care professionals 
into your ranks?
    Admiral Arthur. Sir, I think there are two facets. One is 
the recruiting, to get young men and women to come into the 
medical and dental professions and the nursing professions. I 
think those scholarships and other programs are terrific. I 
hope in the next few months to be able to announce a program in 
the Navy to do a medical enlisted commissioning program where 
we take some bright young corpsmen and put them through medical 
or dental schools.
    I think another important facet is to retain the talent 
that we already have, to craft the bonuses and shape the 
organizational rank structure to keep the gray hairs, if you 
will, the people that have the most experience in combat 
service support and trauma management and have the highest 
degree of medical skill.
    We are seeing, paradoxically, the highest retention rate 
that we have had in some time in our general surgeons. And we 
are seeing that, I believe, because the quality of the service, 
the kinds of service, and the rewards they get from the service 
on these casualties is so great that they will stay in just for 
the satisfaction of the practice.
    Mr. McHugh. General Pollock.
    General Pollock. Sir, the retention bonuses and being able 
to correct them and level some of the disparity between a 
military salary and a civilian salary so that we can keep the 
people that have already developed the foundation of military 
health care and not lose them to the civilian world because 
they are being very aggressively recruited. And as we look at 
the multiple deployments and the year deployment for the Army, 
the year away from their families knowing that they will face 
that year again, it is very, very difficult to retain them.
    Mr. McHugh. General Roudebush, your testimony didn't 
mention you were having recruiting problems. Two years ago 
General Taylor suggested, in fact, stated that there were some 
challenges in that regard. What did you do that has been so 
successful? Great leadership, I know. But beyond that?
    General Roudebush. No, sir. The concerns remain. The HPSP 
program is a major source for us. And thank you for the 
increased authorizations within that pay structure. And now we 
are working--because those are reserve pay dollars that, in 
fact, support that to work to be sure that there are dollars 
available to move into that. We have continued to work both on 
scope and quality of care to retain the individuals once, in 
fact, we do recruit them. But we still have concerns and 
difficulties in recruiting fully qualified.
    The additional bonuses and the authorities in that regard, 
I believe, will be helpful as we work through that. But we are 
no less concerned relative to our ability to do that. And 
certainly, within the realm of nursing, a very competitive 
environment to recruit nurses.
    And I would also suggest that there are also issues within 
the reserve realm in terms of being able to recruit reservists 
of all varieties, whether physicians, nurses, in order to do 
that as well. And we look forward to working certainly with 
Congress on incentives that will make that both more attractive 
and more fulfilling for reserve duty as well because they are 
an important part of what we do.
    Mr. McHugh. Thank you. Just while I have got a yellow 
light, I made a comment earlier that Secretary Winkenwerder 
suggested that the efficiency wedges in the military to 
civilian conversion targets were certainly could be revisited. 
Are you aware of any revisitation happening in that regard, yes 
or no?
    General Roudebush. In terms of within the Department 
revisiting the efficiency wedges, I am not aware of any 
activity. I will tell you with the mil-to-civ conversions 
certainly all the way up through our secretary, Mr. Wynne, we 
are concerned what that means in terms of the 2008 activity, 
particularly because we have to certify by virtue of 
congressional requirement that there will be no detriment to 
neither access or quality of care.
    So for us to be able to certify at the secretarial level, 
we do have some concerns and will be addressing that, sir.
    Mr. McHugh. That is another issue we will get to.
    Okay. Yes or no, any formal re-evaluations?
    General Pollock. Sir, I have been involved in some 
discussions that they were willing to relook it. But I don't 
know what specific steps would be required at the DOD level. As 
a point of clarification on the earlier question, the original 
mil-to-civ conversions that the Army faced was an Army decision 
because of the operations tempo (OPTEMPO) they wanted to move 
more people into the line and away from the fixed or the 
garrisoned organizations.
    So thinking that they would be compatible with conversion 
to civilian support so that they would have the military 
strength in the line organizations. But again, some of the 
decisions we need to relook because what we thought we could 
hire and what would be available across America have not borne 
true.
    Dr. Snyder. Ms. Davis.
    Mrs. Davis of California. Thank you.
    I think we are all familiar with unintended consequences. 
And we really need to look at that.
    I wanted to just share one of the concerns that I would 
have from a number of the families that I have met with. At 
what point do we think that this begins to effect retention? As 
we know, families feel that the medical benefits that they get 
are fabulous. And, you know, they rave about them. And they are 
very important to them.
    But when a mom, you know, can't see the pediatrician or 
doesn't feel that the pediatrician even understands what it is 
like to go through multiple deployments or really relate to the 
military family because it is a civilian conversion, that 
begins to change their on-going decisions.
    And so, I think we just need to be aware of that and make 
sure that we work to do what we can for those families so they 
feel that they are being taken care of. Because otherwise, that 
benefit, you know, to the other person who gets a vote in all 
this doesn't seem very important any more.
    I appreciate it. I know you understand that.
    I wanted to ask you about the article in the New York Times 
Magazine the other day by Sara Corbett. I don't know if you 
happened to see that about women in combat and women in theater 
and the impacts of PTSD on women, particularly as primary care 
givers, but also some of the instances that were cited in the 
article, abuse to women in theater and how that is being dealt 
with and how the services are providing the kind of care and 
support that the women need and being certain that they get 
that while in theater and then they certainly get that when 
they return home.
    Could you speak to that?
    General Pollock. Ma'am, I have not seen that article. But 
we have looked at the gender differences to see if there are 
gender differences for PTSD, for example. And they are 
comparable. They are in the 15 to 20 percent reported rates. 
And there has been some discussion because women traditionally 
have been more willing to talk about their emotions, they are 
more willing to discuss how they are feeling and where they are 
at any one particular time.
    But that is still relatively new for us to look at. And it 
will require more attention and more research as well.
    Admiral Arthur. I also have not read that article. But I 
can tell you that there is a lot more that we need to know 
about women in combat, especially direct combat. This is the 
first conflict where we have really had substantial numbers, I 
think, especially as they come back with significant injuries.
    And this was brought to me by one woman who asked me how am 
I going to hold my baby with this plastic arm. And I was 
immediately embarrassed that I had not thought about those 
special circumstances that we really need to account for. So 
there is a lot that we don't know and that the current cohort 
of women in combat are teaching us.
    General Roudebush. Ma'am, I have read the article. And I 
understand there are some concerns about it. But the issue, I 
think, is a very pointed and a very valid one.
    Certainly, in terms of sexual assault and harassment, we 
have all taken steps to put advocates and a response system 
both at home and deployed to be able to attend to that and to 
be able to address those needs. But there is also, I think, the 
commander's accountability and responsibility to set the tone, 
set what is acceptable within a realm. And I think the 
attention is certainly moving that in the right direction.
    Relative to PTSD, there is no gender immunity. And we need 
to be as concerned regardless of gender. Every individual who 
is exposed to that needs to have those resources available. So 
we are certainly attending to that.
    Mrs. Davis of California. Yes. I appreciate that. I think 
we are all concerned that, you know, for years health studies 
were done on men and perhaps didn't take in the special 
dynamics that would affect women. And I think in this same 
regard, I appreciate your talking about the research because we 
need to be proactive. We certainly need to be helping our 
commanders in the field to have a high level of consciousness.
    But at the same time, you know, there is a lot that perhaps 
we don't know. And so, I would hope that as we see some dollars 
and, you know, perhaps siphoning those off in some way, you 
know, to be certain that, you know, have we thought about this 
and make certain that we are really addressing this issue.
    Admiral Arthur. Yes, ma'am. I can tell you from my initial 
read of the draft of this mental health task force report that 
I am reviewing now this is given a significant amount of 
diligence in that report and looking at not just what are we 
doing, how can we do it better, but what should we be doing, 
what is the model and taking into consideration the entire 
family. So women's health is highlighted in that report.
    General Roudebush. And given the fact that our combat 
service support are at risk in these theaters. There is no 
front line necessarily. Everyone is certainly at risk.
    Mrs. Davis of California. Yes. You know, the other thing 
that we haven't talked about is that even our health care 
providers, in many cases, are susceptible to burnout and trauma 
as a result of treating trauma patients. And we need to be 
thinking about them.
    General Roudebush. Ma'am, we need to take care of our 
medics because every time you put a hand on a wounded 
individual, you are now part of their life. And there is a cost 
to that. It can be compassion fatigue. It can be burnout.
    As we bring our folks back, we have to pay very close 
attention to their recovery and their reconstitution, their 
ability to deal with that because in a microcosm, they are 
giving and giving and giving in a very fulfilling way to be of 
service. But it still comes at a cost. And we need to be 
attentive to that.
    Dr. Snyder. General Pollock and Admiral Arthur and General 
Roudebush, the article that Ms. Davis called to my attention 
last week is from the New York Times Magazine March 18, 2007, 
``The Women's War'' by Sara Corbett.
    And, without objection, Mr. McHugh, let's include this as 
part of our record.
    [The information referred to can be found in the Appendix 
on page 185.]
    Dr. Snyder. And I have no expectation that you all read 
everything that is in the press out there about men and women 
at war and their families. But if you would respond for the 
record to this.
    And, General Roudebush, you can have another bite at the 
apple, too, if you would like, to respond to the record. And 
hopefully you can work your way through the approval system of 
OPM in a way that it will be timely in giving to this committee 
and might be helpful.
    Mr. Jones.
    Mr. Jones. Mr. Chairman, thank you.
    General Pollock, I am very interested--it might be in your 
printed testimony. You might have discussed this before I got 
here. It is one of the more difficult specialties to entice 
graduates of medical schools in the area of orthopedic surgery. 
Is that a problem in trying to recruit those who specialize in 
orthopedic surgery?
    General Pollock. Well, we recruit very few who are board 
certified in orthopedic surgery. Generally we educate our own. 
And as the other offices have identified, our training programs 
are often in the top 10 in the nation. So the men and women 
that we train as orthopedic surgeons are truly phenomenal.
    Mr. Jones. Right.
    Admiral Arthur, it seemed like several months ago I had the 
privilege to visit the hospital at Cherry Point. And in talking 
with those in the leadership at the hospital and knowing of all 
these cuts that you are going to have to deal with and we in 
the Congress are going to have to deal with, there was a 
concern. And I don't know if this has taken care of itself or 
not. And you can answer this.
    That as we began to save monies, instead of being open 24 
hours a day, we would be open 12 hours a day. There was concern 
down at Cherry Point that the fact that there would not be a 
facility open at night from--I don't know what the time was. I 
can't remember. But let's say 12:00 a.m. to 6:00 a.m. in the 
morning, particularly with Marines out training, should someone 
be injured.
    Is this happening at more bases than not, that instead of 
being open 24 hours or having some type of urgent-care-type 
facility? What is the policy? And I would ask all three this 
question. And it can be a very quick answer, if you want to.
    Admiral Arthur. We are looking at what services we can 
provide based on the projected staffing that we are going to 
have. At Cherry Point, as I mentioned before, 20 percent of the 
staff is currently deployed. And we are trying to downsize a 
bit because, as you know, it has been base realignment and 
closure'ed (BRAC'ed). We have got Carteret and Craven, which 
are our main sources of care there. And if an emergency were to 
occur that requires a surgeon or higher level trauma care, 
Cherry Point is not the place to bring them, whether it is 
daylight or nighttime.
    Mr. Jones. Sure, I understand.
    Admiral Arthur. They should go to those other facilities. 
My concern is obstetrician (OB) care and those other family 
issues that as we downsize that facility--and the Marine Corps 
has plans to increase the number of aircraft in squadrons on 
that base--that we provide those families of deployed Marines a 
timely access to family level care. And we are working through 
the issues of the network. I know our TRICARE contractor is 
being very, very diligent there in helping to expand that 
network to support the families.
    Mr. Jones. General.
    General Roudebush. Sir, over the last 15 years we have 
closed a significant number of small hospitals because they 
were both inefficient and, frankly, not busy enough to maintain 
the kind of currency and competency and there was care 
available in the community. And in working with our managed 
care support contracting partners and our community partners we 
have been able to provide that care in those circumstances.
    And relative to the emergency response, we work that in 
partnership with the communities in which our bases are part of 
those communities. So it is a collaborative association. And on 
base in many circumstances, the fire department also has an 
Emergency Medical Service (EMS) capability. And we leverage 
that as well where that is available.
    General Pollock. Across the AMED as well, sir, we have 
looked at the volume and the competency of the staff that would 
be there and made the decision in a number of locations to not 
call them emergency rooms any more because they do not have the 
capacity that justifies being called an emergency room. But for 
many folks, because we have grown up talking about well, if you 
needed care quickly, you went to an emergency room, what we 
need is access to care when we define we need it. And that is 
the expectation of the patients.
    And that is one of the challenges that we face because they 
become very frightened when they understand that how they 
perceive access to emergency care is changing. So it is very 
important that as we make those decisions we have a very 
aggressive communication and education plan so that people 
understand that for what they would need the care is available. 
We are not eliminating that care.
    Mr. Jones. Thank you.
    Thank you, Mr. Chairman.
    Dr. Snyder. I have three more questions which we may be 
able to move through fairly quickly. And then we will go to Mr. 
McHugh and then to Ms. Davis.
    And starting with General Roudebush and going down the 
line, do you have a precise number in your mind about the 
number of medical holds and medical holdovers that you all are 
currently following in the Air Force now?
    General Roudebush. Yes, sir. In the Air Force, we are 
following 52 active-duty and 256 reserve medical hold, if you 
will. However, the definition for medical hold for us is 
somewhat different than the Army. So there is a small 
distinction there.
    For us our medical hold individuals are those that are at 
the end of their term of enlistment or service and they have an 
issue that needs to be attended to before they transit either 
into the VA system or into civilian life. And we work through 
that before we, in fact, go ahead and either separate or 
retire.
    Dr. Snyder. Admiral Arthur.
    Admiral Arthur. Yes, sir, we have 134 Navy, Marines and one 
Coast Guard that are involved in Operation Iraqi Freedom (OIF) 
or Operation Enduring Freedom (OEF)-related injuries. We have 
an additional 203 who are in medical hold for other reasons 
such as cancer and prolonged illnesses. So most of the OIF 
casualties are housed at the wounded warrior barracks at either 
Camp Lejeune or Camp Pendleton.
    Dr. Snyder. General Pollock.
    General Pollock. Sir, we have approximately 1,000 active-
duty medical hold soldiers and about 3,200 medical holdover. 
And so, it depends on where they are in the country. Some of 
them will be co-located at an installation or at one of the 
Community Based Health Care Organizations (CBHCO).
    Dr. Snyder. No, I understand that, General Pollock. I just 
wanted to get a sense of the number.
    And then the question for Admiral Arthur and General 
Pollock. This specific issue of there has been some activity in 
Congress about the events of Walter Reed leading to a proposal 
to change the BRAC decision with regard to Walter Reed. My own 
view is that that, I think, would be a mistake. But I wanted to 
hear you all's perspective since it impacts on both your 
facilities.
    General Pollock.
    General Pollock. Sir, I think that it is very important 
that we continue with the BRAC. But we must be fully funded in 
order to do that. Fully funded in order to do that is about 
$400 million. And that would allow us to truly develop the 
world-class facilities that are essential at both the Bethesda 
campus and down at Fort Belvoir.
    And it will also be important that we have relief from some 
of the requirements and legislation that have prevented us from 
investing in facilities once it is identified as a BRAC 
location. So we will need the funding to ensure that we sustain 
Walter Reed at a high level throughout that entire transition 
period.
    Dr. Snyder. Admiral Arthur, do you have any comment?
    Admiral Arthur. Yes, Dr. Snyder. I agree with what General 
Pollock said.
    We have an opportunity to create a tremendous national 
asset with the Walter Reed National Military Medical Center 
juxtaposed to the National Institutes of Health, the National 
Cancer Institutes with the USUHS, Uniformed Services University 
of Health Sciences, on the property as a great medical school 
and to build the facility that the National Capitol area needs 
in that location as well as to plus-up the Fort Belvoir 
facility. And this is our opportunity to create a much better 
facility than either of the two could be as stand-alones.
    Dr. Snyder. And my final question is the bill that passed 
out of the full Armed Services Committee last week and will be 
on the floor this week that will be called the Wounded Warriors 
Bill. Have any of you had a chance to look at it and have any 
thoughts or criticisms about it. Would you share that with us 
today?
    We will start with you, General Pollock.
    General Pollock. One of the concerns that I do have and I 
have shared with the line Army is it is important that we not 
discriminate against the different warriors. Not all of them 
are combat injuries. And the ones who are not combat injuries 
deserve the same level of care as the others. So I just would 
like to remind you that it is a warrior medical assistance 
process because we certainly don't want to only take care of 
our wounded soldiers.
    I think that I would like to provide some of the feedback 
from the staff in writing as your response. And we can do that 
for you quickly, sir.
    [The information referred to can be found in the Appendix 
beginning on page 209.]
    Dr. Snyder. Is there anything specific in the legislation, 
other than the terminology, the title of the bill, a provision 
that you think specifically discriminates between those who are 
combat wounded and those who maybe have picked up an illness or 
something overseas?
    General Pollock. Well, the concern that we have is so many 
people now--and now the Congress included--is using the phrase 
``wounded warrior.''
    Dr. Snyder. As is the military. Your point is----
    General Pollock. And that is why I said I started with the 
Army leadership.
    Dr. Snyder. Well, your point is a very good one.
    General Pollock. Just trying to make that point, sir, so 
that we don't cause yet other second and third effects.
    Dr. Snyder. I get your point.
    Admiral Arthur.
    Admiral Arthur. Only small things that we have looked at so 
far. One of them is case management. We have a very robust 
program for case management that isn't only centered on the 
nurse case managers, but on social work, on administrative 
staff who are non-medical who support the families and deal 
with the pay and records issues.
    So some of the issues surrounding the case manager and the 
requirement to be an active-duty service member who does that 
we might want to have reviewed because I think we have got a 
robust system that is contracted civilian. It is active-duty.
    And I think the purpose of the bill is to ensure that every 
service member who needs one has appropriate case management, 
which should include the medical and administrative needs and 
the family needs involved in their care.
    Dr. Snyder. General Roudebush.
    General Roudebush. Yes, sir. We, too, use a case manager 
approach also in our reserves. We have at the command level 
case managers who are managing reservists in their communities, 
if you will, getting their care. So we think the case manager 
approach is a very good one. And we look forward to working 
with you to identify both the ratio and the location for 
medical and administrative family support in terms of case 
managers.
    And also the training activities are identified in the 
language are good, particularly with the disability evaluation 
system being sure that our folks that are dealing with that are 
properly trained. And we will look forward to that.
    And if I could add one comment on the BRAC.
    Dr. Snyder. Yes.
    General Roudebush. The focus has been on Walter Reed and 
Bethesda, and very appropriately so. But Malcolm Grow Medical 
Center at Andrews is a key player in the National Capitol area, 
both in terms of the implications and the execution of the BRAC 
as well as meeting the needs for Andrews Air Force Base and the 
key missions that they support. So I just want to be sure that 
as we pay appropriate attention that that is not lost as we 
move through.
    Dr. Snyder. Thank you. Yes. I thank you for that comment, 
General Roudebush.
    Mr. McHugh.
    Mr. McHugh. Well, actually, Mr. Chairman, you took my 
intended question on BRAC. And I am glad you did because I 
think we heard valuable input. And the funding is an absolutely 
critical component of this, including, by the way, over $470 
million if you factor in the cost increases that have been 
effected by inflation and time, as happens in our economy, of 
course. So we have got an important role to play there.
    Let me just state--and if any of the members want to 
comment--that we have had a kind of challenging history, if you 
will, between the services and this Congress with respect to 
military to civilian conversions, particularly as they relate 
to required--beginning in 2006--required certifications. And we 
have had some ups and downs and starts and stops and fits.
    And suffice to say that right now we are by law have a 
freeze on military to civilian conversions prior to an expected 
submission of report that was due in January. I believe it was 
January 17th. And we are still waiting on that.
    Was it you, Admiral, that spoke about you are working on 
that certification? Can you fill me on a little bit more about 
what is happening there?
    Admiral Arthur. We are working on that. It is very 
difficult to certify cost, quality, and access prospectively 
because quality and cost can be a retrospective look at the 
lagging indicators, if you will.
    Mr. McHugh. Well, you owe us a retrospective look as well 
because we required recertification.
    Admiral Arthur. Yes.
    Mr. McHugh. Correct.
    Admiral Arthur. I would say that in clarification these 
conversions cannot be made until the certification is done. 
However, the military billets that derive into that process are 
cut on October 1st. So our military billets are gone by 
recertification.
    Mr. McHugh. You mean Personnel Army Manning Document 
(PMAD)?
    Admiral Arthur. Pardon me?
    Mr. McHugh. You mean the PMAD? I would say yes, there is a 
definitional difference between how the services and how you 
had been instructed that versus how we do. I agree with that. 
And I don't think that is a call you made, but it is a call I 
am very unhappy with.
    Admiral Arthur. Yes, sir.
    Mr. McHugh. Because common sense should tell those who made 
that interpretation for you that Congress intended that to be 
outright freeze. And if you are losing the billets, you are 
losing the people. I mean, that is a conversion.
    Admiral Arthur. No, sir. The billets are gone October 1st.
    Mr. McHugh. Yes.
    Admiral Arthur. And even if we were to convert, we don't 
get the conversion money until third or fourth quarter.
    Mr. McHugh. I understand. But that wasn't your decision.
    Admiral Arthur. No.
    Mr. McHugh. It was somewhere else.
    Admiral Arthur. Correct.
    Mr. McHugh. The conversions or the certifications are 
something we are waiting for. So we are going to get them, 
right?
    Admiral Arthur. It is at the secretary of the Navy level at 
the moment.
    Mr. McHugh. Okay.
    How about the Army? Do you know, General?
    General Pollock. I know it is with the under secretary, 
sir.
    Mr. McHugh. All right. So they are out of your shop?
    Is that the same for you as well, General?
    General Roudebush. Yes, sir.
    Admiral Arthur. Yes, sir.
    Dr. Snyder. Okay. Thank you.
    Mr. McHugh. Thank you, Mr. Chairman.
    Dr. Snyder. Ms. Davis.
    Mrs. Davis of California. Thank you, Mr. Chairman. And I 
know we have more panels, so I will try and be brief.
    I wanted to just address the issues around the Guard and 
Reserve and the fact that we have so many men and women 
returning to communities that may be somewhat remote and with 
difficulty of receiving the kind of follow-up care that they 
might need. How do you see that that is being addressed? And do 
these conversions effect that at all?
    General Roudebush. Ma'am, I can speak for the Air Force. 
For our reservists, our Guard and Reserve, we keep them on 
status. They are put on Manpower Personnel Account (MPA) days, 
which keeps their full benefits and entitlements coming while 
we work through with them in their communities the health care 
issues that are identified.
    So we use case managers at the Major Command (MAJCOM) level 
that deal with these folks on a daily or weekly basis to make 
sure that they are getting the care that they need and that 
their circumstances are properly adjudicated and come to a good 
conclusion. So for us----
    Mrs. Davis of California. Was there a tendency at the 
beginning to not have them return to their home communities? 
And I know their families were----
    General Roudebush. No, for us in the Air Force that is the 
way we have worked it by policy. And that also puts them back 
in their support realm where their commanders can attend to 
them as well so that we have that support structure in place. 
But that is the Air Force policy to do that and has been.
    Admiral Arthur. Navy and Marine Corps do very much the 
same. We send them back to their home units. And we have case 
managers in the Navy and Marine Corps who follow each and every 
member.
    Mrs. Davis of California. Do you feel that the support is 
there, they can get the care that they need?
    Admiral Arthur. I think it is because we have the case 
managers who keep track of each patient and know when their 
appointments are. If they need to be kept on active duty 
because of continuing medical issues or surgery that is needed, 
we do that. So we only let them go back to their home stations 
when they are stable and healing and we are following their 
progress prior to a medical board.
    Mrs. Davis of California. Okay. I guess part of the concern 
would be in defining whether they are going to stay in the 
service or not and what that transition period for the VA is.
    Admiral Arthur. Yes.
    Mrs. Davis of California. And I appreciate that issue. And 
just quickly, I think you spoke to the need to anticipate the 
needs of the service members and so that we are embedding some 
of the behavioral health providers in units. I know that in San 
Diego--and I think that we are going to hear from Mr. McIntyre 
shortly.
    But what they are doing with the special forces there is to 
embed a nurse with the unit because they felt that actually 
they weren't getting some of the care, that that had been a 
problem. Do you see that? Or do we have special forces units, 
for example, that, in fact, have missed out in some ways on 
some of the care that they should be receiving?
    Admiral Arthur. The special forces units, the Seals in the 
Navy have made a decision that their health care providers are 
going to be from the Seal units. They will train their own 
health care providers. So they don't use Navy corpsmen far 
forward. They use Seals that they have specifically trained to 
be paramedics.
    I applaud Mr. McIntyre's efforts to get that nurse embedded 
with the units. I think it is very innovative. And I think it 
speaks to the integration of our TRICARE contractors with our 
military treatment facilities and the dedication of, especially 
Mr. McIntyre and his focus on supporting the warfighter and 
their families. He saw an opportunity and supported it as well 
to support the comprehensive combat casualty care center that 
has just been opened at Balboa, which is a collaboration 
between Balboa, Camp Pendleton Naval Hospital, the Veterans 
Administration, and TriWest as the TRICARE provider.
    Mrs. Davis of California. So hopefully we will see more of 
that kind of activity?
    Admiral Arthur. Absolutely. Put the patients closer to home 
so that they can be properly supported.
    Mrs. Davis of California. Okay. Thank you very much.
    Thank you to all of you.
    Thank you, Mr. Chairman.
    Mr. McHugh. Mr. Chairman.
    Dr. Snyder. Thank you, Ms. Davis.
    Mr. McHugh.
    Mr. McHugh. If I may, just for the good of the order, a 
little housekeeping here. The staff has identified on the New 
York Times Web site an addendum, a correction to one of the 
cases that existed in the article that you have very rightly, 
and I think appropriately, included in the record. I think just 
for procedural sake--and I don't think it in any way changes 
the overall challenge presented by the article.
    But this correction as appearing on the Web site ought to 
also, without objection, be included.
    Dr. Snyder. Without objection, we will include that in the 
record also.
    [The information referred to can be found in the Appendix 
on page 206.]
    Mr. McHugh. Thank you.
    Dr. Snyder. So that you all can respond to the article plus 
the addendum in total.
    Anything further, Mr. McHugh.
    Mr. McHugh. No, thank you.
    Dr. Snyder. Okay.
    Ms. Davis, anything further?
    Mr. McHugh. God bless you.
    Dr. Snyder. We want to thank you all for being here.
    General Roudebush, I appreciate you letting me use you as a 
pawn today in my discussion about the tremendous service that 
all our men and women in uniform and their families give in 
terms of well beyond what most of us perceive as the American 
work week.
    And, General Pollock, I neglected to mention that I spent a 
couple of unexpected nights at Tripper Army Medical Center some 
years ago and probably received the best advice I have ever 
received in my life from a cardiologist there. And I appreciate 
your service and also you stepping forward at a challenging 
time in the position that you are in. We appreciate you being 
here today.
    And, Admiral Arthur, our gratitude to you for your 33 years 
of service to the Navy and to the country. And I look forward 
to seeing you again, perhaps not testifying before this 
committee, but we appreciate your efforts and everything you 
have done for the Navy.
    Admiral Arthur. Thank you.
    Dr. Snyder. And, Mr. McHugh, why don't we say we will pick 
up here in precisely five minutes and give everyone a chance, 
including our next table of witnesses, a chance to bust for the 
restroom if they need to. But this will be in military five 
minutes, not congressional five minutes. So we really will be 
back here.
    [Recess.]
    Dr. Snyder. Let's resume our hearing.
    And, gentlemen, we appreciate your patience and appreciate 
your attending the first session. These issues are obviously 
very important, not just to this subcommittee, but to the 
American people. And we appreciate you being here.
    Our second panel is Mr. David McIntyre, Jr., who is the 
President and chief executive officer (CEO) of TriWest Health 
Alliance; Mr. David Baker, the President and CEO of Humana 
Military Health Care Services; and Mr. Steve Tough, the 
President of Health Net Federal Services.
    And we will begin with Mr. McIntyre and go down in that 
order.
    And as I instructed the first panel, we will have David put 
the light on, but that is just to give you an idea of the time. 
If there are some things after the five minutes that you need 
to tell us, don't let the red light stop you from sharing those 
with us.
    So, Mr. McIntyre, we will begin with you.

