[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 110-29]
CHALLENGES AND OBSTACLES WOUNDED AND INJURED SERVICE MEMBERS FACE
DURING RECOVERY
__________
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
MARCH 8, 2007
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HOUSE COMMITTEE ON ARMED SERVICES
One Hundred Tenth Congress
IKE SKELTON, Missouri
JOHN SPRATT, South Carolina DUNCAN HUNTER, California
SOLOMON P. ORTIZ, Texas JIM SAXTON, New Jersey
GENE TAYLOR, Mississippi JOHN M. McHUGH, New York
NEIL ABERCROMBIE, Hawaii TERRY EVERETT, Alabama
MARTY MEEHAN, Massachusetts ROSCOE G. BARTLETT, Maryland
SILVESTRE REYES, Texas HOWARD P. ``BUCK'' McKEON,
VIC SNYDER, Arkansas California
ADAM SMITH, Washington MAC THORNBERRY, Texas
LORETTA SANCHEZ, California WALTER B. JONES, North Carolina
MIKE McINTYRE, North Carolina ROBIN HAYES, North Carolina
ELLEN O. TAUSCHER, California KEN CALVERT, California
ROBERT A. BRADY, Pennsylvania JO ANN DAVIS, Virginia
ROBERT ANDREWS, New Jersey W. TODD AKIN, Missouri
SUSAN A. DAVIS, California J. RANDY FORBES, Virginia
RICK LARSEN, Washington JEFF MILLER, Florida
JIM COOPER, Tennessee JOE WILSON, South Carolina
JIM MARSHALL, Georgia FRANK A. LoBIONDO, New Jersey
MADELEINE Z. BORDALLO, Guam TOM COLE, Oklahoma
MARK UDALL, Colorado ROB BISHOP, Utah
DAN BOREN, Oklahoma MICHAEL TURNER, Ohio
BRAD ELLSWORTH, Indiana JOHN KLINE, Minnesota
NANCY BOYDA, Kansas CANDICE S. MILLER, Michigan
PATRICK J. MURPHY, Pennsylvania PHIL GINGREY, Georgia
HANK JOHNSON, Georgia MIKE ROGERS, Alabama
CAROL SHEA-PORTER, New Hampshire TRENT FRANKS, Arizona
JOE COURTNEY, Connecticut THELMA DRAKE, Virginia
DAVID LOEBSACK, Iowa CATHY McMORRIS RODGERS, Washington
KIRSTEN GILLIBRAND, New York K. MICHAEL CONAWAY, Texas
JOE SESTAK, Pennsylvania GEOFF DAVIS, Kentucky
GABRIELLE GIFFORDS, Arizona
ELIJAH E. CUMMINGS, Maryland
KENDRICK B. MEEK, Florida
KATHY CASTOR, Florida
Erin C. Conaton, Staff Director
Debra Wada, Professional Staff Member
Jeanette James, Professional Staff Member
Margee Meckstroth, Staff Assistant
C O N T E N T S
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CHRONOLOGICAL LIST OF HEARINGS
2007
Page
Hearing:
Thursday, March 8, 2007, Challenges and Obstacles Wounded and
Injured Service Members Face During Recovery................... 1
Appendix:
Thursday, March 8, 2007.......................................... 63
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THURSDAY, MARCH 8, 2007
CHALLENGES AND OBSTACLES WOUNDED AND INJURED SERVICE MEMBERS FACE
DURING RECOVERY
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Hunter, Hon. Duncan, a Representative from California, Ranking
Member, Committee on Armed Services............................ 1
Skelton, Hon. Ike, a Representative from Missouri, Chairman,
Committee on Armed Services.................................... 22
Snyder, Hon. Vic, a Representative from Arkansas, Committee on
Armed Services................................................. 1
WITNESSES
Chu, Hon. David S.C., Under Secretary of Defense (Personnel and
Readiness)..................................................... 2
Kiley, Lt. Gen. Kevin C., The Surgeon General, U.S. Army......... 7
Schoomaker, Gen. Peter J., Chief of Staff, U.S. Army............. 5
Winkenwerder, Hon. William, Jr., MD, MBA, Assistant Secretary of
Defense for Health Affairs..................................... 3
APPENDIX
Prepared Statements:
Chu, Hon. David S.C.......................................... 72
Kiley, Lt. Gen. Kevin C...................................... 97
Schoomaker, Gen. Peter J..................................... 92
Skelton, Hon. Ike............................................ 67
Winkenwerder, Hon. William, Jr............................... 86
Documents Submitted for the Record:
Chart Funding for the Armed Forces Health Longitudinal
Technology Application (AHLTA) submitted by Dr. Chu........ 158
Letter to the Secretary of Defense submitted by Hon. Jeff
Miller..................................................... 156
Memorandum on the Challenges and Obstacles Wounded and
Injured Service Members Face During Recovery............... 111
Questions and Answers Submitted for the Record:
Mr. Andrews.................................................. 167
Mr. Jones.................................................... 167
Mr. McHugh................................................... 165
Mr. Miller................................................... 168
Mr. Ortiz.................................................... 164
Mr. Skelton.................................................. 161
Mr. Smith.................................................... 166
Dr. Snyder................................................... 166
CHALLENGES AND OBSTACLES WOUNDED AND INJURED SERVICE MEMBERS FACE
DURING RECOVERY
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House of Representatives,
Committee on Armed Services,
Washington, DC, Thursday, March 8, 2007.
The committee met, pursuant to call, at 10:03 a.m., in room
2118, Rayburn House Office Building, Hon. Vic Snyder presiding.
OPENING STATEMENT OF HON. VIC SNYDER, A REPRESENTATIVE FROM
ARKANSAS, COMMITTEE ON ARMED SERVICES
Dr. Snyder. The hearing will come to order.
We appreciate you all being here on this cold, snowy
morning. Mr. Skelton will be joining us probably in the 10:30,
10:45 range, but he wanted us to go ahead and begin the
meeting.
It is a pleasure once again to have all of you here with
us, well-known to this committee: Dr. Chu, Dr. Winkenwerder,
General Kiley.
And, General Schoomaker, you are a bit like the old pair of
slippers that just keeps coming back in the house once it is
set outside. And I think we said goodbye to you the last time
that you were here, thinking it was going to be your last time
to testify. But we appreciate your service and appreciate you
being with us.
Yesterday evening, Mr. McHugh and I met with some of our
staff members for an hour or so, because this body, this house,
is very interested in trying to help resolve some of these
issues involving the medical holdovers, the Walter Reed
situation, with legislation.
And so, you all may interpret that as bad news. We
interpret that as good news. But the good news part of it is
Mr. McHugh and I really want the legislation to be helpful. And
we also recognize that sometimes legislation may not be
helpful.
So I think some of the questions today will try to get at
things that we may at least take a first bite at this here in
the next few weeks, recognizing that there is no one piece of
legislation or one decision by any one of you that is going to
solve the kinds of issues that we are dealing with.
And before going to the witnesses, I will defer to Mr.
Hunter for any comments he would like to make for as much time
as he needs.
STATEMENT OF HON. DUNCAN HUNTER, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, COMMITTEE ON ARMED SERVICES
Mr. Hunter. Thank you, Mr. Chairman.
And, gentlemen, good to be with you. I look forward to your
testimony this morning.
I think the position of the committee clearly is, let's
figure out what went wrong and fix it.
One thing that I did want to say to my colleagues on the
committee is that we have had a bipartisan team of staff
members, Democrat and Republican staff members, attending
medical facilities throughout the country and in other areas
where we have American troops for the last several years.
And, Mr. Chairman, we did something several years ago that
I think had never been done by the Armed Services Committee
before, and that was to dedicate a staff member from the
committee to simply handle issues that patients of our
Department of Defense (DOD) medical system experienced, and to
talk to their families and try to assist them as they go
through the process of coming back from Landstuhl and other
areas to Walter Reed, Bethesda, and then, ultimately, out to
satellite hospitals throughout the DOD complex.
So, gentlemen, I look forward to your testimony. There
certainly appears to be a lot of work to be done.
And, Mr. Chairman, thank you for calling this important
hearing this morning.
Dr. Snyder. Thank you, Mr. Hunter.
Our four witnesses today are well-known to this committee
and this Congress and this country for their service: Dr. David
Chu, the undersecretary of defense for personnel and readiness;
Dr. William Winkenwerder, the assistant secretary of defense
for health affairs; General Peter Schoomaker.
Did I pronounce that right, General? Schoomaker?
General Schoomaker. Schoomaker, sir.
Dr. Snyder. Schoomaker?
General Schoomaker. Yes, sir.
Dr. Snyder. Okay. At the last hearing, you are entitled to
have your name pronounced right for the first time, perhaps, in
your career--Schoomaker, chief of staff of the U.S. Army; and
Lieutenant General Kevin Kiley, the surgeon general of the U.S.
Army.
And we will have your opening statements in that order.
Dr. Chu.
STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF DEFENSE
(PERSONNEL AND READINESS)
Dr. Chu. Thank you, Mr. Chairman, Congressman Hunter,
members of the committee. My colleagues and I each have
prepared statements which I hope you would accept for the
record.
Dr. Snyder. Without objection, all the statements will be
part of the record.
Dr. Chu. Thank you, sir.
I am deeply chagrined by the events that bring us to this
hearing today. As you appreciate, we set high standards in the
Department for our personnel programs and their administration.
You can see the achievement of those high standards in the
conduct of our medical personnel in caring for the wounded on
the battlefield, bringing them home to the United States and
placing them on the road to recovery.
It is evident in the fact that we have the lowest disease
and non-battle injury rate in the history of the republic and
the highest rate of survival from wounds the American military
has ever sustained.
And you can see it also in the generally favorable ratings
that our patient population--active, reserve, retired--gives to
the TRICARE medical program. Indeed, the Congress has added
communities to that program over the last several years, as a
result of the high regard in which it is held.
But I wish to apologize this morning on behalf of the
Department to those individuals where we fell short in
administration, in billeting, in how we carry out the
disability claims process.
And I apologize likewise to the American public.
I would like to ask my colleagues to speak to medical
programs, per se, and I would return very briefly, if I may,
Mr. Chairman, to speak to the disability evaluation system,
which I do think is the area in which long-term legislative
change may be meritorious.
STATEMENT OF HON. WILLIAM WINKENWERDER, JR., MD, MBA, ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
Dr. Winkenwerder. Thank you, Mr. Chairman. Thank you for
your support to all of our efforts over the year.
Mr. Chairman and distinguished members of this committee,
thank you for the opportunity to be here today to talk about
the serious concerns raised about housing conditions and
inappropriate bureaucratic delays and hurdles for service
members at Walter Reed Army Medical Center while those
individuals are receiving long-term rehabilitation and care.
Our wounded service members and their families expect, and
they deserve, quality housing and family support along with
well-coordinated services. In the case of the incidents at
Walter Reed, we failed them.
Today, I welcome the chance to talk about these issues and
what the Department is doing, even at this time, to move
forward.
Corrective action plans in the Army and across the
Department will take the following approach.
One, the top priority is finding problems and fixing them.
Where policy, process, or administrative change is required,
the Department will do it.
Second, we welcome public scrutiny, and that--this point--
that is a difficult thing to say, but we do, as painful as it
is. The problems cannot be solved and the people properly
served if the light is not shed on the problem, and that is
happening.
I endorse the statements of Secretary Gates. He has made it
clear that defensiveness and explanations are not the route to
getting things done. Standing up and making things happen to
meet the needs of our service members and their families is our
only job right now.
Let me just assess the problems before us as follows. And I
think Dr. Chu is kind of touched on this.
It relates to physical facility issues, process of
disability determination--and there will be a lot more to talk
about with that--and the process of care coordination in the
outpatient long-term setting, not in terms of acute outpatient
care.
With regard to the housing, I understand that the Army has
already begun correcting problems and is reviewing all housing
for wounded service members at other locations. The other
services have also undertaken a review, and that review is
ongoing.
With respect to the disability determination process, let
me just say that service members deserve fair, consistent and
timely determinations. The complex procedures must be
streamlined or removed. The system must not be adversarial, and
people should not have to go through a maze or prove or defend
themselves to the benefits that they deserve.
Likewise, regarding coordination of services, there must be
a higher ratio of case workers to wounded service members, so
that people get personalized care, a better support and
communication system with the families, and simpler
administrative processes.
Now let me just address one issue, and I think this is
important--we will have more discussion about it today; make
that very clear. The problems sighted in the press reports are
not result of unavailable or insufficient resources. Nor are
they in any way related to the base realignment and closure
(BRAC) decision to close the Walter Reed campus as part of the
planned consolidation with the National Naval Medical Center.
Significant resources have always been available, and we
continue to invest, even at this day, at Walter Reed for
whatever is needed.
For example, there were some who questioned the decision in
2005 to fund $10 million to construct Walter Reed's new amputee
center. But we have proceeded with that without hesitation. We
think that is the right thing to do. And we will simply not
allow for plans for a new medical center to interfere with
ongoing issues of care or any needed facility improvements.
Secretary Gates' decision to establish an independent
review group to evaluate and make recommendations on this
matter will be very beneficial. The group is a highly qualified
and, again, bipartisan team of former congressmen, line,
medical and enlisted leaders who have already begun their work.
And, of course, in addition to that, there is the commission
that the President just announced here within the last couple
of days, who will also be looking at these issues even more
broadly, including the Veterans Administration (VA).
The entire Department has been informed of the review
group's charter. Group members can go to any installation, talk
to any personnel, review any policy or procedure to get the
information and answers they need. They will have full support
of the Department.
The Department will be driven for results in the actions
that we take in the weeks ahead: engaged, action-oriented, and
focused on making real and permanent improvements.
The people we serve--the service members, families,
military leaders, Congress and the President, the secretary,
everybody--they deserve to know that we are getting the job
done. We have attacked problems in the past and solved them and
come out stronger as a result, and I believe that we can do
that again.
We have established new standards, as Dr. Chu noted, in
virtually every category of wartime medicine. Many people don't
know that we have established new standards in everyday
medicine for America that has a great impact on improving
health care in America.
The quality of our medical care for our service members is
excellent. No one should question that aspect of this issue.
There is no question about that.
On the other hand, with regard to the quality of life for
people while they are receiving that care, that is where our
focus is. That is where we did not meet our standards.
In the current news reports, the trust that has been earned
through our historic achievements has been damaged. And that
trust was earned through a lot of hard work, but we have got to
work even harder to re-earn that trust.
So, in closing, let me just say that, as we work together
on all these issues, I would like to point out one other
important thing, and that is, I believe it is very important at
this time that we maintain the morale of our medical
professionals, of all those who serve our warriors.
And we need to maintain the confidence of our entire
military in the military health system. It is critically
important. People should not question, should not lose their
confidence about the care that they will receive. And I urge
that you work together with us on that matter.
I look forward to working together with you and with the
leaders within the services in the Department in the remaining
weeks of my tenure, and I am grateful to have had the
opportunity to have worked with selfless and committed and
dedicated professionals and patriots who care for our wounded
warriors. They are our Nation's heroes, and, as such they
deserve our very best.
Thank you.
[The prepared statement of Dr. Winkenwerder can be found in
the Appendix on page 86.]
Dr. Snyder. Thank you.
General Schoomaker.
STATEMENT OF GEN. PETER J. SCHOOMAKER, CHIEF OF STAFF, U.S.
ARMY
General Schoomaker. Mr. Chairman, distinguished members of
the committee, you know, as chief of staff of the Army, as a
senior uniform military officer in the Army, I am responsible
for everything that happens and fails to happen in the United
States Army. And so I take full responsibility for the
situation that has caused us to appear before you again today.
As you have already stated, I had hoped that the last
appearance before you would have been my last, and I am
disappointed that these circumstances are the ones that bring
me before you again.
But we have worked well together in the past, and we are
going to need your help to fix the things that we have found in
this.
I will tell you that one of the things that is disturbing
is, with the amount of attention and the amount of resources
that we have placed into this area, that we find the kinds of
conditions and situations that have been reported.
And one of the things we need to find out is why, within
the leadership structure, that these kinds of surprises
surface. It doesn't make sense. We have had hundreds and
hundreds, if not thousands, of visits to all of our medical
facilities. You have visited a great many times. I certainly
have. The leadership has. And to have these kinds of things
appear the way they were is--doesn't make sense to me.
There is an opportunity here that I hope we take, and that
is fix this comprehensively. This isn't about painting things
and dealing with mildew and fixing some administrative
processes. There needs to be a really top-down look at the
statutes that underpin the kinds of things that we do, the fact
that there are different laws--Title 10 for DOD in terms of
compensation, Title 38 for the VA, which has a different
structure for compensation, and I understand even Social
Security/Medicare business is another statute.
We, clearly, have differences in the services and how our
administrative procedures are put together. The policies aren't
uniformly administered.
And so I think that this really, as difficult as it is, is
an opportunity to do a comprehensive fix. And I hope that is
what we are all committed to doing, you know, as we look at
this.
Again, I would like to remind everybody that every day
there are thousands of very dedicated medical professionals
that are tending to our soldiers and their families.
And I really am concerned that we paint broadly across this
entire professional community with some of the things that have
been reported, and we fail to recognize that there are real
heroes in our hospitals--and on the battlefield and everywhere
else in the medical community--that, every day, are working
against great odds and great obstacles, great bureaucracy, to
tend to our soldiers and their families well.
And I hope you will keep that in mind as we go through not
only our discussions, but the subsequent fixes to what we do.
I am very, very proud of these people. And, as you know,
one of them happens to be my brother, and so I have some great
insights into it.
Finally, what I would like to say is, we have been
aggressively fixing this and pursuing fixes, not only with
massive so-called tiger team approach, but we are doing surveys
all across the country, going out and inspecting all over the
place, not just Walter Reed.