STATEMENT OF DAVID J. MCINTYRE, JR., PRESIDENT AND CEO, TRIWEST 
                      HEALTHCARE ALLIANCE

    Mr. McIntyre. Good morning, Mr. Snyder, Ranking Minority 
Member McHugh, and Congresswoman Davis. Thanks for the 
invitation to appear before you today.
    It is an honor to be here to talk about how our 
organization, in collaboration with TRICARE regional office 
West, and our west region military treatment facility partners 
are doing whatever it takes to make good on the promise of 
TRICARE for those that reside in the 21-state region, more than 
2.8 million beneficiaries.
    Together we are taking a concerted proactive approach 
toward ensuring that these most deserving individuals have 
access to quality care and dedicated customer service, that 
which they have earned.
    I request that my written statement be accepted for the 
record. It details much of the work that we have accomplished 
with regard to communication and education of both 
beneficiaries and providers, our robust behavioral health 
initiatives, our comprehensive formalized program to partner 
effectively with the direct care system, a program we call 
Joint Strategic and Operational Planning Process (JSOPP), which 
is affording facilities in our region to do a make, buy 
business case and much more.
    Our overall environment in the west region is one of 
success. It has come from collaboration and as a result of the 
partnership that we together have built and maintained in our 
on-going effort to leverage the strengths of our colleagues for 
the benefit of our joint military family customers. It is on 
these successes that I would like to concentrate my oral 
remarks today.
    Our provider network, which exists to serve as a resource 
and in some cases, a safety net for the military treatment 
facilities, has grown, and we continue to enhance its ability 
to serve our beneficiaries. Our 18 owner organizations also 
serve in the local west region communities as our network 
subcontractors. I am pleased to announce that our network is 
growing 1 to 2 percent a month, and we are now to 117,000 
providers across the 21 states. And it is an example of the 
power of progress inherent in this collaborative focused 
partnership.
    Seeking to make sure that the network reaches into the 
communities where there is a substantial presence of Guard and 
Reserve we have called on the 21 governors of our region to 
join with us in thanking the doctors that are part of our 
network today and encouraging the others to reach out and 
support their fellow citizens in the state, much like, Mr. 
Chairman, the concept that you put in the AMA News a year or so 
ago.
    To date, 15 governors from our states have stepped up and 
done exactly that. Working together we have been able to grow 
the network, particularly in the outlying communities, to make 
sure that the Guard and Reserve have a robust network on which 
to rely.
    In the OB area, an issue of focus for this committee a 
couple of years ago, we placed substantial effort along with 
TMA to try and get them to change the rates so that in no state 
did we have OB rates that were below Medicaid as it related to 
TRICARE. Seven of those states of the nine were in our region.
    I am pleased to say that the folks at TMA did a great job 
with the involvement of this committee in addressing that 
issue. And we have now grown that network by 71 percent in our 
region as a result of the policy change.
    And we thank you on behalf of all of the families in our 
region for your work, especially your leadership personally, 
Mr. Chairman, in this area.
    In spite of all these successes, we are seeing challenges, 
as mentioned by Congresswoman Davis, with behavioral health. A 
5.8 percent cut in reimbursement rates is absolutely 
unsustainable in terms of making sure that the providers rise 
to the occasion in our region and come alongside those that 
have increasing demand in this area. I think, like OB, we have 
a problem because of the anomaly of Medicare and particularly 
given the growth of demand that we are seeing in this area.
    For the Guard and Reserves, we continue our aggressive 
outreach. As many units within our region were activated and 
mobilized overseas and to our borders, we joined forces with 
Tricare Regional Office (TRI)-West to vigorously pursue 
numerous opportunities for educating and growing the 
beneficiary base. We have also done a couple of innovative 
things with the Guard and Reserve. We put DVDs out to all the 
families.
    We are in the process of releasing the second version that 
is aimed predominantly at children and their parents. We have 
embedded the combat stress team concept in the California Guard 
as a test. As Congresswoman Davis was talking about, that is 
being met to much success. And we also have an integrated 
project in Hawaii that links medical surge and behavioral 
health together.
    As was mentioned previously, we now are focusing on those 
that are at the sharpest point of the spear. And that is the 
special operations teams. I have had the ability to visit with 
the head of the Navy Seals and to talk about the challenges 
that they face and their families face in making sure that they 
don't drop through the cracks. These are folks, as we all know, 
who bear a disproportionate burden because they are often 
called at night and leave the next day.
    Their families don't know where they are going. They don't 
know when they are coming back. They don't know how long they 
are going to be gone.
    The Seals tell me that they are suffering nearly a 40 
percent casualty rate. And they are on average on their ninth 
deployment. It is very important that all of us continue to 
look for those gaps in the areas that we together can plug and 
make the system sharper for all. And I am excited about the 
work that we are doing together in our region in that area.
    Last, in response to the Walter Reed situation, we freed up 
$1 million a couple of weeks ago, reached out across our region 
to ask how we might be of assistance to our military partners. 
One of the things that I am most excited about is something 
that we are starting with the Navy and the Marine Corps in the 
West. And that is what I would call an integrated care 
management prototype.
    We are actually taking the concept that we are in the 
process of working with the Seals and embedding that together 
with the Navy and the Marine Corps in our region up and down 
the West Coast. We have a seat at the care management table. 
That allows us not to drive where a patient goes because that 
is not our decision. It allows, though, for us to look as a 
team end to end on what the needs of that patient are and where 
it is possible that we might be able to place them in the 
private-sector network if there is not capability and capacity 
available in the VA system.
    And so, we are very excited about that. It is just starting 
under way this last week or two. And we are looking forward to 
doing our part.
    At TriWest, we believe that the successful delivery of 
services is a cooperative approach, a joint effort among all 
the stakeholders in our region: our company, our owners, our 
TRI-West leaders, our civilian and military medical partners 
and you. By working together with our beneficiaries' best 
interests in mind, we can make this program more effective.
    I would last like to offer one thought on the budget as I 
close. And that is we do have challenges. And I think that it 
is fair to say that none of us, not you, not the services, not 
ourselves anticipated the kind of demand that we are looking 
at. While I know it was politically complicated last cycle, I 
believe that it is time to reopen the question of whether there 
should be mandatory home mail delivery of pharmaceuticals.
    That is not a change in the benefit. It is a change in the 
delivery of a product for maintenance drugs. It has been done 
for the VA for some time. And you can pick up somewhere between 
$600 million and $1 billion by doing that.
    Thank you very much.
    [The prepared statement of Mr. McIntyre can be found in the 
Appendix on page 118.]
    Dr. Snyder. Mr. Baker.

STATEMENT OF DAVID J. BAKER, PRESIDENT AND CEO, HUMANA MILITARY 
                   HEALTHCARE SERVICES, INC.

    Mr. Baker. Thank you, Mr. Chairman. Dr. Snyder, Mr. McHugh, 
Ms. Davis, thank you very much on behalf of the dedicated men 
and women of Humana Military Healthcare Services for the 
opportunity to update you today on the state of the TRICARE 
program from our perspective. I have provided a written 
statement for your consideration.
    Dr. Snyder. I should have said earlier, Mr. Baker, all the 
written statements from both the previous panel and this panel 
will be made a part of the record.
    Mr. Baker. Perfect. Thank you very much, Mr. Chairman.
    Dr. Snyder. Without objection.
    Mr. Baker. For background, our company was awarded its 
first TRICARE contract in 1995. And we began serving military 
beneficiaries in 1996. Since 2004, we have been administering 
our current TRICARE contract for 2.8 million TRICARE eligible 
beneficiaries in DOD's south region of the United States.
    And though it does not seem possible, on Sunday, April 1st, 
we will begin the fourth option year of our five-year contract. 
And as we begin the new option year, it is my feeling that the 
operational status of TRICARE is excellent, thanks in large 
part to the tangible support of this subcommittee, the 
oversight of the Department of Defense, and the superior 
service being rendered by your contractor partners, especially 
those represented on this panel to my right and left.
    I believe active-duty military personnel, retirees and 
their family members have exceptional access to a rich array of 
high-quality health care services that are being delivered as 
cost-effectively as possible. Service levels are outstanding. 
Processes are stable. And all available evidence indicates high 
satisfaction among TRICARE members.
    Mr. Chairman, my written statement highlights the status of 
the program across several domains, including cost control, 
clinical quality, access to health services, and service to the 
deserving members of the military community, both active and 
retired. And I have provided examples of processes and programs 
that we have successfully implemented in the south region under 
the current contract structure. I am happy to report that after 
some initial disruption during startup these processes and 
programs are working very well.
    And I chose this array for my statement cost, quality, 
access, and service, because it reflects the objectives of the 
TRICARE program as originally set forth by both the Congress 
and the Department of Defense a decade-and-a-half ago. To be 
sure, there are challenges for the program, particularly today. 
But the important point is that today's TRICARE program has 
been able to meet the challenges of a changing world 
environment.
    Against that backdrop I am aware that this subcommittee and 
others on Capitol Hill are carefully examining the delivery of 
health care to our service members and veterans alike and that 
the TRICARE program undoubtedly will be subject to careful 
scrutiny. I applaud those efforts.
    But as you go about your critical work, please bear in mind 
that today's TRICARE program is working very well. We at Humana 
Military Healthcare Services look forward to working with you 
and with our Department of Defense partners to continue 
fulfilling the promise of TRICARE for many years to come.
    Again, Mr. Chairman, please allow me to thank the 
subcommittee for the opportunity to be here today. And I look 
forward to your questions.
    [The prepared statement of Mr. Baker can be found in the 
Appendix on page 137.]
    Dr. Snyder. Mr. Tough--and I am pronouncing that correct?
    Mr. Tough. That is correct, sir.
    Dr. Snyder. Mr. Tough.