But at Walter Reed, we have appointed a new commander
there. He happens to have the same last name as I have. He is a
very talented individual. And I know that he will go about
this.
I want to make it clear that I was recused from
participating in the decision to select him, but in my view, he
is the right man to go into there.
We are going to give him--and it will be announced this
week--a brigadier general combat arms officer who will be his
deputy. And that combat arms officer will help look at the
situation at Walter Reed from a perspective of the battlefield
and as a leader of combat soldiers.
We have already appointed a combat arms brigade commander
with experience in the war on terrorism, and he has a command
sergeant major. And we have restructured the entire team out
there to make sure that the soldiers are getting the leadership
and the assistance that they require.
We have established a hotline directly into the Army
Operations Center, which means that every call is recorded and
is required to be reported to the very top leadership of the
Army on anybody that has a problem out there. It would be a
toll-free number. And that will occur.
And there are many other things that we are doing to make
this right, to include looking at an ombudsman program so that
we have advocates that are outside this adversarial system that
can assist our soldiers and their families as they go through
this very difficult bureaucratic process.
So I will wrap up with that, because I know the important
thing is that we have a discussion about this and that you
pursue those things that you are interested in.
But, again, I want to make sure that there is no mistake
about it: I accept responsibility for these failures that have
occurred, and we are committed to fixing them. And as long as I
am in position, there will be great energy behind getting this
done.
And, again, with your help, I believe that we can fix this
in a very comprehensive fashion that will stand the long test
of time. Because I do believe that this long war is going to
require us to continue to have the very best medical care for
our great soldiers and their families.
Thank you very much.
[The prepared statement of General Schoomaker can be found
in the Appendix on page 92.]
Dr. Snyder. Thank you, General.
General Kiley.
STATEMENT OF LT. GEN. KEVIN C. KILEY, THE SURGEON GENERAL, U.S.
ARMY
General Kiley. Mr. Chairman, Congressman Hunter,
distinguished members of the committee, I am here today to
address your questions about the circumstances at Walter Reed.
A commander is charged with the health and welfare of his
soldiers, and a physician is charged with the health and
welfare of his patients. And as you know, in the last few weeks
we have failed in the housing at Walter Reed, and we are
addressing that and many other issues.
I want to offer my personal apology to the soldiers and
families, to the Department of the Army, the Department of
Defense, to you and to the American people for these
circumstances.
I am personally and professionally very sorry that we are
sitting here today, and I take full responsibility and
accountability as the Medical Command (MEDCOM) commander.
There are bureaucratic, complex systems associated with the
disposition and discharge of soldiers that require and demand
urgent simplification, and I am committed to getting on with
fixing this system. I am dedicated to making sure that soldiers
are equitably and fairly cared for, that they reach their full
level of care, and that they are returned to the force or
retired in a manner that shows respect and dignity for them.
As you have heard, we have taken immediate actions. The
chief has listed some of those.
Building 18 is empty as of today, and within weeks we will
begin repair of that building. We have got teams out around our
installations checking to make sure that the quality of life,
communications, command and control, and infrastructure are in
good shape at our other installations.
You know, a soldier won't attack an objective in combat out
of the sight of a medic. And our 68W medics are the best in the
history of our Army. And they are connected inexorably to
Landstuhl Regional Medical Center and to the great facility at
Walter Reed Army Medical Center, which I think you know
provides absolutely outstanding inpatient and, I would suggest
to you, outpatient care.
The doctors, nurses and administrators that are doing that
are doing a superb job. There are clearly questions about our
handling of the soldiers' quality of life and the processing
through the disability system that I would be happy to answer
your questions on.
It is a very complex disability system. It is confusing
and, frankly, we realize it is adversarial and confrontational.
And we have got to fix that. Soldiers tell us it is as though
we don't respect them because of the way that they have to work
their way through the disability system.
Secretary Gates is expecting decisive action, and he and
our soldiers will get it.
The Walter Reed Army Medical Center has got a magnificent
reputation. The care for soldiers on the battlefield is second
to none. That is a combination of the skill of the staff at our
facilities, who prepare themselves and deploy; the technology
that we bring to bear--new technologies almost every year; and
the unwavering support of the Congress and the American people.
We want to re-establish that trust.
It is regrettable that The Washington Post had to bring
this to our attention, but since they have, we are taking
immediate action, as we have already said, to fix the problems.
I have been a physician and a soldier for 30 years. It is
an honor to lead the Army Medical Department, and it is an
honor to serve our soldiers and the nation.
And I look forward to your questions.
[The prepared statement of General Kiley can be found in
the Appendix on page 97.]
Dr. Chu. Mr. Chairman, we recognize, as my colleagues have
underscored, that we have a special responsibility to those who
have suffered severe injury in the service of their nation.
That is one of the reasons that we opened, two years ago, a
Defense medical injured center as a back-stop to the service
programs.
In this arena, you need, really, a layered effort to ensure
that you have dealt with all cases adequately. It is the place
we bring together our sister Federal agencies--the Department
of Labor, the Transportation Security Administration and the
Veterans Affairs Department--so we can provide the kinds of
services that ought to be available to our people. And I am
pleased to say that the Department of Veterans Affairs has
placed representatives in our major hospitals to help with the
disability evaluation process.
It is also the reason that we are proud to partner with
others. Heroes to Hometown is one of those examples, where we
are working with the American Legion, with the state Veterans
Affairs Departments, to ensure that, when the individual comes
back to his or her hometown, that they are greeted
appropriately and the kind of support they should expect is
indeed there.
And we are appreciative that the Congress last year gave us
the statute authority to expand the computer electronics
accommodations program in which we can provide those who need
assistance in order to carry out their tasks, particularly as
they seek re-employment, have the equipment that they indeed
deserve.
As General Schoomaker emphasized, I think one of the
central issues as we move forward here is this question: Do we
have the right paradigm for providing for those who have
suffered grievous injuries in the service of their Nation?
As he indicated, and as you appreciate, we have really
three different programs in the Federal Government that provide
support, assistance--especially monetary assistance--to those
who have been injured in the service to the Nation.
There is, of course, the defense disability system, but
there is also the disability payments system in the Department
of Veterans Affairs, and there is the Social Security
Administration, which, in some cases, will also make payments.
As General Schoomaker suggested, Title 38, which covers the
VA, and Chapter 61 of Title 10 take fundamentally different
approaches to the basis on which you should rate the
individual. It is, therefore, not surprising that we reach
different answers in that regard.
But from the individual's perspective, this is surely
complex, indeed, as the reports suggest, frustrating in its
character.
Pending that large debate, the Department is indeed
revitalizing its own system. We will soon be issuing new
instructions for the governance of that system. The services,
in their areas of responsibility, are relooking at their
processes. The Army has its transformation initiative for its
disability evaluation system.
I am confident that with this energy, this level of
attention, and your support for necessary, statutory stages,
that we can replicate, in the way we administer and the way we
run the disability evaluation system, the success we have
enjoyed in the clinical area and that is so properly and widely
celebrated in our country.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Chu can be found in the
Appendix on page 72.]
Dr. Snyder. Thank you all for your testimony.
I am going to ask unanimous consent also to have admitted
to the record the committee memo that the staffs worked
together on. And I think it is a good summary of some of the
challenges.
[The information referred to can be found in the Appendix
on page 111.]
And for anyone out there who would love to have a copy of
it before the transcript of the hearing is made publicly
available, just holler at the staff members, because I think it
gives a good summary of the history of some of the problems,
but also some of the involvement of this committee.
The second point I wanted to make--and Mr. Spratt came in
here in a very timely fashion.
Dr. Winkenwerder, you specifically stated in your written
statement, I think in your oral statement also, that you don't
think it is a money problem. That conflicts a little bit with
what General Schoomaker says in his written statement, which he
thinks there may be some military construction (MILCON) needs
that would take congressional action.
But I would encourage you all--I mean, the fire is hot
right now. We have got trains revved up and ready to go that
can carry some money in your direction to help solve this
problem. And if you think that there are areas there that some
additional funds in specific areas would be helpful, please let
us know. Because I think that this is something the American
people want to get solved.
Obviously, we don't want to put money out there and not
have it be helpful. But if you think there are money problems,
then this is the time to deal with it.
The third point or comment I wanted to make: When I first
heard the interview with Dana Priest, who was one of the
reporters in The Washington Post, she made this comment that
when members of Congress would go out there, as a lot of
members do just to see what is going on and visit with families
and be supportive--I can't speak for everyone on this
committee, but we don't have a formal notification process when
there are--when our constituents are wounded, or when they are
admitted to any of the military treatment facilities or when
they are in a medical hold status.
Now, some of us have made some informal arrangements. I
think it has been a couple years or so since my office has been
notified of any wounded. I think there are some privacy issues,
some Health Insurance Portability and Accountability Act of
1996 (HIPAA) issues.
But the point I want to make is one of the things that Dana
Priest said is that when a member of Congress found out that an
individual was having a problem--I mean, her comment was a lot
of times it would get taken care of. We would get ahold of your
staff and work through these issues.
Now, what I am trying to say is I think you have got about
close to 900 people in a medical holdover status at Walter
Reed. That averages out about two per member of Congress who
would be advocates for those people if we can work around some
of these privacy issues.
I don't say that--I thought of that last night to myself,
almost facetiously. I thought about it more today. I thought,
``No, that is the way this system works.'' And you all know
that is how it works.
We hear things from families and constituents and we get
ahold of your folks, and a lot of times there are legitimate
concerns that you all get straightened out. But we do not get
formal notification because of privacy issues. Any comment on
that?
Who should I direct this to? Maybe General Kiley. How many
people today do we think systemwide--or maybe Dr.
Winkenwerder--are in a medical hold or holdover status?
General Kiley. Mr. Chairman, I can take the exact answer
for the record. But in a rounding figure----
Dr. Snyder. Yes.
General Kiley [continuing]. About 900 MedHold, which are
active duty, and about 3,200 MedHold Over, which are reserve
and National Guard, across our installations.
And also, in that 3,200 are about 1,800 that are in our
CBHCOs, our community-based health care. So they are living at
home, getting care in the community, reporting to their
National Guard armories.
Dr. Snyder. And so how many today are in the Walter Reed
status?
General Kiley. At Walter Reed, I believe the number is
around 600.
Dr. Snyder. Around 600 today. Those are about the numbers I
have.
General Kiley. Yes, sir, I can get you exact numbers.
[The information referred to can be found in the Appendix
beginning on page 166.]
Dr. Snyder. Dr. Winkenwerder, do you have----
Dr. Winkenwerder. And let me add to that, there is
another--again, I don't have the exact number, but rough order
of magnitude 1,000 or so that are Navy, Marine, or a smattering
of Air Force. The bulk is the Army.
Dr. Snyder. And I think it is important we keep these
numbers in mind, because this is a well-defined universe. It is
not a large group of people for this country to deal with. And
there has got to be a way for us to get a better handle on
this.
I am told that you all--that somebody sits down in a weekly
manner with you all, and you can pull up and have a list of
everyone on medical hold, hold over status. Is that correct?
General Kiley. Yes, sir, I believe that is correct.
Dr. Snyder. That doesn't necessarily mean that you know
where they are at, but you actually have a list of them.
General Kiley. We know where they are at, too.
Dr. Snyder. You know where they are assigned to. That is
not the same as knowing where they are at, because they may
have walked away on you, or their case managers may have lost
track of them, correct?
General Kiley. Well, I wouldn't say that it never happens.
But our intent is for us to know where they are, if they are at
home in the CBHCOs. We are keeping contact with them.
Dr. Snyder. Okay, I understand that.
General Kiley. If they are assigned to the MedHold or
MedHold Over at their installations, they have case managers
who are keeping track of them.
Dr. Snyder. But your formal system doesn't say that, ``They
were last seen by a medical facility on February 7.''
General Kiley. No, sir. No.
Dr. Snyder. Which gets to the case managers. Who pays the
case managers? Are they military personnel, civilian personnel,
or both?
General Kiley. I believe they are a combination of both.
Most of them are civilian, a combination of nurses and social
workers.
Dr. Snyder. Who do they work for? Who pays their check?
General Kiley. Well, if they are civilians, I pay their
check through MEDCOM.
So if they are working at our facilities as case managers,
they work for the commander of the hospital in managing the
cases. And as I understand it, I would pay through the
hospital's finances for their salaries as contractor general
schedule (GS) employees.
Dr. Snyder. If I ask these 3,000-plus people today, ``Do
you consider your case manager your advocate?'' what do you
think the answer would be?
General Kiley. I think their answer would be that in
general they are. We have surveyed MedHold Over soldiers and
directly asked them the questions about how they feel about the
case managers. We are just standing this up. I have just gotten
some responses back, and they seem to be very pleased with
their case managers in general.
Dr. Snyder. Well, ``in general'' may speak to the heart of
the problem, because--what do you see the job as case managers
to be, Dr. Winkenwerder and General Kiley? Do you see their job
as to be advocates?
General Kiley. Absolutely.
Dr. Winkenwerder. Yes. Yes, sir.
Dr. Snyder. You don't see their job as trying to explain to
them why they are not going to get their appointment for 60
days; you see their job as to have them get their appointment
in 5 days. Is that correct?
Because that is not anecdotally what we have heard from
some of these warriors. They have not seen their case managers
as being their advocate.
Dr. Winkenwerder. I think that is unfortunate, where that
has happened. They should be----
Dr. Snyder. Do you agree that it has happened?
Dr. Winkenwerder. Well, the reports--I have read about the
same ones that you have, and I think of a case manager, case
worker, social worker, nurse as someone who cares about that
individual; is trying to do the best for them, get them in,
help them with their appointments, make sure they are followed
up, if they are not certain or clear about what they need to do
next.
They are there to help them. That is the job. It is really
personalized attention.
Dr. Snyder. Mr. Hunter.
Mr. Hunter. Mr. Chairman, thank you.
And, Mr. Chairman, this is a problem which is especially, I
think, both devastating and significant, because it is one that
occurred in a place where there are lots of eyes and lots of
folks and are close to a center of power.
And I can tell you that, in fact, I was at Walter Reed I
believe the same day that this story started to come out,
visiting some of our wounded folks in the inpatient area. All
of us have been down there a lot.
You know, this is one of those things that doesn't lend
itself to statute and legislation and regulation, because we
have got a lot of that. It lends itself to an answer that
focuses on the military families, that focuses on the ability
of a Marine wife, whose husband is severely injured and has two
kids in school and just drove 300 miles to get here and doesn't
understand the situation, to be able to easily find out what
the program is and to be able to easily access that program and
to have a program that is simple enough that folks that aren't
experts on military medical law can get taken care of.
And I think it is important for our committee to know that
we have had a great oversight team, Democrat and Republican,
with Ms. Wada on the Democrat side and Ms. James on the
Republican side, visiting literally dozens and dozens of
medical facilities throughout the country, as well as Walter
Reed and Bethesda.
And one thing we did several years ago that we have never
done as a committee, is I appointed one of our professional
staff members, Mr. Godwin, to be an ombudsman for the families
and for the people who wear the uniform of the United States
who are the patients at Walter Reed and Bethesda.
Mr. Godwin undertook more than 80 visits to Walter Reed, a
couple fewer visits to Bethesda. And his job was to go in, sit
down with military families, but almost exclusively in the
inpatient area; talk to them, find out what their problems
were, direct them to the right place, try to make sure that
they had housing, that they had transportation and that the
wounded soldiers and Marines were taken care of.
Now, while we were doing that, we thought that we would do
another thing, and that is to start getting jobs for guys that
were transitioning out, and ladies who were transitioning out,
who were going to be moving out into the private sector.
And so we started to have jobs fairs in a couple of the
hospitals, one in California. And I attended one that we put
together here at Walter Reed, where members could come down
into the day room, tell us a little bit about what they did,
what their professions were, and see if we couldn't hook them
up with folks in the government but also folks in the private
sector.
So we started doing that. After we had done that for about
a week and we had actually landed some jobs for a couple of our
wounded folks, I was informed that I was on the verge of
breaking the law because there might be an ethics problem with
a member of Congress or professional staff members helping to
get jobs for wounded soldiers and Marines with the private
sector, on the basis that the private sector would then expect
a quid pro quo from the committee.
So to handle that, we then offered a resolution before the
full House which passed--and I think almost every member of
this committee voted for it--essentially laying the groundwork
for the Ethics Committee and the Administration Committee to
approve us having professional staff members on the committee
who would assist wounded people, wounded personnel, who were
separating from the service with getting jobs in the private
sector without having an ethics ramification.
That resolution passed the full House. It is awaiting
action by the Ethics Committee, which hasn't been forthcoming.
So I would just recommend to my colleagues that one great
thing that you can do for folks who are wounded is to make sure
that when they get that transition, if a guy is a generator
mechanic and he is going to go back to Maine, we should be able
to contact the companies in that location and see if we can't
get a good job interview perhaps put together while he is in
Walter Reed or while he is in Bethesda.
So I thought, Mr. Chairman, it is important for our
committee members to know that we have had a strong oversight
team going throughout the United States, conducting also
sensing sessions with over 1,000 personnel and their families
with no brass present and with no administrators present so
they could talk candidly to us.
Nonetheless, this problem has occurred basically right
under our noses, right here in the center of power.
And I would offer that the key to this thing is to have a
system which is consumer- and customer-friendly. And that means
when that young wife of a wounded Marine comes in and she has
got two kids that she has left with her mom while she drove 300
miles down here to see her husband, perhaps for the first time,
that she not only has a path of things that she has to do with
respect to applications and filling our forms and waiting, but
that she is given very important person (VIP) treatment--that
is, preferential treatment, that she has somebody who leads her
through this path that she has never had to walk down before.
We need to have a system that is customer-friendly, because
there is no family that is more vulnerable, nor in more of a
state of anxiety and, to some degree, confusion, than a
military family whose loved one has been injured. And in 99
percent of the times of the cases, that means that they have
got to travel some distance so they are away from home. They
have major expenses.