  STATEMENT OF STEVEN D. TOUGH, PRESIDENT, HEALTH NET FEDERAL 
                            SERVICES

    Mr. Tough. Thank you. Good morning, Chairman Snyder, 
Congressman McHugh, and Congresswoman Davis. And I appreciate, 
as was stated by my colleagues, to be here this morning to 
share with you perspectives in experience with the TRICARE 
program and in particular, the Health Net experience.
    Let me begin by giving you some background about the Health 
Net Federal Services and the dedicated 1,700 employees who are 
focused and clearly targeted on delivering high-quality 
benefits and services to the beneficiaries of TRICARE.
    Health Net has a long history in working in partnership 
with the Department of Defense. As Foundation Health Federal 
Services, we were the first company to develop comprehensive 
managed care programs for military families. Under the first 
Civilian Health and Medical Program of the Uniformed Services 
(CHAMPUS) reform initiative contract, a precursor program to 
TRICARE, we provided health care services to DOD beneficiaries 
located in California and Hawaii.
    During the first generation of TRICARE contracts, Health 
Net administered 3 contracts covering 5 regions, 11 states, and 
2.5 million TRICARE beneficiaries. Under the current TRICARE 
contracts, we administer health care services in the TRICARE 
North region, which includes 2.9 million beneficiaries in 23 
states primarily in the Northeast. In addition to our North 
region contract, our sister company, MHN, provides behavioral 
health counseling services to military members and families 
through a number of contracts with the Department of Defense.
    These services include military family counseling, rapid 
response counseling to deploying units, victim advocacy 
services, and reintegration counseling. We also perform a 
number of health care-related services for the Department of 
Veterans Affairs. And through these various programs, we have 
helped the VA save over $150 million since 1999.
    The primary underpinning of the success of the TRICARE 
program is our partnership with the military health system. Our 
19 years of working with the Department of Defense gives us a 
clear appreciation for the need to understand and be aligned 
with our government customer and continuously work to improve, 
tailor, and integrate our services to be most responsive to the 
evolving needs of the health system and the beneficiaries we 
serve.
    We do this by working in close collaboration with the 
Department, the military services, maintaining strong 
relationships and open and proactive communications with the 
beneficiary associations and by tapping into the advice and 
counsel of a group of former military, senior military leaders 
throughout the TRICARE advisory board. Based on our interaction 
with these groups as well as our strong performance levels, our 
perspective of the current state of the TRICARE program is that 
the program is working exceptionally well. And let me expand on 
some of the key points.
    Health Net and the TRICARE regional office North have 
fostered a strong collaborative relationship. This relationship 
ensures open, honest, transparent communications as well as a 
clear understanding on our part of the goals and expectations 
of our customer. It also helps ensure that we prioritize our 
initiatives appropriately, focus on those that help DOD achieve 
and even exceed the TRICARE contract objectives.
    For example, we have been working actively in concert with 
numerous initiatives to improve on health care costs and 
quality for the TRICARE beneficiaries. One such initiative is a 
collaborative effort undertaken recently to increase TRICARE 
mail order pharmacy usage. I am sure you are aware that DOD 
achieved significant savings on prescription drugs purchased 
through the mail order pharmacy program. And that is because 
the DOD has access to the Federal supply schedule for 
pharmaceuticals under the mail order program but not to the 
retail pharmacy outlets.
    To help DOD encourage the use of mail order program, Health 
Net implemented a multi-faceted approach at no cost to the 
government. This approach had several components: educational 
efforts targeted to beneficiaries in our disease management, 
case management, and transitional care programs, an educational 
program that targeted our high-volume providers with low 
TRICARE mail order pharmacy penetration and offering e-
prescribing tools to a select group of network providers.
    These efforts have resulted in a demonstrative increase in 
the overall pharmacy usage within the north region up 25 
percent over the past year. We talked about earlier about the 
performance excellence. This generation of TRICARE contracts 
contains a number of performance standards that exceed those 
used in the commercial health care marketplace. Even though 
these standards are higher, we are either meeting or exceeding 
those standards. And I will just give you a highlight of a few.
    Beneficiaries calling our toll-free customer service line 
on average are connected to a customer service representative 
in four seconds. Health Net now obtains nearly 78 percent of 
network claims electronically. This is significantly higher 
than the average commercial mass care experience of 55 to 72 
percent. Health Net tries to minimize provider hassle factor 
paying providers promptly, on average paying within 6 days for 
claims submitted electronically, 13 days for paper claims and 
within 2 days for Web-submitted claims. And referrals and 
authorizations are processed within 2 days.
    The efforts to reduce the provider hassles seem to be 
paying off. Our network is robust. We have nearly 100,000 
contractor TRICARE providers servicing the TRICARE North 
beneficiaries. This number is up by 35,000 or 53 percent since 
the start of the service delivery in September of 2004.
    Regarding the beneficiary satisfaction levels, this program 
is also performing well in this area. Beneficiary satisfaction 
with the TRICARE program remains very high, higher than with 
commercial or other governmental agency programs, according to 
a recent survey by the Wilson Health Survey Group.
    Of all the plans and programs included in the Wilson 
survey, TRICARE was the top rated health insurer in member 
satisfaction for the fourth year in a row. The results are 
consistent with surveys of TRICARE users performed by the 
TRICARE regional office North, which have also found high 
beneficiary satisfaction levels.
    For the past 5 quarters all beneficiary satisfaction levels 
have averaged between 87 and 88 percent. Additional proof that 
the program is working well is the survey results of MTF 
commanders. For the past 5 quarters, overall MTF commander 
satisfaction has averaged 86 percent. However, I am pleased to 
report the most recent performing quarter Health Net received a 
94 percent satisfaction rating from the north region MTF 
commanders.
    Earlier I mentioned our 19 years of experience with DOD has 
taught us the value of understanding our customer and aligning 
with the objectives of the military health system. Again, we do 
this by tailoring our services to meet the unique needs of the 
Military Health System (MHS). Perhaps the best example and the 
one of most interest to this committee, based on the recent 
events, is the way we stand ready to help and support the 
health care needs of our active-duty service members.
    While, as you know, the active-duty service members receive 
most of their care from the direct care system, we do provide a 
number of important support services. As you know, we support 
the facilities in the national capital area, which include 
Walter Reed Army Medical Center and the National Naval Medical 
Center in Bethesda. And we provide an extensive network of 
civilian health care providers to augment the services at the 
MTF.
    We also operate a TRICARE service center on-site at each 
military treatment facility to provide customer service, 
including enrollment, claims, and referral assistance. The 
TRICARE service center at Walter Reed averages over 600 
beneficiary visits per month.
    We provide a full range of medical management support to 
the wounded warriors and other MHS beneficiaries referred out 
to care within the civilian network. These include benefit 
review, customer support and service, transitional care, case 
management, and discharge planning. Specifically at Walter 
Reed, Health Net has been participating in various committees 
and tiger teams developing solutions for implementation where 
appropriate.
    Our medical management and field operations team are 
assisting with the training of the wounded warrior transition 
brigade case managers. And our behavioral health company, MHN, 
has readied three licensed clinical social workers to provide 
additional social service support at Walter Reed.
    MHN has also identified additional experienced consultants 
who can be made available on short notice. These social work 
consultants are experienced in providing non-medical supportive 
consultation services to active-duty members and their 
families. If requested, Health Net is prepared to provide 
additional support to support the Walter Reed Army Medical 
Center and our Nation's wounded warriors.
    Another way we provide support to both active-duty members 
and their family members is through reintegration counseling. 
We provided this service in response to the reintegration and 
redeployment needs at installations where large numbers of 
returning troops called for greater support for health care 
access and coordination. This support also extends to the Guard 
and Reserve members.
    MHN for the military family counseling services contract 
provides short-term, face-to-face problem resolution for 
military personnel and their families with over 150 counselors 
on sites at military installations across the United States and 
overseas. MHN provides rapid response counseling to the 
National Guard and Reserve members and their family members to 
help them best cope with the stresses of deployment or 
reintegration to the civilian life after deployment.
    There are two other examples of our tailored approach that 
best meet the needs of the Department and the TRICARE 
beneficiaries and include our involvement with the Fort Drum 
regional health planning organization and our efforts to 
advance disease management and consumer empowerment. My written 
remarks go into both of these initiatives in much more detail.
    On the disease management and consumer empowerment front we 
have been talking with the Department of Defense about 
establishing a program to pilot the use of commercial decision 
power program as an enhanced disease management, consumer 
empowerment service that helps members better manage their own 
health care, navigate the complex health care system, and have 
a more proactive and productive discussion and interaction with 
their physicians.
    In closing, I would like to thank you for inviting me to 
testify before this committee today. The TRICARE program is 
stable and performing exceptionally well. And we are very proud 
to be a proactive and coordinated partner with the MHS system.
    Thank you.
    [The prepared statement of Mr. Tough can be found in the 
Appendix on page 156.]
    Dr. Snyder. Thank you, gentlemen.
    And we will put ourselves on the five-minute clock again. I 
think all three of you were here. I saw Mr. McIntyre and Mr. 
Baker in the audience.
    You were here also, Mr. Tough, during the preceding 
testimony. Is that correct?
    Mr. Tough. Correct.
    Dr. Snyder. I wanted to give you all a chance to make any 
comments that you might want to with regard to anything the 
surgeon generals said, particularly with regard to their--what 
we referred to as wedge efficiencies and so on.
    Beginning with you, Mr. McIntyre, anything that you heard 
this morning that you would like to comment on?
    Mr. McIntyre. I think that you all put your finger on the 
topic of relevance for the direct care system. The challenge is 
how do you make the system more efficient in its use of 
resources. But from the services' perspective, at least our 
perspective has been they suffer for the ability to hire people 
on a contracted basis, oftentimes taking as much as 18 months 
to find people, if they can find them at all. And staying 
attuned to that issue and pushing through the detail, I think, 
is going to be very constructive and very useful for the system 
itself.
    Dr. Snyder. Mr. Baker.
    Mr. Baker. I would echo Mr. McIntyre's comments and the 
comments of the previous panel members.
    As you know, Mr. Chairman, I go back a long way in the 
military health system. It has always been my belief that it is 
better to deliver care to military family members, to military 
members, and indeed to retirees, better to do so when possible 
in the military system. Our TRICARE contracts are established 
in a way that incentivizes us to try to make that happen.
    I urge the military departments to look carefully at the 
notion of conversion to civilians and indeed the reduction in 
military medical personnel. I don't think that serves the 
system well.
    As one of the panel members indicated a moment ago, care is 
going to be delivered. The question is will it be delivered 
within the military system or within the purchased care system. 
I believe this Nation is better served if it is delivered 
within the purchased care system.
    Dr. Snyder. Mr. Tough.
    Mr. Tough. Yes, thank you. I would agree with both David 
and Dave.
    You know, it is important to keep in mind that there is a 
dual mission of the military health system. It is military 
readiness, military medical readiness, and peacetime health 
care delivery. And so, it is important that we have that MTF as 
that centerpiece for care.
    And certainly, one of the primary objectives of this 
contract is to optimize the military treatment facility. And it 
is difficult to do that with a declining base of active-duty 
military medical personnel.
    Dr. Snyder. I wanted to ask about the reimbursement online. 
I think all of you would be in agreement that over the last 
several years the reimbursement to providers has gotten more 
efficient. Would you all just briefly describe how you have 
done that?
    How do you handle those small practices that are still 
struggling a bit with the electronic age? Is it a paper claim? 
Or do you have a program where you actually install a computer 
yourself for access?
    Again, if you would just make this brief, if we could. Just 
go down the line, starting with you, Mr. McIntyre.
    Mr. McIntyre. It is a challenge for small practices. My 
father actually retired as a surgeon a couple of years ago, not 
because of loss of dexterity, but because he didn't want to go 
through the cost of converting and suffered for the fear of 
what Health Insurance Portability and Accountability Act 
(HIPAA) was going to bring. And, you know, it really has to be 
worked practice by practice by practice.
    And what we did is we have started with the highest volume 
practices and are working our way down that list, not because 
the smaller volume aren't important. But the larger bang for 
the buck from a taxpayer perspective is to move those things 
along more readily where there is higher volume. And we are 
finding success with that.
    I was involved a couple of years ago in an effort to wire 
offices. The challenge is when only three percent of the 
services that a practice provides are to this population. Why 
would you retrofit your entire operation by involving software 
that you are only going to use three percent of the time?
    And so, it is a little bit of a challenge. I am not sure we 
are ever going to get to the last mile, which is the smallest 
doctor's operation with the smallest volume. But we have seen a 
dramatic change in the amount of electronic submission since we 
have started this contract a couple of years ago.
    Dr. Snyder. Mr. Baker.
    Mr. Baker. I would echo Mr. McIntyre's comments. We, too, 
have had a strategy. In fact, a TRICARE contract has 
incentivized us to try to move from paper to electronic 
submission. In our region now for all providers, or all care 
rendered, rather, we are hitting over 73 percent of the claims 
are being submitted electronically.
    But just as Mr. McIntyre has done, it has often been by the 
ones. It has started with those providers who had the highest 
volume of TRICARE claims. They were the ones most interested. 
And we have tried to make it as easy as we possibly can. We 
continue to work that every day.
    There are simply some providers, though, who are never 
going to come onboard. Because averages are a bit misleading. 
In our region, we have over 42 percent of the licensed 
providers are in our networks. And part of the deal there is 
that you agree to submit your claims electronically. But they 
are responsible for 3.7 percent of the population of the 
region. So that disparity in some areas, some practices have 
high volumes. Others have very, very low volumes.
    We just have to demonstrate to them the benefits of the 
electronic filing, the statistics that Mr. McIntyre referenced 
and indeed Mr. Tough referenced about speed and accuracy and 
payment and so forth and the cash flow advantages seem to 
resonate. But it is a game of inches.
    Dr. Snyder. Mr. Tough, anything to add?
    Mr. Tough. Yes, just similar comments. Again, we try to 
pick them off in order of the highest volume. I think David 
McIntyre's comment about small percentage of TRICARE 
beneficiaries in an office practice will not necessarily drive 
up an individual physician's interest to specific activities 
that might work more inclined to electronic communication, 
electronic transfer of claims.
    The Web-based efforts we have undertaken--we have about 
eight percent of our claims on Web-based transactions. If we 
can get providers to consider that, that is a fairly simply way 
to transact claims with us. It also is the fastest turnaround, 
two days to pay.
    Dr. Snyder. My time is up, Mr. Tough. But so I understand 
you, when you say Web-based, you mean that the physician's 
office would not necessarily have to have any new software or 
anything. He just would go to your Web site with a code and be 
able to enter it in even if they have a paper-based records 
system in their own office. Is that a fair way of describing 
it?
    Mr. Tough. Yes. There is an express claim process that we 
have built with our subcontractor at Palmetto Government 
Benefits Administrators (PGBA). And it allows for that kind of 
ease in transaction.
    Dr. Snyder. Mr. Jones.
    Mr. Jones. Mr. Chairman, thank you. And I couldn't help but 
think--I have been here 13 years, 7 terms. And I have Camp 
Lejeune, Cherry Point and Seymour Johnson Air Force Base. And I 
want to say to you and your companies and corporations that you 
have made tremendous progress in a very difficult system. And 
you have talked about it today in certain answers to the 
chairman with, you know, electronics.
    And I realize that no system is perfect. But I would have 
to say that you have made such progress. And who benefits? The 
user. And that is our military and our retirees. And you 
certainly have done a tremendous job.
    I want to go to one statement that Mr. Baker said that I 
think General Pollock, who just left--you know, we all realize 
that this nation is in serious financial shape. I mean, I don't 
care which side of the aisle you are on. Anybody that would 
look at the debt--when I came in 1995, it was $4.9 trillion, 
$4.6 trillion in debt.
    It is well over $8.3 trillion. And if you talk to David 
Walker, who has spoken to this committee, subcommittee and 
committee, you know, he will tell you that the true debt is 
probably somewhere around $50 trillion.
    Not only do we have to provide the quality of medical care 
to our military, but we also have to make sure that they are 
getting the best value for the dollar. Which, that is your 
responsibility. And again, I compliment you on that.
    Mr. Baker, you made the statement that, you know, at some 
point in time--at least I interpreted it this way, and I could 
be mistaken. At some point in time when you have to make the 
decision of whether the military is going to have to make some 
very difficult decisions as to the quality of care on base--and 
we heard General Pollock talking about, you know, pediatrics 
and Obstetrics and Gynecology (OBGYN)--those services now are 
pretty much out in the public more so than it used to be.
    And then she also mentioned that it is going to be an 
education process, that from the standpoint of the services 
that you used to have on base. Let me explain that. Used to 
have on base we now don't have on base. So therefore, the 
education to the quality of life--I am not sure you can answer 
this question, but I am going to ask it anyway.
    What do you see 10 years down the road? And this is your 
personal opinion. It is not your professional opinion. Or it 
could be. What do you see 10 years down the road for your 
industry in providing the service and what the military can 
provide knowing that we have got some very, very difficult 
decisions to make, whether we have the war on terrorism or it 
has all been over? We have got some really difficult times 
based on the economy of this country and what the government 
has to spend.
    Mr. Baker. Sir, I am humbled that you would ask my opinion 
on such a question. And I would be the first to say that my 
crystal ball is not only cloudy, it is probably scratched up a 
bit. So it is really hard for me to make that kind of 
prediction. I think the outcome is going to be predicated on 
the kinds of decisions that were discussed with the earlier 
panel. And that is the future of the direct care system.
    I mentioned to the chairman that I have been around for 
quite some time. I had a full Air Force career as a health care 
administrator and actually grew up in a military family. So I 
have seen the military health system all my life. And I can 
tell you that one of the things I have seen during my life is 
an on-going contraction of the size of the military facilities 
on installations, the scope of services provided.
    General Roudebush made mention of the Air Force and some of 
the changes that have occurred with the small community 
hospitals over the years. I saw a statistic not long ago that 
really drove things home. And forgive me if I don't have the 
numbers exactly right. But somewhere a little over 100 
hospitals among the three services being operated. I remember a 
day when the Air Force operated 120 facilities.
    So if we follow the same glide path, it strikes me that we 
are going to continue to contract. The people who can change 
that are resident in the Congress and they are resident in the 
Pentagon. And I urge them to look very, very carefully at what 
we are trading off.
    Mr. Jones. The other two gentlemen?
    Mr. McIntyre. If I might, Congressman Jones. I think as Mr. 
Baker said, you put your finger on an important issue. And I, 
too, have somewhat of a warped crystal ball. I started my 
career on Capitol Hill doing health policy on the Senate side 
for a decade before I came to do operations. And I grew up in a 
health care family, my father having served in the Army at Fort 
Bliss for a while while I was a child.
    I look at this from the standpoint of what is it that we 
can afford and how is it that we properly make the right make, 
buy decisions. In my own company, I buy spikes or surges in a 
contracted way. I staff to the average. And I came to that 
conclusion--and I have now been running this company that I 
built for a decade. And I came to that conclusion when I 
started looking at the spikes and the changes in my budget from 
cycle to cycle. And I started to come to the conclusion that I 
need to figure out what are those averages and how do I make 
that work.
    And the first responsibility, as we all know, that the 
military health system has is to be ready to support the 
warfighter as they go into combat. The second responsibility is 
to make sure that they have got caseload that will give them 
the capacity to keep those skills sharp and to serve basic 
needs of the family. And then the third is to either build or 
purchase the rest of that care.
    And I think that one of the challenges we have together in 
this environment is what is the right make, buy analysis. How 
do we do that right? And how when we look at this over the 
complexity of the Federal debt--and that was a topic when I was 
working for Senator Gorton in Washington state in the mid-
1980's when we lost the Senate on the Republican side over the 
debt issues and our reaction to the debt issues or the members' 
reaction.
    I think the challenge is to look at the system on the 
totality of the budget, not just firewall component parts and 
get all the pieces at the table to include the VA, to talk 
about the care from end to end. How do we leverage where the 
DOD spent money, for example, to pay the three of our 
organizations to build massive provider networks to support the 
DOD's direct care system when they have to surge?
    Why would the VA be buying with a different checkbook? Why 
wouldn't we size it together? Why wouldn't we buy one way? Why 
would we not only spend one check of the taxpayers' rather than 
two? And I think the examples of that go on and on.
    And I think my hope is that the heat of Walter Reed and the 
fire and the focus has all of us backing up together and asking 
the kinds of hard questions that you all this morning have been 
asking of all of us, those of us that contract, those of us 
that support in that area, the VA, the DOD, and Congress coming 
together to talk about what is the right way for us to do this 
for the next century, not for the one we have been through.
    Mr. Tough. If I can take a moment and add, agree with my 
colleagues. Again, I have 19 years of experience with this same 
contract. And I reflected back as Dave Baker and David McIntyre 
were talking and said I can recall when the CHAMPUS reform 
initiative contract was started in California and Hawaii. 
Letterman Naval Hospital, Oakland, McClellan--those facilities 
aren't there anymore.
    So I think the key is really what is the basic floor of 
what is needed for military readiness and to prepare the 
warfighters for the military medical system for warfighting and 
combat. And I think that is a question that needs to be 
solidified because, again, we see a retraction of the system.
    I would also agree with Dave McIntyre's comment about joint 
spending. God save me for using this term, but there is a need 
for, you know, a common checkbook. We even see it a little bit 
in today's contractors. There is the military health system 
activity, and then there is the civilian health care spending.
    And I think if we look more jointly as to that as being one 
common checkbook and how we would best manage those assets in 
make, buy decisions, then we can decide exactly what we want to 
purchase in the military health system and exactly what we want 
to purchase in the external system and then configure those 
purchases in different kinds of ways. Dave has taken it a step 
further in embracing the VA, which is yet but another dimension 
of government spending.
    Mr. Jones. Thank you very much.
    Thank you, Mr. Chairman, for that time.
    Dr. Snyder. I have to share this anecdote with you. But it 
was some years ago prior to--I don't know, seven years ago or 
something. And I, in my early fifties, came down with 
appendicitis when I was here and was referred to Bethesda Naval 
Hospital.
    And it was about 2:00 p.m. in the afternoon. And I am 
laying on a stretcher looking at a bunch of people looking down 
on me. And the surgeon who was going to do the surgery said, 
``We have a slight delay on an operating room availability.'' 
He said, ``Let's spend that time talking about military 
medicine.'' Now, that is lobbying. [Laughter.]
    And I appreciate the discussion that is going on. I think 
it is an important one. I think back to a friend of mine who 
maybe still is, but was in the Army Reserve and had a solo 
private practice as a family doctor and was mobilized during 
the first Gulf War and was struggling, scrambling trying to 
find someone to cover his practice and I don't think he did.
    And I think his life--I mean, he loved the military and 
loved the participation. But it was a big, big hit on his 
family and his business, which was a solo medical practice 
because we can talk about it is great to have these reserve 
medical people and we can surge them when we need them, 
forgetting what is left behind. So that was----
    Mr. McIntyre. A lot of providers lost their practices 
during that period.
    Dr. Snyder. Right.