Now, I think it is important to note that we have a number
of great organizations, like the Semper Fi organization and a
number of others, that will provide cash and will provide help.
And we also have great on-hospital facilities like the Fisher
House and others where families can put up without paying that
120 bucks a day in the Washington area for hotel rooms while
you are here.
But this a problem, I would just say to my colleagues.
And, you know, if the buck stops here, General Schoomaker,
my gosh, all of us have been down to Walter Reed numerous
times. I think I was there visiting a patient when the story
broke. So the buck stops here also.
But I think that the answer to this question is not going
to be regulations. Regulations got us here. It is the same
regulation that means, when a soldier is carried off the field
on a stretcher and gets to Walter Reed, he ends up receiving a
bill for the equipment that he lost when he was hit with the
improvised explosive device (IED).
It is a bureaucratic system, and you have to keep mowing
the grass to make sure that you keep that from developing a
system that is very unfriendly to the customer. And the
customer is the men and women who wear the uniform of the
United States who are receiving the medical care.
So I think that the answer to this has to start with the
people. It has got to start with the soldier, and it has got to
start with the family. And what we have to have is a simple
system.
Now, before you fix all the regulations, or we try to fix
something structurally so that this doesn't happen again, there
is one way to get through this early.
And that is to assign lots of people to the families and to
the wounded personnel, so that when you have that 18-step
program somebody has to go through before they get their
compensation or before they get the next booking for therapy,
you have got somebody standing next to them saying, ``I will
take care of this,'' and they take care of it. And that wife
who has driven 300 miles has the answer and the solution,
rather than simply a direction as to what the second of 35
different steps is going to be.
So I think if we start with the personnel, with the wounded
soldier, sailor, airman, Marine, and his family, start with
them--let's fix them up first, make sure we have got somebody
that takes care of them, just like there is somebody if a VIP
comes to Bethesda or Walter Reed; there is somebody there to
walk them through that system, to get them through the
bureaucracy. We need to have a VIP system attached to every
single person that wears the uniform.
Let's undertake that, because that will give us a result a
lot earlier than a series of legislative steps.
And I think largely this is not a solution that requires as
much legislation as it requires a cultural change.
So if we could do that, if we could focus on the wounded
American service member and the family first, attach lots of
people to them to get them through this cumbersome system, then
fix the system, I think that will expedite things.
Thank you, Mr. Chairman.
And I am glad that you put into the record the oversight
activities that the Democrat and professional staff members
have undertaken.
And you know we have a great system. We have all seen the
incredible wounds that would not have been survived 10 or 15 or
20 years ago that now are survived because of excellent care,
literally, from that medic on the battlefield right through to
the skilled hands of the surgeons and the medical providers.
What we have to do is match that capability with a
streamlined bureaucracy that is soldier- and Marine- and
airmen- and sailor-friendly. If we do that, we will retrieve
this great system.
Thank you, Mr. Chairman.
Dr. Snyder. Thank you, Mr. Hunter.
I think Duncan had such wisdom there that I would like each
of you to respond to what he was talking about in terms of
having a consumer-friendly system.
Because my guess is if we asked you a month ago, ``Do you
think you have a consumer-friendly system?'' you all would have
said, ``Yes, we have been really working at it and we get good
feedback.'' But it is apparent that we don't.
So starting with you, General Kiley, how do you see where
we are at today and where we are going to get with regard to
having the kind of consumer-friendly--help families and the
soldiers walk through that system.
I suspect this is going to get to what two or three of you
said in your written statement--working on the training and
numbers of case managers as a part of that--but would each of
you respond to what----
General Kiley. Yes, Mr. Chairman.
Dr. Snyder [continuing]. Mr. Hunter talked about?
General Kiley. I think Congressman Hunter is exactly
correct. My assessment is we have come a ways in customer-
friendly activity, but I don't think we are totally there.
I think the turnover of personnel in our facilities is a
constant training program. And I think it only takes one person
not being customer-friendly to potentially ruin the reputation
of an organization, even something as big as Walter Reed.
I think we just need to redouble our efforts and refocus on
exactly those issues. An ombudsman program is clearly something
that would be of benefit in our installations.
And I think, clearly, if we can put more people helping
soldiers and sailors and their families now, which we can do--
we can hire, and we can call for volunteers. There are several
different ways we can do to take this on. It will clearly
expedite some of these stories we have heard of soldiers being
left without knowing what the next step is.
We have had more than 6,000 combat soldiers come through
Walter Reed since the start of the war, and we have learned a
lot of lessons and made it better. But it still needs more
work, needs to be further improved.
Dr. Snyder. General Schoomaker.
General Schoomaker. Well, I will probably say something
heretical here, but I think that what we need to do is focus on
output, focus on results.
And, you know, in government and in the military, a lot of
people take a lot of pride in complying with processes,
checklists, procedures, working real hard, getting up real
early, going to bed real late. And as far as I am concerned,
you don't get any credit for all that stuff. What we get credit
for is what comes out the other end of the pipe.
And so if we want a customer-friendly system, which we all
do, we need to measure it at the customer end and make sure
that what we are doing is satisfying that.
And, unfortunately, part of our problem here is that as we
have been touching the customer and asking them, we have not
been getting the kind of feedback that we need. And so we got
to figure out why.
And my view is it probably comes down to trust and some
other kinds of things that we need to regenerate. And if we can
do that, get the communications, then I think we will be able
to measure what we need to measure.
Dr. Snyder. Dr. Winkenwerder.
Dr. Winkenwerder. Oh, I agree with what Congressman Hunter
had to say. I totally agree with it. I think it is right on
their mark, and I would concur completely with General Kiley
and General Schoomaker.
And, to me, you know, if you have done what you need to do
when the people you are caring for, your customers, tell you
that you have done a good job. And if they don't, that is your
best indication.
So I think it is that communication, and there are tools--
surveys help, but sometimes it is just talking to people. It is
focus groups. It is talking to people, and it is listening. And
it is not saying, ``Why can't you do something?'' It is turning
back to the bureaucracy and saying, ``Why can't we do this? Why
can't we do this to make it easier on the person?''
That has got to be the mentality. And I agree. Sometimes,
in the military--and even outside the military, with my
experience--people get into, ``Well, this is the way we do it.
This is the checklist, you know, and this is supposed to be the
right way.''
Well, if it is not meeting the needs of the customer, it is
not getting the job done. And that is the outcome. That is the
result. And that is what we ought to be focused on.
Dr. Snyder. Dr. Chu.
Dr. Chu. First, I hope Congressman Hunter gets a favorable
ruling from the Ethics Committee. Otherwise, we may be in
trouble, too, because we have held a half a dozen of these job
fairs, as you know, Congressman, last year. We are committed to
at least half a dozen this year. I think the most recent was at
Fort Dix, if I recall correctly.
On a more serious note, I could not agree more. I do think
we need to look at the structure within which the advocate
works. Let's come back to case workers for a moment: I think
that is the source of some of the situations described most
recently.
From the early days of the conflict, we had too few case
workers. We have beefed it up considerably; I think the Army is
now to a point where the case worker-to-cases ratio is at
approximately the right level.
But the system in which they work is one in which these
decisions are all sequential. And one of the things we are
looking at with the new energy, attention that has been focused
on this challenge is, why is it sequential? Why can we not
gather up all the decisions in a package for the soldier,
sailor, et cetera, to confront at one time, as opposed to going
through this one step at a time?
We are committed to the standard that you advocated. I
think the issue ahead is, how do you get there? How do you get
there quickly? And how do we start making at least the major
improvements in the next few weeks and months?
Dr. Snyder. Thank you, Dr. Chu.
We will now go and start our questions for the committee
members. Dr. Winkenwerder has a mid-afternoon plane, but I
think everyone else is committed to being here for some
distance from now. So we should get to everyone.
Mr. Ortiz.
Mr. Ortiz. Thank you, Mr. Chairman.
Welcome to our hearing this morning.
A few years ago, we took a tour, a group of Republicans and
Democrats, because we wanted to see the worst facilities of our
military. And we took a tour. Fort Sill, we saw a new facility,
a big facility, where the young soldiers were taking a shower
and the water was dripping out the walls.
I think that we did that, and I know we did that, because
sometimes we feel that the budget is not patient-driven or
soldier-driven; it is budget-driven.
Sometimes we give you a bunch of money. We don't know the
size of the facility if we go. I visited Walter Reed and
Bethesda many times. But unless we know what are the worst
facilities that you have, we won't be able to fix them for you.
Now, when I was touring Building 18 about three, four days
ago, we looked around and I asked some of the people working
there, ``What happened here?'' They said, ``A-76.''
What happened with A-76? There was a contract, and even
though the civilian workers submitted a better bid, they gave
it to the contractor. Now, correct me if I am wrong. And he
says, ``You know what happened, Congressman? A lot of
experienced, knowledgeable workers walked out the door.''