    Mr. McIntyre. I was on the Senate staff at the time. And it 
is one of the reasons why the deployment cycles for doctors 
have changed in the reserves.
    Dr. Snyder. Yes.
    Mr. McIntyre. Was to reflect that burden.
    Dr. Snyder. I wanted to ask specifically, again, a brief 
question for the three of you.
    I think, Mr. McIntyre, you talked the most about the 
improvement that has been made specifically in obstetricians, 
which I appreciate. As you are looking ahead now rather than 
back, what do you see as the needs that you are facing with 
regard to either numbers of providers or geographic areas with 
regard to providers or specialty needs with regard to 
providers? Is there any gaps that you see out there or issues 
that are facing you in the provider issue? Shall we start with 
Mr. Tough just to----
    Mr. McIntyre. Sure, go right ahead, yes.
    Mr. Tough. Actually, certainly, in low-supply areas we are 
always going to have some difficulty in gaining access to 
providers because providers in low-supply areas have choices 
that they may wish to make. But in terms of gaps, we haven't 
seen as many gaps as early on in the program. And I think a lot 
of that has to do with the fact that a lot of the other 
improvements that have occurred in the relationships. The 
streamlining of the relationships has helped.
    We always have a concern regarding compensation. So that is 
going to be--it is an on-going issue. And quite frankly, we 
live with some concern that Medicare can change a reimbursement 
on us, and then we are off running trying to figure out how to 
resolve relationships with providers.
    I see the one that is coming downstream, the one that 
concerns us the most has been talked about here earlier is in 
the mental health arena. We have about 800 mental health 
providers, different kinds of categories from physicians to 
psychologists to licensed clinical social workers. But I think 
to strike to the point, the current circumstances of the war on 
terrorism has created some added stress.
    We are in an environment we haven't seen in an awfully long 
period of time. And I don't think some of the mental health 
issues or the family issues are going to surface for a while, 
whether those are child issues or spousal issues or other kinds 
of mental stresses and strains that exist. And I think that is 
the one area that we have the most concern.
    We have some pocket areas, as you know. We talked a little 
bit about the Fort Drum area. We have got a special effort that 
has being undertaken with the Fort Drum regional health 
planning organization. And we are very dedicated and focused on 
that community in particular. We have done some gap analysis 
work with the community.
    It is one of the few communities, quite candidly, that I 
have seen a totally engaged and embraced effort by the medical 
community, the military system, and ourselves to try to find 
the best way of meeting the needs of that military system up 
there as well as the community at large. But we are, in fact, 
working on mental health case workers to bring into that 
community specifically to respond to the, we know, the on-going 
up and down pressures of deployment, redeployment.
    Dr. Snyder. Mr. Baker.
    Well, let me ask a follow-up. You say you are bringing in 
mental health. Who do they then work for?
    Mr. Tough. They will actually be working--they are actually 
contracting providers. We bring them in under contract and set 
them up in clinical practice in the community to respond to the 
need.
    Dr. Snyder. So it is essentially a full-time military 
family caseload?
    Mr. Tough. Yes.
    Dr. Snyder. Yes.
    Mr. Baker.
    Mr. Baker. Yes, sir. I would echo Dave's comments. I think 
over the years that we have done better in terms of networks 
and in terms of those non-network providers who are 
participating. There are pocket shortages in our region just as 
there are in the others. But overall I think our coverage is 
pretty good.
    The mental health issue that we have talked about today 
concerns me a great deal because I am not sure that we yet know 
what the demand is going to be. We know it is increasing. We 
know that we are not particularly rich in terms of mental 
health providers as a Nation. And so, I worry about that, I 
would say, a great deal.
    The other piece, though, that I would also pass along is 
relevant to the earlier discussion and the question that 
Congressman Jones raised a moment ago about the on-going 
downsizing. That can have a significant impact on the 
availability of care in a community. If you think about it, the 
medical community in a civilian setting flexes to the demand. 
And it flexes to the demand based on the amount of care that is 
required for the civilian members of the community, but also 
the amount of care that has been coming out from the base.
    Significant reductions in the capacity and capability of 
the military facilities can often put a stress on the 
availability of medical care in a civilian community, whether 
it is a TRICARE beneficiary or not a TRICARE beneficiary. And I 
worry about the impact of what we are seeing long-term here, 
particularly where we have our bases located today.
    Dr. Snyder. Mr. McIntyre.
    Mr. McIntyre. I would like to associate myself, Mr. 
Chairman, with my colleagues' comments because I think they are 
right on. We are all working at this as hard as we can. There 
was a year a couple of cycles ago when we were all talking 
about dramatic concern around reimbursement rates. I stated at 
the time that I didn't think it was just rates. I thought it 
was about how we pay. It was about making the system more 
effective for providers.
    And at the end of the day, it is about----
    Dr. Snyder. We used to talk about it was low, slow and 
complicated.
    Mr. McIntyre. That is exactly right.
    Dr. Snyder. And I think you all are taking care of slow and 
complicated, but we have still got low to deal with.
    Mr. McIntyre. Yes, sir. That is right. And, you know, the 
challenge is it is the Federal budget. And I remember when I 
came to Capitol Hill in the middle of the 1980's, my father was 
an ophthalmologist. They were the first ones to go under the 
knife on Medicare provider cuts. And, man, I didn't want to go 
home. In fact, he wouldn't pay for my tickets home when I was 
working as a young staffer because he wanted to disown me.
    I think we have made it complicated. Yet what we are doing 
is we are demonstrating that it can work. And when you ease the 
complication and you pay people quickly, it is money that they 
are not having to subsidize out of their own pocket for already 
tight rates. And I think all three of us and our staffs are 
told regularly you are the fastest payer in the marketplace. 
That is a great thing. They deserve that. And they deserve 
every piece of what we can do.
    We, too, have embedded mental health folks at our own dime 
into certain areas because that is important. There is one item 
that has not been covered that I think is one of the very 
complicated things that members of the military family are 
facing. Particularly, it has been spearheaded by the Marine 
Corps in terms of the focus. You all have addressed this in the 
way of asking for some reports. But that is the issue of 
autism.
    And I had the privilege of spending a day at Camp Pendleton 
a few weeks ago with General Conway's wife where we listened to 
beneficiaries and their families talk about the challenges in 
autism. And the thing I was struck by--and this is where our 
greatest challenge, I think, as an enterprise with your 
assistance, is going to be.
    There is only one certified provider to care for autistic 
kids in all of New Mexico. And it stretches from Florida with 
3,800 providers to California with 1,700 to Hawaii with 22 to 
New Mexico with one. How do we address that?
    And how is it that we take care of the challenge that is 
being faced by these families when they rotate every couple of 
years based on their time in the military and the role that 
they have and they drop to the bottom of the state's 
eligibility priority list and they can never earn their way all 
the way back up that list before they rotate again?
    And I think there are some opportunities there to do some 
very focused and specific work and something that I would hope 
would be on your priority list as you are working through this 
legislative cycle.
    Dr. Snyder. I think that report--Jeanette or David, you can 
correct me--I think the autism report is scheduled to come back 
to us in April, is my recollection. I think that is right. And 
we will see what that shows. It is an interest of mine. And 
there are so many dynamics to it, as, you know, we are aware 
more and more how frequent the diagnosis is, about one in 94 
boys now.
    The intensive therapy seems to help substantially, but it 
is not without cost. And then you think of our military 
families who are dealing with a child, a special needs kid or 
kids--this can be more than one child in a family. And then one 
of them is literally pulled out of the household for a year or 
16 or 18 months in a mobilization, which can happen both with 
the reserve component or active component. And what the change 
in the family dynamic is. So it is an important topic to this 
committee.
    Mr. Wilson for five minutes.
    Mr. Wilson. Thank you, Mr. Chairman.
    Actually, I apologize. I was at another committee meeting. 
And as the ranking member, I wanted to stay through the 
conclusion. But I want to thank you for your service and 
providing services to our veterans and current military.
    And particularly, Mr. Baker, I am very pleased that PGBA-
LLC is in the district that I represent along with Blue Cross-
Blue Shield.
    And they are, Mr. Chairman, extraordinary public minded 
companies that if anybody needs a sponsor for the 5K run, 
somehow they get called upon and participate. And so, they 
promote health in different ways.
    And again, I am just happy to be here. Thank you for your 
service. And truly a way--I know you are doing a good job. And 
I think this may apply to all of us is the number of complaints 
we get, which are so few. And indeed, my late predecessor, the 
late Congressman Floyd Spence, was such a promoter and person 
supporting the development of TRICARE to really serve our 
military. And thank you for bringing that to fulfillment.
    I yield the balance of my time.
    Dr. Snyder. Mr. Jones.
    Mr. Jones. Mr. Chairman, thank you. And as you were talking 
about mental health, I was looking at the paralyzed veterans. 
They had supported the supplemental bill that was up last week. 
And in their letter to Members of Congress, it was all about 
the funding issue. And I am reading here very quickly of that 
total of the $1.7 billion total. Of that total, $100 million 
would go for contract mental health care for men and women 
returning from the war.
    And, Mr. Baker, you and the other two gentlemen, I am sure, 
would--I took from your comments--and maybe it is the other two 
as well--that we know with the PTSD, the brain injuries that 
this is something that is going to be hard to project. You can, 
through your experts, determine that, yes, there are going to 
be a larger number of men and women that are going to have 
these mental health needs. But we don't know exactly how many 
and how long.
    You made the comment--and I wish you would all three pick 
up on this--that as this need grows and expands over the next 
two or three years--because if a man or woman--I will never 
forget a kid. All of us go visit the hospitals. But I will 
never forget a kid from New Mexico named Eric. Eric was in a 
wheelchair. His mother was there from New Mexico. His little 
sister, about seven or eight, was there with him. And the 
doctor--it was another Member of Congress. And I think it was 
Gene Taylor. I stand to be corrected.
    But anyway, when we left the room, Eric could not speak. 
And his mom kept saying, well, you know, these nice congressmen 
came to visit you. And all he could do was move his finger that 
was on his chest. And I will never forget the doctor when we 
walked out said that Eric is going to need care. He was 26 
years old. Eric will probably need care for the next 45 or 50 
years. And I realize that is not quite the same as mental care, 
but it is a brain injury. So it is related.
    Where do you see--this is the question. Your comments, 
well, we have got a problem because we need the medical 
experts, whether they be psychiatrists or psychologists or 
doctors. Do you see that pool is in a situation where we need 
to as a government, both state and Federal Government, we need 
to encourage more young people to look at that as a profession? 
Because where are we going to get the providers if we don't 
educate and get out in the field?
    Mr. Baker. Well, again, I appreciate the opportunity to 
offer an opinion on that.
    Mr. Jones. Sure. Right, certainly.
    Mr. Baker. But it is not very informed. And I need to be 
the first to indicate that. But the truth of the matter is that 
I think we probably do need to try to encourage people to go 
into those sorts of professions. I believe the demand is going 
to increase. I think that is one of the outgrowths of this 
conflict. And I am not sure that we have the capacity to deal 
with that increased demand, whether it is within the military 
health system or outside.
    Mr. Tough. I would have to agree with Dave's comments. I 
don't think we really have a full sense of what the magnitude 
of the patient load is likely to become.
    I know that as a result of the efforts that are being 
undertaken to manage the active-duty service members who may 
suffer from traumatic brain injury we are in the process of 
doing a national survey and search for every hospital that has 
the capacity to do treatment for TBI and try to develop an 
inventory of those services and a relationship with those 
contract facilities or those facilities individually as well as 
providers who are well-schooled and trained in TBI cases so 
that we can use them as advisers on cases that may be of a 
difficult nature.
    The beauty of a national program such as TRICARE is that we 
have three contractors we can coordinate and communicate with 
regarding care across the country. And we recognize that there 
is also an infrastructure of VA that also has similar types of 
support mechanisms. There are four traumatic brain injury 
centers in the VA.
    So it is trying to look at the pool of the universe of what 
we can access. But being quite candid, I don't think we yet 
know what the requirements are going to be for whatever is 
extended into the future.
    Mr. McIntyre. The challenge in this area is obvious. The 
challenge is to figure out how much demand are you going to 
have. And then do you build it or do you buy it or do you use a 
combination thereof? In this environment in this city, the 
decision was made to build it. That probably is the right 
decision.
    In San Diego, as was referenced previously, the military 
and us made the decision that while we wanted people to come 
closer to home, the volume that was going to end up there 
probably did not justify the full construction of everything to 
be resident on the Balboa campus.
    And so, we searched the market in San Diego, which is very 
medically robust, and brought two institutions to the market, 
to the table that have specific expertise in brain injury, now, 
not blast brain injury like what we are seeing in Iraq and 
Afghanistan, particularly in Iraq, but brain injury nonetheless 
that they could work from.
    I am struck--and I spend time like you all at these 
facilities from time to time every couple of months just to 
keep me grounded in why it is important to stay focused and 
what the needs are. I had the chance about six weeks ago to 
spend time with the highest ranking patient at Walter Reed. He 
is a reservist one-star general from Florida. And he was the 
military attache to the U.S. ambassador to Afghanistan.
    And he was second in line behind a Humvee that blew over. 
And he hit his head against the crossbar. This is a very, very 
smart guy. I know his law partner in Florida personally. He is 
a medal of honor recipient. And he was walking me through his 
journey of the last 18 months in dealing with this.
    And here is a judge, and, you know, very articulate, but 
struggling. And so, it is going to show up in a lot of 
different ways. And I think the analogy of sports injuries is a 
good one. And you all are putting focus in this area, which is 
to be applauded. All of us as a society are going to learn 
about this going forward.
    And the challenge is to be impatient about it, but also 
very focused and to be marshalling the resources that are 
available and matching those with things that need to be 
constructed but to be very careful to not build capacity where 
it may not be warranted long-term or we are going to create an 
on-going expense that can't be sustained to the degree that we 
are able to get out of this kind of conflict in the near 
future.
    Thank you.
    Mr. Jones. Thank you, Mr. Chairman.
    Dr. Snyder. And we will continue to learn about this for 60 
or 70 years as this generation of veterans ages and deals with 
these impacts.
    I think we are winding down here, gentlemen. But I had a 
few more questions I wanted to ask.
    When you all first picked up the newspaper when The 
Washington Post began running their stories on Walter Reed and 
then saw the events that occurred over the next several weeks 
up until now, what did you all and do you all see today as your 
responsibility in dealing with this whole complicated issue 
of--I mean, obviously you don't have responsibility for mold at 
Walter Reed--but that whole issue of the medical holdover care?
    What did you all see as your responsibility or do you see 
as your responsibility?
    Mr. McIntyre. I believe that we have the responsibility to 
do two things. One is as the partners of those that wear the 
uniform and who lead organizations like Walter Reed--and they 
are all over our regions of all different service types. And 
there are challenges in many of them. How do we come to the 
table to bring our assets and expertise to assisting them where 
there are gaps that we can plug together? That is first.
    Second, I believe strongly that the real challenge that 
came from Walter Reed--and it was not the mold and the 
cockroaches and all of that. It is the bureaucracy. And it is 
having patients and their families fall into the trap of the 
bureaucracy. And how is it that we streamline the focus to make 
sure that we are having the system serve the patient, not the 
system be a slave--or the patient be a slave to the system?
    And clearly, the focus that you all are putting in this 
area to look at the medical boarding process and the like is 
very useful. The plussing up, the care coordination is useful. 
I believe that we have a responsibility to share in the work on 
care coordination. It is why we are working on the pilot with 
the prototype with the Navy and the Marine Corps right now in 
the West.
    And it does come down to a resourcing question but also a 
make, buy portion of that resourcing question. But it is 
solvable. And it is going to take the kind of heat, in my 
opinion, having served on the Senate side as a staffer for a 
while. It is going to take this kind of heat to melt the 
bureaucracy in our programs in a direction that is more 
responsive to the patients and their families.
    Dr. Snyder. Mr. Baker.
    Mr. Baker. Sir, I think we all do have a responsibility 
here. And in terms of the steps that we took after the Walter 
Reed story started to break, one of the first things we did was 
to reach out to the commanders of the military facilities in 
our region, again, to try to determine was there something that 
we could do to assist. We felt like that was a key component.
    The other thing, frankly, that we looked at was facility by 
facility where did we have the opportunity to flex. That is, 
where did we have networks that perhaps were too large as 
justified by the demand, but also that those other facilities 
where perhaps our network was not as robust as it might have 
been and what could we do to renew our efforts on the theory 
that if the commanders were going to have pressure to process 
the troops through faster, that could displace some care for 
non-active-duty folks down into the network. So we felt like we 
had to do that.
    The third thing we looked at was, again, to make an offer 
under the terms of our contract. Are there services that you 
need that we could bring into your particular military 
facility? Under a program in this contract that we 
collectively, I think, all refer to as optimization--is there 
something we could do there? Is there a nurse or a technician 
or something that you need that we could help you acquire? So I 
think across those domains those were the kinds of activities 
that we engaged in.
    Dr. Snyder. Mr. Tough, anything to add?
    Mr. Tough. Yes, I think this is uniformly the same approach 
we all took, was that we are partners with the military health 
systems, counterparts. And when the need arose, we immediately 
tried to jump in and assist them and how we could best support 
them.
    Clearly, the majority of the care is in the direct care 
system. But when that care is in need of being outsourced to 
the civilian sector, we need to make sure it is a seamless 
transition and to make sure that we have solid case management 
support between that case that has been transferred from within 
a military treatment facility to the civilian sector.
    Dr. Snyder. If I might ask you all--and, in fact, we will 
go down the line. Because it was General Pollock, I think, that 
she and I had a brief exchange about she was--I don't know if 
the word was critical, but concerned about that she couldn't 
follow quality control so much with services that were 
contracted in the private sector.
    Do you remember that comment?
    Mr. Tough. Correct.
    Dr. Snyder. I think this is what you are getting at here. 
Would you comment on what she said, please, about that?
    Mr. Tough. Well, exactly. What she was trying to get at is 
that when we do get into that transfer of care into the 
civilian sector, we are going to have to have a mechanism to 
get that information back into a centralized point of control.
    And I think that is now being more actively worked as a 
result of the Walter Reed experience, I think, more clearly 
today than probably ever before because a centralized point of 
control is now evolving within the Walter Reed and certainly 
other military treatment facilities. So it is that information 
flow back and forth.
    We recognize, too, that sometimes in the nature of the care 
we are asked to get engaged in some of that might be very 
short-term in nature. It could be as simple as an out-patient 
visit or a short-term burst. But it could be longer term in 
nature. It could be a case managed activity that is in a 
civilian facility for a longer period of time. So it is 
important that we have that ability to communicate those case 
records back into the system.
    The difficulty we are challenged with and faced with right 
now is that is not electronic. It is going to be paper. So one 
of the things we are going to have to work and overcome--but 
again, we are also involved in other kinds of activities 
similar to what Dave Baker just mentioned. We have been asked 
to do some case manager training as they begin to ramp up their 
case managers within the system.
    We have also stepped forward and indicated we would be 
willing to help recruit those case managers. We would even 
deploy some of our staff. We have several of our personnel that 
work for us that actually came out of the Walter Reed facility. 
And we told them we would be happy to just deploy them back 
into the system because they are well-familiar with the Walter 
Reed's needs, put them back on the ground, and they could use 
them in any ways they wished.
    I think the challenge, quite frankly, that remains is when 
you get into the civilian sector--and this may be true for the 
active-duty side as well--is the beneficiary is going to move 
down a continuum of coverage. They are going to move from 
TRICARE. They might move to VA. And they might even move to 
Medicare.
    And so, we have to make sure that that process is as 
seamless as possible because there are going to be differences 
in the way that care is managed. There might be pass points 
that need to be thoroughly flushed out. And there might be 
differences in scope of coverage. So we have to make sure that 
that becomes a fairly clear and clean process.
    Our takeaway of all of this is that we really have to 
understand that when there is an active-duty service member 
that ends up in our hands or at any point that they need 
somebody's hand to hold. That is the primary issue. And we 
actually should treat this as both a concierge service, that we 
really have to care--take the ultimate in care management to 
that active-duty service member.
    Mr. McIntyre. That is the very reason why in our region we 
have done what we have done with the Marines and the Navy, is 
to get all three legs of the stool under the chair. And that is 
the VA, the DOD, and downtown. And it is this seamless handoff 
issue that is critical.
    It is important to look at the needs of the patient through 
that entire cycle and do it together. And it is important to 
make sure that if we are going to place someone downtown like a 
reservist that was at 29 Palms whose family was in Colorado who 
could be placed in Colorado for a while to convalesce and then 
potentially come back into the reserves that the only way to 
manage that well is to make sure that all three of those 
domains are focused on that individual as they morph in and out 
of the different systems getting what they need. And this 
notion of surge capacity is very, very important.
    This is where we are going to struggle, in my opinion, 
because it is not----
    Dr. Snyder. With the surge capacity?
    Mr. McIntyre. Well, potentially the surge capacity because 
it is not natural for people to say well, maybe I should buy it 
versus build it. That is the first thing. That happens in our 
own organizations. It happens everyplace.
    The second thing, I think, where we are going to struggle 
systemically is this notion of really making sure that all the 
parties are at the table at the same time because there is this 
natural inclination that I own this, I want to make sure that 
it is delivered the right way. The challenge is, if you go back 
to medical hold of a couple of years ago growing out of 
Georgia, you can't hire case managers or move them off a ward 
and have them take care of TBI and know what to do the next 
day.
    They flat out can't get there. It is a very, very 
specialized niche. And that is where it is important to draw 
from the assets that are available as we continue to share 
information and train each other in how to optimally manage 
these patients.
    Dr. Snyder. Which is why, as we are closing down here, Mr. 
McIntyre, I disagree a little bit. I don't use the term. I 
don't say that I think the problem at Walter Reed is a 
bureaucracy problem. That implies that somehow the laws are 
perfect and the people that are there--it just kind of gets 
lost in the maze.
    I think if we don't have adequate numbers of people with 
adequate training with well-understood expectations of what the 
laws are, I don't think it is fair to call that a bureaucracy 
problem. I mean, it is a maze. But I think that may not 
recognize the real cause of the problem. We as an institution 
may be the cause of the problem if we have disability laws that 
are really hard to navigate through.
    I have one final question. I think it is probably just a 
yes or no to you, Mr. Tough. In your written statement, you say 
that 95 percent of the calls to your hotline are answered 
within 30 seconds. Is that a real person that answers them?
    Mr. Tough. Yes.
    Dr. Snyder. Thank you very much.
    Mr. Wilson, do you have further questions?
    Mr. Wilson. No, Mr. Chairman.
    Dr. Snyder. Mr. Jones, do you have any further questions?
    Mr. Jones. Mr. Chairman, I just want to thank this panel 
and the first panel. This has been very, very helpful and 
educational to me.
    Mr. Chairman, I want to thank you as well.
    This is an issue that you have all articulated extremely 
well. It is with us. It is in front of us.
    And, Mr. McIntyre, I will use your term. Hopefully we will 
encourage the common checkbook, one check, I hope.
    Dr. Snyder. Mr. McIntyre, Mr. Baker and Mr. Tough, we 
appreciate you being here.
    The committee is adjourned.
    [Whereupon, at 12:21 p.m., the subcommittee was adjourned.]
     
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                            A P P E N D I X

                             March 27, 2007

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                             March 27, 2007

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             QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD

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                   QUESTIONS SUBMITTED BY DR. SNYDER

    Dr. Snyder. General Pollock and Admiral Arthur and General 
Roudebush, the article that Ms. Davis called to my attention last week 
is from the New York Times Magazine March 18, 2007, ``The Women's War'' 
by Sara Corbett.
    I have no expectation that you all read everything that is in the 
press out there about men and women at war and their families. But if 
you would respond for the record to this.
    General Pollock. Sara Corbett's Article ``The Women's War'' 
published in The New York Times Sunday Magazine 18 March 2007 is a 
thoughtful, balanced, and detailed examination of unique problems 
facing some service women today. The Iraq war has seen unprecedented 
numbers of female Soldiers serving with many Combat Service and Service 
Support units. As the article highlights, both the military and 
Department of Veterans Affairs are devoting increasing attention to the 
unique problems of female service members. More attention needs to be 
given to studying the effects of combat on our female warriors. The 
development of effective treatment programs tailored to women should be 
a priority for our military Behavioral Health community.
    The Army takes the issues of Sexual Harassment and Sexual Abuse 
very seriously and has set up an extensive program to encourage victims 
of harassment or sexual assault to seek help. The Army's Sexual Assault 
Prevention and Response Program (SAPR) provides confidential victim 
advocates who diligently work with victims to provide them with 
treatment resources and support. Annual training on the SAPR is 
required for all military personnel. A detailed explanation of the Army 
program can be found at: http://www.sexualassault.army.mil/.
    In regard to the noted increase in reporting since the initiation 
of the SAPR program, we feel this is a positive development. It has 
long been understood that when one pays attention to a problem by 
encouraging reporting and offering protection to those who report, the 
rates of reporting will rise. This increase therefore likely reflects 
victims who previously did not report, rather than an actual increase 
in assaults. While no one believes we are reaching 100% of the victims 
of sexual assault, early intervention and the support of victim 
advocates are helping many women recover.
    On the issue of PTSD, there has long been demonstrated a 
significant gender difference in willingness to seek help between males 
and females, with female personnel more open to doing so. Our data from 
the Mental Health Advisory Team studies do not show any gender 
difference, but more research needs to be done.
    The Department of Defense is currently engaged in unprecedented 
efforts to find and help service members adversely affected by their 
deployment experiences. The Post-Deployment Health Assessment given 
immediately upon re-deployment and the Post-Deployment Health 
Reassessment, given 90-180 days after re-deployment bring soldiers into 
direct contact with Behavioral Health personnel and give them the 
opportunity to obtain immediate assistance. Additionally the physical 
examination process has been revised to a Periodic Health Assessment, 
which also looks for evidence of depression, anxiety or substance 
abuse. Although more can and needs to be done in this area, the Army is 
aware of the challenges faced by both male and female Soldiers and is 
doing everything possible to ensure their needs are met.
    Dr. Snyder. General Pollock and Admiral Arthur and General 
Roudebush, the article that Ms. Davis called to my attention last week 
is from the New York Times Magazine March 18, 2007, ``The Women's War'' 
by Sara Corbett.
    I have no expectation that you all read everything that is in the 
press out there about men and women at war and their families. But if 
you would respond for the record to this.
    Admiral Arthur. In reference to the article titled ``The Women's 
War'', the following comments are provided on Navy Medicine's efforts 
for providing medical care for the physical and psychological sequelae 
of women serving in the Navy and Marine Corps as a result of combat 
experience.
    Navy Medicine seeks to proactively address the broad range of 
combat and operational stress injuries, to include PTSD, in a number of 
ways. In November 2006, Navy Medicine established a directorate at the 
Bureau of Medicine and Surgery led by an experienced combat stress 
psychiatrist specifically dedicated to addressing mental health stigma, 
combat stress training needs, non-stigmatizing care of returning 
deployers, and support services for Navy caregivers. Other efforts 
include prevention, outreach, and early intervention to warfighters 
using Navy mental health providers trained in clinical best-practices 
related to combat and operational stress control. One specific example 
is Operational Stress Control and Readiness teams providing early 
intervention, outreach, and prevention at the unit levels in close 
proximity to operational missions in order to reduce stigma that can be 
encountered in conventional mental health care settings.
    Navy Medicine plans to utilize existing data sets to study combat 
stress and gender. Naval Health Research Center's Millennium Cohort 
Study is addressing a variety of combat-related behaviors in both men 
and women. Additionally, the first phase of the Navy's in-theater 
Behavioral Health Needs Assessment (BHNAS) is complete, and analysis of 
gender differences associated with deployment stress is currently 
underway.
    Service Members returning from deployment are screened using the 
Post Deployment Health Assessment (PDHA-DD Form 2796). A review of 
261,008 PDHA forms completed from January 2003 to present demonstrate 
that 2.2% of male Marines and Sailors were referred for mental health 
services, compared to 2.6% of returning female Marines and Sailors 
(Defense Medical Surveillance System, 19 June 2007).
    Researchers from Walter Reed Army Institute of Research (Hoge et. 
al., 2007) have reviewed recent studies of military personnel with 
service in Iraq and Afghanistan, and reported that ``military duty in 
Iraq confers a similar risk of [Post Traumatic Stress Disorder] and 
depression by gender.'' The authors suggest that risk for developing 
significant combat stress disorders is a factor of intensity and 
frequency of combat exposure, rather than gender (Hoge CW, Clark JC, 
Castro CA. Commentary: Women in combat and the risk of post-traumatic 
stress disorder and depression. International Journal of Epidemiology 
2007).
    The issue of compassion fatigue among Navy Medicine personnel is 
also of significant interest. Navy Medicine has established a Care for 
the Caregiver mandate in order to address this concern. Assessment of 
operational and occupational stress of medical personnel, to include 
focus groups, will begin in summer 2007.
    Dr. Snyder. General Pollock and Admiral Arthur and General 
Roudebush, the article that Ms. Davis called to my attention last week 
is from the New York Times Magazine March 18, 2007, ``The Women's War'' 
by Sara Corbett.
    I have no expectation that you all read everything that is in the 
press out there about men and women at war and their families. But if 
you would respond for the record to this.
    General Roudebush. The Air Force is concerned about all Airmen with 
trauma-related mental health problems, regardless of gender. We have 
procedures to guide base helping agencies as they assist Airmen who are 
transitioning back to their home station from deployment. These 
procedures include education on the recognition of PTSD signs and 
symptoms and where to go for help. Upon redeployment and then 3 to 6 
months later, we ask Airmen to complete a survey describing their 
current health status. This survey includes questions about PTSD; when 
Airmen screen positive, they are referred to their primary care 
provider for further evaluation and, if indicated, onto a mental health 
specialist. Ms. Corbett makes note of Dr. Edna Foa's Prolonged Exposure 
Therapy for the treatment of PTSD. I am pleased to tell you that the 
Air Force brought Dr. Foa to a number of our bases to train mental 
health professionals in her evidence-based treatment. To date, she has 
trained 100 mental health professionals. We are working with her 
currently to have her provide training to an additional 300 
professionals. We are also working with Dr. Patricia Resick, another 
one of our nation's top PTSD clinician/researchers. Dr. Resick will be 
providing training in her Cognitive Processing Therapy, the other main 
evidence-based treatment for PTSD.
    Dr. Snyder. My final question is the bill that passed out of the 
full Armed Services Committee last week and will be on the floor this 
week that will be called the Wounded Warriors Bill. Have any of you had 
a chance to look at it and have any thoughts or criticisms about it. 
Would you share that with us today?
    General Pollock. I'd like to thank the Congress for its commitment 
to care for our warriors in transition, as demonstrated by the wounded 
warrior legislation recently passed by the House. The attention of 
Congress at the strategic level and as an oversight body will help 
ensure that the Department addresses concerns regarding outpatient care 
and the Physical Disability Evaluation System with the right level of 
attention, enthusiasm, and resources. My major comment regarding your 
legislation relates to timing and specificity. The Army is moving 
forward very quickly to correct deficiencies and improve processes. 
There are currently a number of efforts and investigations underway 
within the Army, the DoD, and the executive branch that will provide us 
with findings and recommendations to move forward. Legislating 
solutions now, before the commissions and reviews are completed, would 
be premature. We are in the process of developing a supporting 
infrastructure for our wounded warriors and would prefer to determine 
how all the pieces fit together before pursuing specific ratios. 
Furthermore, I am not comfortable with the thought that one solution 
suits the entire military health system. Depending on supporting 
structure, case complexity, and a variety of other factors, staffing 
ratios must remain flexible. We understand your interest in appropriate 
access and availability to case managers, physical evaluation board 
liaison officers (PEBLOs), and advocates. I would suggest establishing 
a reporting requirement so the Department can regularly update Congress 
on existing ratios and practices.
    I would also like to comment concerning the provision for 
congressional notification. I believe that Members of Congress should 
be notified when a Soldier-constituent is evacuated from a combat 
theater to a hospital in the United States. The majority of evacuations 
out of theater, however, do not result in hospitalizations in the U.S. 
Many are returned to duty within a matter of days. I do not believe it 
is the intent of Congress to track these Soldiers. In addition, 
congressional notifications should be limited to those members of 
Congress who represent the district or state that includes the 
Soldier's home of record.
    Dr. Snyder. MG Pollock stated that she has asked the Department of 
the Army to re-look the efficiency edge figures for FY 2008-09. What is 
the status of this re-evaluation?
    General Pollock. A decision was made on 19 June 2007 by the Under 
secretary of Defense, Personnel and Readiness, to establish a study 
group to re-evaluate the efficiency wedges. We look forward to 
participating in this re-evaluation.
    Dr. Snyder. MG Pollock agreed to provide written answers on the 
current status (process and numbers) of the Army's military to civilian 
conversions.
    General Pollock. The initial analysis to select military billets 
for conversion considered availability of skill sets in the local 
market, projected costs, and historical fill rates. Billets linked to 
operational readiness were not targeted. The Army has certified to 
Congress that 1,504 of the 1,669 military-to-civilian conversions 
programmed for FY06 and FY07 will not increase cost or reduce access to 
care or quality of care. Of the 165 positions not certified for 
conversion, 52 were determined to be hard to fill. The Army is 
currently re-evaluating its strategy on medical military-to-civilian 
conversions and does not want to stop conversions when it makes sense 
due to operational demands, cost or level of care. During execution of 
programmed medical conversions, some hiring actions took longer than 
expected due to shifts in the health care market. Inability to backfill 
converted military billets in a timely manner with equally qualified 
civilian health care workers could impact mission capability. 
Therefore, we are reassessing our plans and program for medical 
military-to-civilian conversions. Military-to-civilian conversions play 
a key role in increasing Army operational capabilities. Backfilling 
medical positions in the Institutional Army with civilians and 
realigning military positions to the operational Army helps reduce 
stress on the force.

                     ARMY MEDICAL DEPARTMENT (AMEDD)
                    MILITARY TO CIVILIAN CONVERSIONS
                              (CUMULATIVE)                                                 FY06     FY07     FY08AMEDD Officers                                     127      191      224
AMEDD Warrant Officers                               4        8       15
AMEDD Enlisted                                     498      978     1210
AMEDD TOTAL                                        629     1177     1449Non-AMEDD Officers                                   3        3       12
Non-AMEDD Warrant Officers                           6        6        7
Non-AMEDD Enlisted                                 430      483      774
Non-AMEDD TOTAL                                    439      492      793
Total Programmed Conversions                      1068     1669     2242
Total Certified Conversions                       1068     1504
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MR. MCHUGH
    Mr. McHugh. Since the widely publicized problems at Walter Reed 
Army Medical Center, there has been much discussion on the MEB/PEB 
system. For several years this committee has heard complaints about the 
timeliness and accuracy of both systems. I understand that only the MEB 
system is under the control of the Service medical departments. Please 
tell us what steps you have taken to ensure that the documents that are 
considered by the Medical Evaluation Board are complete and accurate. 
What mechanisms are in place for ensuring that a service member has 
gained the maximum medical benefit from the treatment provided before 
they are referred to the MEB?
    General Pollock. Due to past complaints about the Physical 
Disability Evaluation System (PDES), several steps have been taken to 
ensure quality control and consistency of process, while still taking 
into account the requirements to respond to the individual Soldier's 
needs as well as the needs of the Army. The newly implemented ``triad'' 
of patient care: the primary care physician, the nurse case manager and 
the squad leader, are all to be involved in the determination of when 
maximum medical benefit is achieved. As a check/confirmation of this, 
as Soldiers enter the MEB process, they are each given a comprehensive 
physical exam. The purpose of this exam is to ensure that each and 
every condition the Soldier is adequately addressed prior to submitting 
his/her MEB to the PEB. One of the outcomes of this comprehensive 
physical may be additional consults to other specialties. Ideally, once 
initiated, an MEB should be processed efficiently and with care and 
compassion for the Soldier. However, every Soldier's case is unique and 
there are instances where the MEB process is actually stopped to 
provide additional treatment and/or surgery if deemed medically 
necessary.
    As discussed above, additional dedicated medical resources (such as 
dedicated MEB physicians) have been and are in the process of being 
hired/assigned throughout the Army Medical Department to process MEBs 
and assist Soldiers in their healing and recovery. These dedicated 
personnel have received training on the evaluation and processing of 
Soldiers undergoing the physical disability evaluation process. We have 
enforced a corporate understanding of the process through 
standardization of MEB Physical Evaluation Board Liaison Officer 
(PEBLO) and physician training requirements.
    In May 2007 a Worldwide PEBLO Conference was held, where physicians 
and counselors participated in dedicated training tracks, problem-
solving breakout sessions and certification testing. There is a 
dedicated website repository, available for counselors and physicians 
to utilize as a resource for additional information. An Army Medical 
Action Plan (AMAP) was developed by Army agencies/activities involved 
in the PDES process to implement and execute new business practices as 
it pertains to clinical and administrative quality improvements.
    To summarize, the PDES is designed with a number of checks and 
balances in place to ensure adequate due process. The senior clinical 
physician in the hospital is the local deciding authority for appeals 
to the MEB and any questions regarding maximum medical benefit. 
Soldiers also have the ability to appeal their MEB findings. Based on 
their appeal, the MEB can stand as written, be sent back to health care 
provider for further information, or be forwarded to the PEB with 
attachments or additional notes. Finally, the regional PEBs have the 
discretion to reject the MEB if they feel it is not complete and the 
Soldier has not reached optimal medical benefit.
    Mr. McHugh. Since the widely publicized problems at Walter Reed 
Army Medical Center, there has been much discussion on the MEB/PEB 
system. For several years this committee has heard complaints about the 
timeliness and accuracy of both systems. I understand that only the MEB 
system is under the control of the Service medical departments. Please 
tell us what steps you have taken to ensure that the documents that are 
considered by the Medical Evaluation Board are complete and accurate. 
What mechanisms are in place for ensuring that a service member has 
gained the maximum medical benefit from the treatment provided before 
they are referred to the MEB?
    Admiral Arthur.