Now, if I am correct, this facility won't shut down on
2011. Am I correct? When is it supposed to--2011?
General Schoomaker. The installation is to close in 2011
under the BRAC realignment.
Mr. Ortiz. In the meantime, we have a surge. More soldiers
are going to Iraq and Afghanistan. More wounded soldiers will
be coming back. I wanted to ask, General Kiley, do you think
that you can give us a list of your worst facilities so that a
group of members here can go see it so that we can be in a
position where we can help you fix those facilities?
A lot of members might say, ``You know what? We are
shutting it down. Why do we put any more money here?'' But
those lives are very precious. They are soldiers. They are
young sons and daughters.
And at the time, I want to know, did A-76 have an impact as
to what happened in Walter Reed?
General Kiley. Congressman, I will take for the record your
request and work with General Wilson to look at worst
facilities across our Army facilities. And I would defer to the
chief if he wants to talk about the larger barracks MILCON
issue.
We clearly are looking at the A-76 study. I think the
garrison commander was challenged as the contract was getting
ready to stand up, and some of this workforce was leaving for
that exact reason--probably more about A-76 than BRAC.
There were other issues. We have identified some of those,
and we are fixing them.
[The information referred to can be found in the Appendix
beginning on page 164.]
Mr. Ortiz. Do you think that we might be able, for the
committee, to get a list of the facilities so that we know
exactly how much money you need and what we need to fix?
I mean, we are at war. And as much as we would like to have
a budget-driven budget, we have got to think about our soldiers
and our families. And I think that this Congress would be
willing to give you the money to fix what is wrong.
And if any of you would like to elaborate on my question--
--
General Schoomaker. Well, Congressman Ortiz, I couldn't
agree with you more, and we would be glad to give you a list of
what we consider to be our worst facilities.
With your help, you might remember that over the last three
years, what we have been doing is putting enormous amounts of
money to not only upgrade existing facilities, but to build new
facilities where we have languished so long.
You know that our SRM, our sustainment, repair, and
maintenance funds, traditionally have always taken a hit,
because of priorities and money has had to shift.
And I can remember times in my career past where
installations were being funded at less than 50 percent of
requirement, which means that you are fixing things that break,
not fixing and staying ahead of the power curve.
So Secretary Harvey and I made it a priority. And we came
to you and asked for money, and we put hundreds of millions of
dollars into both barracks upgrade and the new thing.
On the other hand--and I am going to say this, and this is
not a criticism, but I think we all recognize how difficult it
is, through the budget process.
This year we still don't have a veterans, MILCON, BRAC
budget. We are six months into the fiscal year and we do not
have a bill.
And the amount of energy that this committee and we and
everybody else has spent trying to get that through is
indicative of how much energy that senior levels has taken,
trying to get things to come together, that would be better
spent, quite frankly, getting things done, you know, with the
resources.
Now, there is no question we are going to get these
resources. But again, we are into this business of half the
fiscal year is gone before we get going on it.
As you know, at Fort Bliss, the MILCON, BRAC business has
called a stall out there in building facilities for the growth
of the Army and for the repositioning of the Army globally. And
we have discussed it, and you have helped us with that.
But I just think that we--you know, it is bigger, and we
would be glad to give you a list, and you can go look, but I
think that, again, what we have to do is systemically look at
things and recognize the fact that we are a Nation at war, yet
we are trying to overcome what I have testified here many times
in the past is the historic underfunding of the United States
Army--a significant underfunding and investment in the United
States Army.
And we are trying to fill that underinvestment, at the same
time that we are consuming ourselves, at the same time that we
are trying to grow. And that is a big challenge. And we need a
lot of help to get that done.
Dr. Snyder. Mr. Saxton.
Mr. Ortiz. Let me just say one thing, Mr. Chairman.
We are not here to point fingers at anybody. We are here
because we want to help you. Because these are our soldiers.
And we are not here to point fingers. We want to help you.
Dr. Snyder. Mr. Saxton.
Mr. Saxton. Thank you, Mr. Chairman.
Let me just do a couple of things. Let me say a couple of
things.
First of all, let me commend you, Mr. Chairman, as chairman
of the Personnel Subcommittee, and Mr. McHugh, as the Ranking
Members of that subcommittee, for the very serious, studious,
bipartisan, substantive job you are doing in looking at this
issue.
This is an issue that could be fraught with politics and a
whole bunch of stuff that wouldn't be productive. And your
leadership on this issue is very much appreciated. So, thank
you very much.
Second, you know, to listen to this conversation, you would
think the whole system is broke. And I have got to tell you it
is not.
I have had some great experiences in observing how this
system works, from Fort Bragg, where medics are highly trained
in lifesaving procedures that have kept soldiers alive time
after time after time.
I have seen the results of that training in the field. I
have been able to experience the great job that is done in
field hospitals in-country, particularly in Iraq. I have been
able to visit wounded soldiers in Landstuhl and the great job
that is done there, and the nurse getting me by the arm and
saying, ``We need to make this place bigger.'' And I have seen
the care that is offered here in this town.
And I am very proud, by the way--Dr. Chu, earlier this
week, I had a conversation with the commander up at Fort Dix,
and he was so proud because Lieutenant General Wilson, the
installation management commander, recently commended him on
having one of the best facilities in the Army to take care of
soldiers.
And so, there are good things to be said along with some
problems to be pointed out with this system.
And I know that we have tried to fix things as we go along.
I visited Fort Dix I guess two years ago, or three years ago,
and I found out that we didn't have specialists there to take
care of some of the problems and that soldiers had to be loaded
in a van at 5 o'clock in the morning, driven to Walter Reed,
wait there to be treated, and be treated, and drive back to
Fort Dix that evening. I called General Schoomaker and he fixed
it.
Still a couple of specialties that we have to use that
process, but the number of soldiers that have to go through
that process from Fort Dix to Walter Reed is a fraction of what
it used to be, because General Schoomaker fixed it.
And so there are good things.
And currently at Fort Dix we don't have enough space, so
the Army has decided to take a barracks, gut it, remodel it.
And that process is under way as we speak.
So for members who are experiencing this conversation,
maybe in the early stages of their experience with this--need
to know that it is not all negative. There are a lot of very
positive things, from one end of this process to the other.
So I guess that is not a question, but I just wanted to
point that out.
I guess the question that I would ask is, within this
system of, I think, mostly good, what are the things that you
need us to concentrate on to help you fix those problems?
Dr. Chu, why don't we start with you?
Dr. Chu. First of all, sir, thank you for your kind words
about the things that are going right. I do agree with you
there are a lot going right in this system, and I think we do
see, back to the earlier issue raised, a large number of
satisfied personnel, particularly with the quality of their
clinical care.
I think there are two major areas where you can help. And
General Schoomaker has already touched on one: that is, the
timely appropriation of funds we need.
I do think the fact that we don't have the full MILCON
appropriation completed is a problem, particularly given the
statutory deadlines for the base realignment and closure
actions.
We need to move forward. We need to get those new
facilities built. The Army is expanding. We need to make sure
the right facilities are in place, or we will have more
nominations for Congressman Ortiz's list in two years, with
people at the expanded installations not able to enjoy the
facilities they ought to have.
So I really would hope that when the supplemental is
enacted--I recognize that is not this committee's lane--but
when it is enacted, that there is the full restoration of the
BRAC money that was originally requested.
I think the second place where you can help us--and this is
a little bit further down the road, I don't think we are ready
yet to make a proposal, but I do think, back to Congressman
Hunter's standard, if we can streamline this process so that
the complexity that now exists is no longer a problem for the
beneficiary, that we will substantially improve the customer-
friendliness of the system.
And that may take some statutory change, because the two
major disability systems, VA and DOD, are operating on
different purpose foundations in the underlying statute that
come out of history. Indeed, I think if you look at our major
conflicts in American history, late in or after every conflict
there has been great controversy about what is the right place
for the Nation in terms of veterans' benefits. It was true
right after World War II.
But the basic regulations in this regard, the basic
statutes in this regard, really date to 1949. And I do think it
is time for a reconsideration, particularly in light--as you
have all emphasized, these are relatively small numbers. We
ought to be able to manage this problem as a nation.
Now, the Department will do everything in the next few
weeks and months within its statutory limitations to get to the
goal I have outlined. But I believe that at the end of the day
we will need some statutory assistance.
Dr. Snyder. Mr. Smith.
Or does anyone else have a comment in response to Mr.
Saxton?
Dr. Winkenwerder. I will echo--since you asked for a
response from everybody--I would agree exactly with those
things. The timeliness of funding is really important. That is
particularly relevant with the base realignment and closure and
being able to move forward to do things that we need to do.
I think in addition to that, we can and we will take a look
at medical facilities and come back to you and see if we have
any needs. By and large, from all the feedback we have gotten,
our facilities are very good facilities. But I think it is a
time to take a look and to make sure that you and we both
agree.
And we really appreciate your offer to help us on this. So
thank you.
General Schoomaker. I would like to reinforce what
Congressman Saxton said.