Steps to Ensure Complete and Accurate Documentation

    Accurate and timely submission of the Medical Evaluation Board 
Record (MEBR) to the Physical Evaluation Board (PEB) is a critical 
component of caring for the ill and injured sailors and Marines who 
have volunteered to serve their country. Steps to ensure that the 
documentation that is presented to the PEB is complete and accurate 
include the provision of thorough policy guidance, training, 
documentation review and program oversight.
    Policy Guidance: Detailed guidance about documentation required in 
a medical board package is outlined in ManMed Chapter 18-12 through 18-
16, including templates for a complete medical evaluation board report 
and non-medical assessment. This guidance was last updated in January 
of 2005, includes PEB policy guidance contained in SECNAVINST 1850.4E, 
and has subsequently been reviewed to ensure that it continues to 
provide proper instruction on the scope and content of information 
required by the PEB.
    Training: Navy Medicine has recently combined the Annual Patient 
Administration Conference with the Annual Physical Evaluation Board 
Liaison Officer Conference to ensure maximum participation and 
interaction between DON PEB Staff, BUMED staff, Patient Administration 
Officers and PEBLOs. This interactive conference serves as an 
opportunity to ensure proper training of administrative staff and 
counselors as well as to identify problems, and solutions, with all 
stake holders at one location. Patient Administration Officers receive 
additional training at the Quarterly Patient Administration Courses. 
Clinicians involved in the dictation of MEBRs or who serve on the 
Medical Evaluation Board receive training prior to assuming this 
responsibility and periodically throughout their career. The DON PEB 
provides training to clinicians and administrative staff upon request 
as well as during site visits to Military Treatment Facilities.
    Documentation Review: The Convening Authority (the hospital's 
Commanding Officer) along with the involved service member has ultimate 
responsibility to ensure the accuracy and quality of the MEBR prior to 
sending it to the PEB. A minimum of two physicians trained in the MEB 
process will review the MEBR for accuracy and completeness. The Patient 
Administration staff reviews all documentation of the MEBR for 
completeness prior to presenting it to the Convening Authority for 
signature. The MEBR package presented to the service member for review 
must be complete, including all medical documentation, non-medical 
assessments and line of duty determinations that are to be submitted to 
the PEB. The service member has 5 days to review the MEBR and either 
sign it for submission as a complete package or provide a rebuttal. If 
they submit a rebuttal they can submit additional documentation that 
they feel should be included for the PEB's review.
    Program Oversight: MedBOLT (Medical Board Online Tracking) is the 
database used by Navy Medicine to track efficacy in executing the MEB 
process. All parts of the MEB process can be tracked in this system to 
assist in ensuring completeness and timeliness of submission. The 
system also allows communication of historical MEB data across MTFs 
allowing for a complete and accurate picture of the individual's 
history. MedBOLT has technical safeguards in place that alert the user 
to ensure all necessary forms and supporting documentation are complete 
prior to submission to the PEB. The Patient Administration Officer is 
responsible for running periodic reports to ensure timely progress 
through the MEB process. Additionally, Navy Medicine Inspector General 
(MEDIG) performs reviews the MEB process during their periodic MTF 
inspections.

Mechanisms to Ensure Maximum Medical Benefit Prior to referral to MEB

    The timing of referral to the PEB must be individualized for each 
service member to ensure maximum benefit to the patient. For instance, 
there are circumstances in which referral of the service member to the 
PEB early into medical treatment may be in the best interests of the 
member, as it could maximize the delivery of disability benefits and 
compensation. Examples of cases in which the member may desire early 
referral are very severely injured members whose disabling condition 
makes them ratable by the VA at 100%. Those members would be eligible 
for financial benefits not otherwise available while they are still in 
an active duty status. DoN ran a pilot program in conjunction with the 
VA last year, with a small sampling of eligible members to determine 
the best processes and develop procedures to streamline benefits 
delivery. There are other circumstances when it is in the best interest 
of the service member to defer referral to the PEB until the patient 
has reached maximum medical benefit and the condition is stable. Policy 
outlined in ManMed Chapter 18 allows for this provision. When a service 
member has a medical condition that limits their ability to fully 
perform their job and the condition is expected to persist for over 90 
days, they are to be placed in a Limited Duty Status (LIMDU). While 
each period of LIMDU is for no more than 6 months, subsequent periods 
of LIMDU are authorized if the medical condition is not stable or 
maximum medical benefit has not been reached to make a determination of 
fitness for continued service/disability. The policy outlines 
procedures for requesting Service Headquarters approval of subsequent 
LIMDU to ensure that members do not linger in this status. However, if 
the clinician caring for the patient outlines reasons for continuation 
of LIMDU, including need for ongoing care prior to referral to the PEB, 
Service Headquarters can grant extended LIMDU until the condition is 
stable or maximum medical benefit has been achieved. Moreover, the PEB 
applies a separate assessment of completeness and clinical 
appropriateness upon receipt of an MEBR and does not hesitate to seek 
further documentation with respect to a variety of issues including 
diagnostic and treatment status as indicated from the referring MTF.
    Mr. McHugh. Since the widely publicized problems at Walter Reed 
Army Medical Center, there has been much discussion on the MEB/PEB 
system. For several years this committee has heard complaints about the 
timeliness and accuracy of both systems. I understand that only the MEB 
system is under the control of the Service medical departments. Please 
tell us what steps you have taken to ensure that the documents that are 
considered by the Medical Evaluation Board are complete and accurate. 
What mechanisms are in place for ensuring that a service member has 
gained the maximum medical benefit from the treatment provided before 
they are referred to the MEB?
    General Roudebush. In the AF, a service member's physician will 
start an MEB when the physician feels the member has obtained optimum 
benefit from treatment (in compliance with DODI 1332.38, paragraph 
E2.1.22). Once the physician feels there is enough information to 
determine the member's ability to return to duty, the physician submits 
a narrative medical summary to the MEB clerk. The AF requires three 
physicians to review each MEB package. If there is a psychiatric 
diagnosis (e.g. PTSD), a psychiatrist must be one of the three MEB 
physicians. If the physicians feel a member has not yet obtained 
optimum benefit, they can recommend additional treatment for the 
member. Additional medical specialty evaluations may be requested if 
the physicians are unsure about the member's fitness for duty. Once a 
MEB recommendation has been made, the senior MTF physician (SGH) 
reviews the case to provide senior clinical oversight. Additionally, 
the PEB Liaison Officer (PEBLO), while not typically a medical 
clinician, may also provide advice to the physicians based on the 
PEBLO's past experience with similar MEB cases. Every attempt is made 
to tailor the process to meet the individual patient's needs.
    Mr. McHugh. Recent emphasis on traumatic brain injury suffered by 
service members in Iraq and Afghanistan has raised the awareness of 
Congress and the American public to this often deceptive medical 
condition. What mechanisms does each of you have in place to identify 
TBI in redeploying service members, including those who are not 
obviously wounded or injured? How are military health providers 
distinguishing TBI from other mental health conditions, such as PTSD? 
What additional resources do you need to identify and treat TBI?
    General Pollock. We recently modified the Periodic Health 
Assessment (PHA) screening questions to include TBI specific questions. 
The PHA screen will be fully functional in July. If a Soldier answers 
``yes'' to a potential traumatic brain injury event like a fall, a 
motor vehicle accident, or being near an explosion, then an additional 
more detailed questionnaire will open and be reviewed by a clinician. 
This tool will be used to ``catch up'' the entire Army by screening for 
TBI at the time of an annual health assessment. In addition, we will be 
using the recently revised Post Deployment Health Assessment (PDHA) (DD 
Form 2796) and Post Deployment Health Reassessment (PDHRA) DD Form 
2900) as specified by Health Affairs. These revised forms include 
several TBI screening questions that have been recommended by the 
Defense Veterans Brain Injury Center (DVBIC) and other subject matter 
experts. Concurrently, we are compulsively performing TBI screening for 
Soldiers in theater following blast exposure even when no other wounds 
or injuries have occurred. We published an ALARACT, ``Documenting Blast 
Exposure/Injury in Theater Medical Records'' (15 June 2007) requiring 
documentation of exposure in the electronic health record (AHLTA-T), 
mandating specific International Classification of Disease (ICD-9) 
codes, and requiring the use of the Military Acute Concussion 
Evaluation (MACE) template.
    This Blast ALARACT builds on the increased awareness and improved 
identification of Soldiers with potential TBI from the ALARACT 
published 27 July 2006, ``Concussion in Soldiers on the Battlefield''. 
The Concussion ALARACT delineated the signs and symptoms of concussion 
and provided guidelines for Commanders and staff to determine when to 
refer Soldiers for medical evaluation. In addition, we have recently 
initiated pre-deployment baseline neurocognitive testing of several 
deploying units, including the 101 st Airborne Division and 
the 1st Armor Division. We are using the Automated 
Neuropsychological Assessment Metrics (ANAM) TBI Battery as the 
instrument of choice at this point in time as the ANAM has military 
norms based on over 9000 Soldiers from Fort Bragg for comparison in the 
assessment of the Soldier's neurocognitive performance. We have 
established a process to test large groups of soldiers; transmit and 
store the baseline test results and subsequent test results on a 
central server; allow providers in theater and in fixed facilities to 
access the baseline data remotely and generate a results report; and 
conduct post-deployment testing. The ANAM output report is designed to 
meet the needs of primary care providers and will be included in the 
Soldier's electronic medical record. We are following the DVBIC 
Clinical Practice Guidelines for theater, specifically using the 
Military Acute Concussion Evaluation (MACE) immediately after an 
exposure or injury and using the ANAM if the Soldier is still 
symptomatic 24 hours after the injury. Providers at all levels can 
administer the ANAM to get an objective assessment of cognitive 
functioning and performance to use in the overall evaluation of a 
Soldier's condition and to track the Soldier's recovery. In conjunction 
with the pre-deployment testing, we are providing TBI assessment and 
management training for providers as well as offering Neurology and 
Neuropsychology teleconsultation for providers seeking advice and 
assistance through the DVBIC. The demand for ANAM pre-deployment, post-
injury, and post-deployment testing from both the medical unit and line 
Commanders is growing dramatically. All Service members medically 
evacuated through LRMC are also screened for TBI using the MACE if 
their condition permits. Since medically evacuated Soldiers may not 
receive a Post Deployment Health Assessment (PDHA) prior to departing 
the combat theater or they may not be in a condition to be screened for 
TBI at LRMC, I have directed Medical Treatment Facility (MTF) 
Commanders to ensure that all OIF/OEF medically-evacuated Soldiers 
receive or have received the following three evaluations: (1) the PDHA; 
(2) TBI screening and follow-up with a clinician if necessary, and (3) 
the Post Deployment Health Reassessment (PDHRA).
    Traumatic brain injury is a neurologic injury with possible 
physical, cognitive, behavioral, and emotional symptoms. Like all 
injuries, TBI is most appropriately and accurately diagnosed as soon as 
possible after the injury. TBI is not a mental health condition. The 
range of TBI includes mild, moderate, severe, and penetrating. Well 
after the injury event, if the TBI was of mild severity and if the 
symptoms are primarily behavioral and emotional, the co-existence of or 
distinction from PTSD can be difficult to discern. Certainly some 
Soldiers have both residual symptoms from a TBI and new or emerging 
PTSD symptoms. If proper injury documentation is not available, a 
compassionately obtained description of the traumatic events in theater 
usually allows a well-trained clinician to make a distinction between 
TBI and PTSD or other mental health conditions. We are committed to the 
earliest identification and documentation of TBI. We provide education 
for our providers prior to deployment and while in theater. We are 
implementing a mandatory standardized web-based TBI training program 
for all health care professionals to include clinical support 
personnel.
    Mr. McHugh. Recent emphasis on traumatic brain injury suffered by 
service members in Iraq and Afghanistan has raised the awareness of 
Congress and the American public to this often deceptive medical 
condition. What mechanisms does each of you have in place to identify 
TBI in redeploying service members, including those who are not 
obviously wounded or injured? How are military health providers 
distinguishing TBI from other mental health conditions, such as PTSD? 
What additional resources do you need to identify and treat TBI?
    Admiral Arthur. As military spokesperson for consolidation of 
Traumatic Brain Injury (TBI) initiatives in the DOD and DVA, I am 
gravely concerned about our ability to diagnose and treat TBI, 
particularly the mild to moderate forms of TBI that may not be 
immediately apparent on initial examination. TBI in personnel who are 
exposed to a blast but do not suffer other demonstrable physical 
injuries is particularly difficult to detect. Redeploying 
servicemembers who have suffered such injuries may later manifest 
symptoms that do not seem to have a readily identifiable cause, with 
potential negative effect on their military careers. As many as 20% of 
injured servicemembers may have TBI as an additional diagnosis.
    Navy Medicine uses a validated clinical assessment tool, the 
Military Acute Concussion Evaluation (MACE), in field settings to 
detect neuropsychological sequelae to blast exposure. MACE is used in 
assessing all concussion type injuries, including blast. Our 
standardized Emergency Treatment Record, that is a part of the Joint 
Trauma Registry, also has a series of screening questions about blast 
exposure and concussion symptoms. In October 2006, we deployed field 
devices at Navy Medicine Echelon II trauma facilities for neurotologic 
auditory-vestibular evaluation. We are actively pursuing full roll-out 
of a field tested computerized assessment, the Automated 
Neuropsychological Assessment, which can be administered via a hand-
held device. In spite of these advances, much needs to be done to 
ensure that screening is comprehensive and accurate.
    TBI often exists in the context of polytrauma, including 
psychological trauma, and its symptoms may overlap with those of 
behavioral disorders or diagnoses, such as Post Traumatic Stress 
Disorder (PTSD). Although PTSD is a less common problem than other 
psychological disorders such as depression or anxiety, it is a 
significant concern in our population. We screen all redeploying 
servicemembers for symptoms of combat stress on our Post Deployment 
Health Assessment/Reassessment devices. Those whose responses suggest 
some distress are referred for full evaluation. All returning 
combatants treated in our military treatment facilities receive a 
psychological evaluation to detect for comorbid symptoms of emotional 
disorders in conjunction with other injuries.
    We urgently require research to better understand the etiology of 
TBI resulting from blast, as evidence suggests the resulting symptoms 
differ from those resulting from TBI from other injuries. We must 
examine universal pre-screening to assess for baseline levels of 
cognitive function. Clinically usable, hand-held computerized devices 
will also require significant test and development. On the treatment 
side, we have identified needs across all echelons of care, from 
enhanced recognition at the point of injury through definitive 
rehabilitative care. We have significant gaps in care when critically 
short critical specialty providers are required and we lack the 
capability to provide for a continuum of care for servicemembers and 
their families in all locations.
    Mr. McHugh. Recent emphasis on traumatic brain injury suffered by 
service members in Iraq and Afghanistan has raised the awareness of 
Congress and the American public to this often deceptive medical 
condition. What mechanisms does each of you have in place to identify 
TBI in redeploying service members, including those who are not 
obviously wounded or injured? How are military health providers 
distinguishing TBI from other mental health conditions, such as PTSD? 
What additional resources do you need to identify and treat TBI?
    General Roudebush. Screening patients for TBI can be challenging, 
especially when not accompanied by obvious physical injury. Airmen with 
moderate, severe, or penetrating brain injury are readily identified, 
entered into the Defense Veterans Brain Injury Center (DVBIC) registry, 
and treated according to established protocols. All service members 
aeromedically evacuated from theater are screened for TBI using a 
questionnaire developed at Landstuhl Regional Medical Center (LRMC). In 
addition, all airmen returning from deployment complete both a Post-
Deployment Health Assessment (PDHA) within 30 days and a Post-
Deployment Health Re-Assessment (PDHRA) at 3-6 months. Specific TBI 
screening elements are being added to each.
    It is important when treating patients with mild TBI or PTSD to 
begin therapy early and it is possible to see patients with elements of 
both conditions. To distinguish between mild TBI and PTSD, our 
providers use clinical symptoms, physical examination, imaging studies 
(x-rays, CT scans, MRIs) and neuro-psychologic testing.
    Mr. McHugh. In your written statements you mention the health care 
professionals who are deployed in support of our troops in the field. 
Between the Army and the Navy close to 16,000 medical personnel are 
deployed around the world on any given day. At the same time military 
medical personnel are working in military treatment facilities caring 
for our troops, their families and our retired beneficiaries. DOD and 
the military Services have testified on many occasions regarding the 
need for rotation policies for deploying troops. I am wondering about 
the rotation policy for medical personnel. Please describe the 
deployment policies each of you have for military medical personnel in 
support of OIF and OEF. How many medical personnel have been deployed 
once, twice, three times or more? Given the challenges in recruiting 
and retaining medical personnel, how long will you be able to sustain 
your current deployment policies?
    General Pollock. We have various deployment policies under which 
Army Medical Department (AMEDD) personnel deploy.
    MEDCOM MEDICAL AUGMENTATION Replacement Policy--all Medical Corps 
(MC) Dental Corps (DC) and Army Nurse Corps (AN) 66Fs (Nurse 
Anesthetists) in an Individual Augmentee (IA) or Medical Augmentee 
status will deploy for 180 days (90 days if the filler is an MC Program 
Director).
    180-day AMEDD PROFIS Replacement Policy (APRP)--MC and DC (select 
AOCs) and 66Fs in a PROFIS or IA status at Echelons Above Division 
(EAD) units deploy for 180-days.
    90-day Program Director Policy--Medical Corps Graduate Medical 
Education Program Directors in a Professional Officer Filler System 
(PROFIS)/IA status at EAD units will deploy for 90-days.
    DA Policy--All other AMEDD, PROFIS/IA, TCS or assigned permanent 
party will deploy 15 months/until mission complete.
    90-day Boots on the Ground--Reserve component MC, DC and Nurse 
Anesthetists (not in leadership positions) in an assigned status will 
deploy/mobilize for 90 days (boots on the ground, 120 days door-to-
door).
    DA Policy--All other AMEDD in an assigned status will deploy/
mobilize for 365 days.
    Mr. McHugh. In your written statements you mention the health care 
professionals who are deployed in support of our troops in the field. 
Between the Army and the Navy close to 16,000 medical personnel are 
deployed around the world on any given day. At the same time military 
medical personnel are working in military treatment facilities caring 
for our troops, their families and our retired beneficiaries. DOD and 
the military Services have testified on many occasions regarding the 
need for rotation policies for deploying troops. I am wondering about 
the rotation policy for medical personnel. Please describe the 
deployment policies each of you have for military medical personnel in 
support of OIF and OEF. How many medical personnel have been deployed 
once, twice, three times or more? Given the challenges in recruiting 
and retaining medical personnel, how long will you be able to sustain 
your current deployment policies?
    Admiral Arthur. There are three parts to Navy Medicine's deployment 
policy for medical personnel deployed away from Navy medical facilities 
in support of OIF/OEF. First, they should be onboard at least six 
months prior to deploying; second, they should return from deployment 
within 6 months of their PRD; and third, there should be 365 days dwell 
time after returning from a deployment. We strive to ensure that all 
qualified personnel have deployed once before we order someone to 
deploy twice.
    Based on the FY06 OSD (Health Affairs) Tri-Service study, 14,677 
(13,020 Active and 1,657 Reserve) Navy medical personnel were deployed 
to OEF/OIF. Of the 13,020 Active deployers, 9,451 (73%) were deployed 
once and 3,569 (27%) were deployed more than once. Of the 1,657 Reserve 
deployers, 1,430 (86%) were deployed once and 227 (14%) were deployed 
more than once. We plan to request this study be updated with FY07 
data.
    Based on current operational tempo, we expect to average 2,500 
medical deployments per year to CENTCOM. About half, or 1,250, will be 
sourced from our medical facilities. We continue to closely monitor 
some high demand communities such as, surgery, mental health, 
preventive medicine and independent providers (nurse practitioners, 
independent duty corpsman and physician assistants).
    Mr. McHugh. In your written statements you mention the health care 
professionals who are deployed in support of our troops in the field. 
Between the Army and the Navy close to 16,000 medical personnel are 
deployed around the world on any given day. At the same time military 
medical personnel are working in military treatment facilities caring 
for our troops, their families and our retired beneficiaries. DOD and 
the military Services have testified on many occasions regarding the 
need for rotation policies for deploying troops. I am wondering about 
the rotation policy for medical personnel. Please describe the 
deployment policies each of you have for military medical personnel in 
support of OIF and OEF. How many medical personnel have been deployed 
once, twice, three times or more? Given the challenges in recruiting 
and retaining medical personnel, how long will you be able to sustain 
your current deployment policies?
    General Roudebush. Air Force medics deploy following the Air 
Expeditionary Forces (AEF) construct. The AEF involves deployment of 
personnel for 4 months, followed by 16 months at home station (there 
are exceptions, particularly with those deploying in support of Army 
missions that have longer deployment cycles). Non-traditional taskings 
extending up to a year or longer have to be worked outside of the AEF 
construct.
    Since 2003, 25.5 percent of our medics have deployed. Of those 
deployers, 8 percent have deployed twice and one percent have deployed 
three times. Some service members have deployed as many as 8 times but 
most do so voluntarily. We continue to monitor our personnel being 
deployed, its impact on our members and their families, and our 
recruiting and retention. At this time, we believe we can sustain our 
AEF rotation policy for the foreseeable future.
    Currently we have 1,464 Air Force medics deployed around the world. 
DHP medical assets are also assigned to garrison and are heavily 
involved in providing direct beneficiary care every day. When one looks 
at Service-specific deployed DHP (only) medical assets, Air Force, Army 
and Navy are almost equal in their contributions to supporting GWOT 
operations (see chart below).