First of all, we have, undoubtedly, the best military
health care system in the world. Everybody else looks at what
we have and they marvel. We have treated Canadians, Brits,
Romanians, Poles, El Salvadoreans, all kinds of folks and
soldiers, and they marvel at it.
Other nations have others solutions. But the issue is not
comparing against what others have, but are we as good as we
should be and could be in terms of what we do?
And that is why I made that statement up front that I hope
that we recognize the fact that we do have a very good system
and we have a lot of very dedicated professionals in it, but
there is a lot of room for improvement, and we need to look at
it, I believe, from a comprehensive view.
Second, it is not just battlefield medicine we are talking
about. This is an integrated system, from the combat lifesaver,
the soldier on the battlefield; through the medic; through the
medevac system, into the definitive care of the combat surgical
hospitals that we have forward; through the system that
regulates them to Landstuhl; into the Walter Reeds and the
Brooke Army Medical Centers (BAMCs) and all these kinds of
places. And everybody is focused on that.
But we also have a huge mission in providing military
medicine for readiness purposes to the active, guard, and
reserve soldiers and their families. And it is a huge piece of
our recruiting and retention of these families and a huge piece
of how we compensate soldiers and families for their service.
And so, I think, you know, as Congressman Hunter said and
as everybody else has talked about, this is very important that
we take a look at this comprehensively and recognize that there
is more than just a battlefield medicine piece of it is
important.
And I would remind you that my view in this world today,
the most dangerous world, I believe, that we have faced in a
long time, that our military capacity in the health care
business is going to be important for homeland security,
homeland defense; and that there are unique capabilities inside
of military medicine that are not resident out there in the
civilian sector, especially in the area of chemical,
biological, radiological kinds of issues.
And so that is, kind of, how I would come at it. I mean,
this is something. We have an opportunity here to look at this
very broadly and to not try to patch things together, but to
really make this and pull it into the 21st century in a way
that it should be.
General Kiley. Congressman, I would echo all the other
presenters' comments and simply say that we need to get on with
it as quickly as we can. This can't be a six-month or one-year
solution set. We have got some opportunity right now to make
some of these changes almost immediately.
STATEMENT OF HON. IKE SKELTON, A REPRESENTATIVE FROM MISSOURI,
CHAIRMAN, COMMITTEE ON ARMED SERVICES
The Chairman [presiding]. I thank the gentleman.
Before I call on Mr. Smith, let me thank Dr. Snyder for
assuming the chair for me. I was unavoidably detained, working
on funding you folks in the supplemental.
And it appears from my observation that the battlefield
through the acute care gets rave reviews, and from there it
seems to be going downhill. I think we will be discussing that
as we go along in this hearing.
Mr. Smith.
Mr. Smith. Thank you, Mr. Chairman.
A couple points and a couple of questions.
First of all, I think your budget point is outstanding, and
we have got to change the way we do things in Congress. It is
not even really contemplated by members of Congress that we are
going to have our appropriations process done on October 1st,
okay? And we have, sort of, institutionalized and accepted
that. The last couple of Congresses, it is not even
contemplated that it was going to be ready by January 1st.
But October 1st is a huge day, for you guys certainly, but
for everybody that we fund and they just, sort of, hang out for
two or three months waiting to see what is going to happen.
And I appreciate you making that point, because I think we
need to change the way we do our structure around here to try,
as much as possible, to get as many of our appropriations bills
as possible done on October 1st because that is when things get
really complicated if we don't do it.
And, now, like I said, it is to the point where we don't
even think about doing it by that timeframe--maybe by the end
of the month, maybe by November. But we have got to do better
on that.
I also will say that I think--you know, I take the point
about it is not necessarily a money issue, and I think in any
given situation, you can look at the resources that you have
and figure out how to use them better. No doubt about that, and
that has got to be the first piece.
But based on what I have worked on, it seems like there is
at least a little bit of a dollar issue. I mean, we have had a
massive influx of veterans in the last few years because of
Iraq, because of Afghanistan. I know out in my area, in the
Seattle-Tacoma area, we have waiting lists for the VA. And that
is money. That is facilities.
You know, I will tell you a money issue. You can't park
most of the time at the Seattle VA, okay? So you are obviously
injured and you have got to park blocks away. Building a
parking lot: money issue.
So let's not go too far down the road of, you know, ``We
are fine; we have got the money we need.'' Because it sure as
heck isn't the case out where I come from. And I doubt that
that is somehow unique.
The other piece of this: The casework is critical. And I
don't know what the numbers are, in terms of what--you need an
advocate. Because no matter who you are--I mean, my wife and I
are both lawyers; you know, very attention-to-detail people.
And whenever we have to go through a health care situation, it
is a nightmare trying to figure out, you know, what forms do
you fill out; you know, what are you covered for; what aren't
you covered for; you know, let alone an injured service man.
I mean, you need to have case workers who are advocates.
And if, you know, 30 cases for one person isn't getting it
done, then we have got to figure out a way to cut that in half
so that that case worker is taking care of all that
bureaucratic B.S. that is necessary. You can't just go giving
the money away, but you have got to somebody fighting for that,
so the soldier and the family aren't going through that.
So, again, I think that, too, is a money issue.
A couple question areas.
Guard and reserve, a totally different situation because
they are not active duty. There is the complaint about the
level of services; they have to get services on base. We have
had that complaint. On base isn't where they live most of the
time. It sets up a different situation.
So I want to hear what you are doing for the challenges for
guard and reserve, particularly on the mental health piece, if
they don't necessarily get the same care, don't have the same
community, making sure that they are drawn in.
I know, out at Fort Lewis, there is a program, now, where
everyone who goes in-theater, when they come back, they have to
go in for a mental health review--I think it is 30 days after
they come back; it is whatever window the psychiatrists think
is the best one to do it--so that they don't have to volunteer
and say, ``Hey, I have got mental problems; help me out.''
Because, as you know, most people, let alone most soldiers,
aren't going to do that. You need to reach out to them. So I
want to know if we are doing that.
And for the record, maybe, if you can't answer this, I am
very interested in electronic medical records. As part of this,
also as you are moving patients around the system, do the
records follow them? Do we have electronic medical records
(EMRs) within the military, so that we are not losing track of
records?
And last, just to make it really complicated, how system-
wide is this?
This was what we have heard. There has been a lot of focus,
in my neck of the woods, on Madigan and what kind of job they
are doing out there.
Is Walter Reed uniquely problematic, or is it more system-
wide, and what is your judgment on that?
And we are down to 30 seconds, so what you can't answer for
me, if you could--you know, we will submit these questions for
the record and try to get them back. Thank you.
General Kiley. I can attempt to answer.
Congressman, we will take your questions for the record, to
include some discussion of guard and reserve and to include
some discussion of mental health. I agree with you completely.
I would like to say one--I have sent teams out with Bob
Wilson, General Wilson, to look at our other installations, to
see if there is any replication there of the issues we found
with living conditions at Walter Reed.
I do think that, systemically--we have already alluded to
this--there are issues of the complexity and confusion about
the medical board process.
Even if case manager ratios are low, the medical community
attempts to document all the health care. And then the physical
disability DOD process has to determine the disability. And
therein is a problem that is systemic in nature and which we
are going to attempt to address here in short order.
So that is a short answer. The rest of those questions, we
can take----
[The information referred to can be found in the Appendix
beginning on page 166.]
Mr. Smith. A quick stab at the EMR thing. How is your----
General Kiley. We do have one in the DOD. It is ALTA. It is
worldwide. A doctor can pull up a record of a soldier that was
cared for at Landstuhl. But it doesn't talk yet with the VA
system. And we are working pretty aggressively to get the two,
ALTA and Veterans Integrated System Technology Architecture
(VISTA), together.
I would defer to----
General Schoomaker. Congressman----
General Kiley. Excuse me, sir.
General Schoomaker. No, go ahead.
General Kiley. No, I was just going to say I would defer to
Dr. Winkenwerder at the DOD level for that.
General Schoomaker. I would like to make just one comment
on the guard and reserve. Because I think we clearly have our
emphasis--I mean, our focus right now on the back-side, once
they have served, and going through the process that we are
talking about.
But there is huge opportunity, up front, with the guard and
reserve, to improve medical readiness. Part of our challenge
has been--during this particular conflict--has been the
unreadiness of guard and reserve, medically, in terms of--
because many of them don't have health care in their civilian
life; there isn't money in the system to provide them health
care prior to mobilization.
And so we find, once we mobilize them, we are having to
deal with dental issues, things like diabetes, and all kinds of
things that we should have been able to detect and deal with
prior to mobilization. Because once they are mobilized, we then
must return them corrected, when they demobilize.
And therefore that is why you see the numbers of guard and
reserve in the system that are, right now, compared to active,
because we are dealing with that issue and what is required
there.
So, again, looking at this comprehensively, this really is
a readiness issue, and it really does have to do with how we
resource guard and reserve and prevent some of this stuff, you
know, then we have to deal with in a catastrophic way once they
are mobilized.
The Chairman. Dr. Kiley, when do you think you can get back
to Mr. Smith on that answer?