               Military Medical Service Deployment History
       Billets with Program Element Codes = Defense Health Program
------------------------------------------------------------------------
                            Estimated Full Time Equivalents
   Service   -----------------------------------------------------------
                FY 2002     FY 2003     FY 2004     FY 2005     FY 2006
------------------------------------------------------------------------
Army                369       1,419       1,139       1,147       1,375
------------------------------------------------------------------------
Navy                 39       1,952         882         908       1,205
------------------------------------------------------------------------
Air Force         1,078       1,275       1,105       1,141       1,134
------------------------------------------------------------------------
 ASource OSD/HA

                                 ______
                                 
                   QUESTIONS SUBMITTED BY MRS. BOYDA
    Mrs. Boyda. We hear that funding for TBI research has been cut 
back. Can you address that? Do you know anything about that? Is that 
true? And is there something that Congress can do?
    General Pollock. Army core research programs on Traumatic Brain 
Injury (TBI) did not suffer a cut in funding in Fiscal Year 2007. 
Congress expressed some concern that the Defense and Veterans Brain 
Injury Center (DVBIC), a major contributor to military TBI initiatives 
both clinical and research, would lose funds as the result of an 
organizational realignment. The Defense Appropriations Act for FY06 
directed the transfer of the full amount of DVBIC funds from the 
Uniformed Services University of Health Sciences (USUHS) to the US Army 
Medical Research and Materiel Command (MRMC). This transfer of funds 
coincided with DVBIC's move from USUHS to MRMC. Additionally, in FY06 
MRMC provided the DVBIC approximately $12M of Defense Health Program 
funding, including congressional adds. In FY07, MRMC provided $19.8M of 
DHP funding. Research on traumatic brain injury and the effects of 
blast injuries is a high priority for MRMC and the Army. We will 
continue to dedicate resources to this critical research.
                                 ______
                                 
            QUESTIONS SUBMITTED BY MRS. DAVIS OF CALIFORNIA
    Mrs. Davis. I wanted to ask you about the article in the New York 
Times Magazine the other day by Sara Corbett. I don't know if you 
happened to see that about women in combat and women in theater and the 
impacts of PTSD on women, particularly as primary care givers, but also 
some of the instances that were cited in the article, abuse to women in 
theater and how that is being dealt with and how the services are 
providing the kind of care and support that the women need and being 
certain that they get that while in theater and then they certainly get 
that when they return home.
    Could you speak to that?
    General Pollock. Sara Corbett's Article ``The Women's War'' 
published in The New York Times Sunday Magazine 18 March 2007 is a 
thoughtful, balanced, and detailed examination of unique problems 
facing some service women today. The Iraq war has seen unprecedented 
numbers of female Soldiers serving with many Combat Service and Service 
Support units. As the article highlights, both the military and 
Department of Veterans Affairs are devoting increasing attention to the 
unique problems of female service members. More attention needs to be 
given to studying the effects of combat on our female warriors. The 
development of effective treatment programs tailored to women should be 
a priority for our military Behavioral Health community.
    The Army takes the issues of Sexual Harassment and Sexual Abuse 
very seriously and has set up an extensive program to encourage victims 
of harassment or sexual assault to seek help. The Army's Sexual Assault 
Prevention and Response Program (SAPR) provides confidential victim 
advocates who diligently work with victims to provide them with 
treatment resources and support. Annual training on the SAPR is 
required for all military personnel. A detailed explanation of the Army 
program can be found at: http://www.sexualassault.army.mil/.
    In regard to the noted increase in reporting since the initiation 
of the SAPR program, we feel this is a positive development. It has 
long been understood that when one pays attention to a problem by 
encouraging reporting and offering protection to those who report, the 
rates of reporting will rise. This increase therefore likely reflects 
victims who previously did not report, rather than an actual increase 
in assaults. While no one believes we are reaching 100% of the victims 
of sexual assault, early intervention and the support of victim 
advocates are helping many women recover.
    On the issue of PTSD, there has long been demonstrated a 
significant gender difference in willingness to seek help between males 
and females, with female personnel more open to doing so. Our data from 
the Mental Health Advisory Team studies do not show any gender 
difference, but more research needs to be done.
    The Department of Defense is currently engaged in unprecedented 
efforts to find and help service members adversely affected by their 
deployment experiences. The Post-Deployment Health Assessment given 
immediately upon re-deployment and the Post-Deployment Health Re-
Assessment, given 90-180 days after re-deployment bring soldiers into 
direct contact with Behavioral Health personnel and give them the 
opportunity to obtain immediate assistance. Additionally the physical 
examination process has been revised to a Periodic Health Assessment, 
which also looks for evidence of depression, anxiety or substance 
abuse. Although more can and needs to be done in this area, the Army is 
aware of the challenges faced by both male and female Soldiers and is 
doing everything possible to ensure their needs are met.
    Mrs. Davis. I wanted to ask you about the article in the New York 
Times Magazine the other day by Sara Corbett. I don't know if you 
happened to see that about women in combat and women in theater and the 
impacts of PTSD on women, particularly as primary care givers, but also 
some of the instances that were cited in the article, abuse to women in 
theater and how that is being dealt with and how the services are 
providing the kind of care and support that the women need and being 
certain that they get that while in theater and then they certainly get 
that when they return home.
    Could you speak to that?
    Admiral Arthur. In reference to the article titled ``The Women's 
War'', the following comments are provided on Navy Medicine's efforts 
for providing medical care for the physical and psychological sequelae 
of women serving in the Navy and Marine Corps as a result of combat 
experience.
    Navy Medicine seeks to proactively address the broad range of 
combat and operational stress injuries, to include PTSD, in a number of 
ways. In November 2006, Navy Medicine established a directorate at the 
Bureau of Medicine and Surgery led by an experienced combat stress 
psychiatrist specifically dedicated to addressing mental health stigma, 
combat stress training needs, non-stigmatizing care of returning 
deployers, and support services for Navy caregivers. Other efforts 
include prevention, outreach, and early intervention to warfighters 
using Navy mental health providers trained in clinical best-practices 
related to combat and operational stress control. One specific example 
is Operational Stress Control and Readiness teams providing early 
intervention, outreach, and prevention at the unit levels in close 
proximity to operational missions in order to reduce stigma that can be 
encountered in conventional mental health care settings.
    Navy Medicine plans to utilize existing data sets to study combat 
stress and gender. Naval Health Research Center's Millennium Cohort 
Study is addressing a variety of combat-related behaviors in both men 
and women. Additionally, the first phase of the Navy's in-theater 
Behavioral Health Needs Assessment (BHNAS) is complete, and analysis of 
gender differences associated with deployment stress is currently 
underway.
    Service Members returning from deployment are screened using the 
Post Deployment Health Assessment (PDHA-DD Form 2796). A review of 
261,008 PDHA forms completed from January 2003 to present demonstrate 
that 2.2% of male Marines and Sailors were referred for mental health 
services, compared to 2.6% of returning female Marines and Sailors 
(Defense Medical Surveillance System, 19 June 2007).
    Researchers from Walter Reed Army Institute of Research (Hoge et. 
al., 2007) have reviewed recent studies of military personnel with 
service in Iraq and Afghanistan, and reported that ``military duty in 
Iraq confers a similar risk of [Post Traumatic Stress Disorder] and 
depression by gender.'' The authors suggest that risk for developing 
significant combat stress disorders is a factor of intensity and 
frequency of combat exposure, rather than gender (Hoge CW, Clark JC, 
Castro CA. Commentary: Women in combat and the risk of post-traumatic 
stress disorder and depression. International Journal of Epidemiology 
2007).
    The issue of compassion fatigue among Navy Medicine personnel is 
also of significant interest. Navy Medicine has established a Care for 
the Caregiver mandate in order to address this concern. Assessment of 
operational and occupational stress of medical personnel, to include 
focus groups, will begin in summer 2007.
    Mrs. Davis. I wanted to ask you about the article in the New York 
Times Magazine the other day by Sara Corbett. I don't know if you 
happened to see that about women in combat and women in theater and the 
impacts of PTSD on women, particularly as primary care givers, but also 
some of the instances that were cited in the article, abuse to women in 
theater and how that is being dealt with and how the services are 
providing the kind of care and support that the women need and being 
certain that they get that while in theater and then they certainly get 
that when they return home.
    Could you speak to that?
    General Roudebush. The Air Force is concerned about all Airmen with 
trauma-related mental health problems, regardless of gender. We have 
procedures to guide base helping agencies as they assist Airmen who are 
transitioning back to their home station from deployment. These 
procedures include education on the recognition of PTSD signs and 
symptoms and where to go for help. Upon redeployment and then 3 to 6 
months later, we ask Airmen to complete a survey describing their 
current health status. This survey includes questions about PTSD; when 
Airmen screen positive, they are referred to their primary care 
provider for further evaluation and, if indicated, onto a mental health 
specialist. Ms. Corbett makes note of Dr. Edna Foa's Prolonged Exposure 
Therapy for the treatment of PTSD. I am pleased to tell you that the 
Air Force brought Dr. Foa to a number of our bases to train mental 
health professionals in her evidence-based treatment. To date, she has 
trained 100 mental health professionals. We are working with her 
currently to have her provide training to an additional 300 
professionals. We are also working with Dr. Patricia Resick, another 
one of our Nation's top PTSD clinician/researchers. Dr. Resick will be 
providing training in her Cognitive Processing Therapy, the other main 
evidence-based treatment for PTSD.

                                  
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