General Kiley. Sir, within a week, if that is soon enough,
Mr. Chairman.
The Chairman. That would be fine.
Mr. McHugh.
Mr. McHugh. Thank you, Mr. Chairman.
Gentlemen, proper manner suggests I should say how happy I
am you are here. Honesty demands that I tell you I am not. I
suspect you are not particularly happy to be here either. It is
hard to tell what the greater emotion is: that of yell in anger
or cry in sorrow.
But we all understand the great challenge we have here. And
I want to associate myself with the comments of the gentleman
from New Jersey, my friend Mr. Saxton.
At the point of care--the point of the hypodermic, if you
will, rather than the spear--this is a great system. The
doctors, the nurses, the physician assistants, those folks
providing that care on the hospital floors and the field
hospitals that we have all visited are outstanding, and we are
so grateful for their service.
But this is a system in its structure is broken. It has
turned what should be a support system, where soldiers view it
as a place of shelter and hope and help, into one of
adversaries. And you have said it yourselves.
And, frankly, it is not a surprise. Dr. Chu mentioned the
GAO report that this committee placed into the 2006
authorization bill, dealing with the Medical and Physical
Evaluation Boards.
Dr. Snyder and I, back when I had the chance to chair the
Personnel Subcommittee, had not one but two hearings on medical
holds and medical holdovers.
General Kiley, you sent your deputy; the surgeon general
for the Navy was there. We had soldiers, sailors, Marines in,
talking about their frustrations.
We knew this. We knew it. And yet somehow the kinds of
problems we have been reading about and we have been hearing
about in the media came about in any event.
I trust the services, and we are going to watch very
carefully--we are going to find those responsible and take the
necessary action. Frankly, I think, you know, companies and
military units tend to do what commanders inspect, so there are
command problems here.
But on the broader issues, as I have heard many of my
colleagues on both sides of the aisle here this morning say, we
as Congress have to be a productive part of that.
Budgets--let's talk a little bit about budgets.
Dr. Winkenwerder, I believe I heard you say that in your
judgment, resourcing has not been a problem. I am concerned
about it nevertheless.
We have a little factor in budgets now called efficiency
wedges. That is a nice way to say, ``You will find savings
somewhere. And we are not going tell you where. The only thing
we are going to tell you is they are going to come out of the
medical treatment facilities, the MTFs.''
And if we go back to when this started, back in 2006, we
had an efficiency wedge of $94 million spread across the Army
and the Navy and the Air Force against the medical treatment
facilities. Then again in 2007, it was $167 million--$167.3
million. In 2008, $212.3 million has been inserted as an
efficiency wedge against the medical treatment facilities.
Roughly added, that is over $473 million.
Now, we have talked to some folks who are concerned because
these efficiency wedges by the Administration's budget are
documented out through the fiscal year 2013. We have been told
that if the efficiency wedge in 2009 is implemented, the only
savings that are going to be available to probably both the
Army and the Navy will be the actual closure of facilities, a
facility in each.
General Kiley, do you have any opinion on where that
efficiency wedge might take us by 2009 and that statement that
others have unofficially told us?
General Kiley. I am concerned by 2008 and 2009 we will have
efficiency wedge that, at least as I sit here now, I cannot see
efficiencies gained to recover that.
I think the number in 2008 of $140 million is about
equivalent to a MEDACS annual operation, and in 2009 it is
equivalent to one of our medical centers' operations at the
$200 million to $240 million.
So I have grave concern if we are going to be able to meet
those budgetary cuts in those out-years.
Dr. Winkenwerder. Let me respond----
Mr. McHugh. Yes, Dr. Winkenwerder.
Dr. Winkenwerder [continuing]. And separate some things out
and try to take a crack at explaining here.
With respect to the matter of Building 18, I think many
have said--and to clarify there--that resources to have avoided
that having happened were not an issue; resources were there.
There is no question about that. Those were judgments----
Mr. McHugh. If I may, that probably makes it worse.
Dr. Winkenwerder. Right.
Mr. McHugh. But I understand your point. Thank you.
Dr. Winkenwerder. With respect to the broader issue about
the so-called efficiency wedge, that was determined as an
approach forward three years ago, and planned and agreed upon
by the three services and our office and Dr. Chu and others. It
was premised on the notion that there were ways to be more
efficient and more effective with delivering care, but it was
also caveated by saying that we would look at this every year
to ensure that this was something that was achievable.
I believe, no question, that at this point we have got to
look at it. We will look at it. I think that if there is
anywhere--and I have said this many times--that we do not want
to stress the system, it is on the direct care of our
beneficiaries, of our soldiers, sailors and their families--
airmen and their families.
So we will look at this. And I think it is a timely point
to do that.
If you look from this point backward, I think the dollar
amounts are relatively insignificant, such that they have not
had any effect that we would be concerned about.
In fact, we have returned dollars last year because we
didn't fully execute our budget. We returned dollars to the
services to be used for whatever was needed. So we really
didn't have an issue this past year.
Mr. McHugh. It was nearly a quarter of a billion dollars.
The Chairman. Gentlelady from California, Ms. Sanchez.
Ms. Sanchez. Thank you, Mr. Chairman.
And thank you, gentlemen, for being before us today.
And I just want to back up the comments that Mr. McHugh
just made with respect to the fact that, sitting on the
Personnel Subcommittee, we have been very concerned. And also
our current chairman, Mr. Snyder, being a doctor, I think the
medical issues are really something that we have delved into as
a subcommittee on this overall committee. And it is a real
concern. It is a real concern.
As you know Dr. Winkenwerder, when you came before us just
a few--maybe about a month ago and we talked about the $2
billion or $1.8 billion plus $236 million of efficiency costs
that you were trying to shave off of the budget, that when we
look at a normal business plan, most businesses anticipate
anywhere between 5 and 8 or 10 percent increase in their
medical costs for their employees. And, unfortunately, and what
has been the case with spiraling costs, can sometimes be 15,
17, 18 percent a year.
So it is a real issue for us when you are telling that you
are holding down costs. And we want to hear that, but the fact
of the matter is, there may not be enough money there.
General Kiley, I want to take the opportunity--you were the
commander of Walter Reed between 2002 and 2004. Is that
correct?
General Kiley. Yes, ma'am.
Ms. Sanchez. During your tenure, were you aware of the
problems with the adequacy of the housing for the patients at
Walter Reed?
General Kiley. When I was the commander at Walter Reed, all
the patients were on the installation. There were no patients
in Building 18.
Ms. Sanchez. Were you aware of the problems with losing
paperwork?
General Kiley. I was aware that the process of doing
medical boards, particularly for reserve and National Guard,
was complex; that there were 22 different forms.
Ms. Sanchez. But you didn't know that your staff was losing
it there, the paperwork?
General Kiley. I was not aware of an individual case, no.
Ms. Sanchez. Were you aware that there were problems with
the lack of bilingual staff?
General Kiley. I think we recognized that we needed
bilingual support. We didn't have a robust bilingual staff when
I was there to assist, but we did have cases where we had to
find someone to assist a patient or their family.
Ms. Sanchez. So you didn't think it was a problem? You
thought you could just grab a ten-year-old child who happens to
be the son who could speak English or something like that? I
mean----
General Kiley. No, I just--I didn't address that issue.
Ms. Sanchez. And that is what happens in some of the
clinics that we have. I mean, the child, for example, becomes
the interpreter between the doctor and the patient which,
unfortunately, is not a very good one, as you can imagine.
General Kiley. That is not typical.
Ms. Sanchez. So you knew there was a problem but you didn't
address it?
General Kiley. I don't remember that I specifically gave
directions to increase bilingual staff. But it is an issue that
we are going to take on and we are fixing.
Ms. Sanchez. Were you aware of the problems patients
described with having access to their case workers and access
to care?
General Kiley. We have recognized that we needed more case
workers. We had social workers on the staff of the hospital,
but it became obvious, as we have talked about earlier, the
value of case workers. I think what I failed to realize was
that a ratio of one case worker to, say, 50 soldiers was too
much. They were attempting to do too much.
We have taken that on. We have lowered those ratios. And we
are going to reexamine that and probably lower them again.
Ms. Sanchez. Gentlemen, I just returned from leading a
Congressional Delegation (CODEL) in Iraq this past Monday. And
when I spoke with my soldiers, many of them from California,
they had just learned that they were going to be extended--
maybe about a week ago they learned. They were supposed to be
going home actually this week. Their morale was, as you can
imagine, incredibly low. And, in fact, most of them, or all of
them, said, ``Get us out of here.''
Now, we have asked our active duty and our reservists and
our National Guardsmen to sacrifice a lot and we send them on
these multiple tours. Many of them are extended, in particular.
Many are going to find themselves extended because of the
President's surge.
And while our troops haven't been to Walter Reed, they are
reading the newspaper and they are finding out that their
buddies who are returning home are being treated this way: lack
of case workers to help them through the process, lack of
bilingual staff, lack of paperwork, losing paperwork, being
housed in slum tenant conditions.
What do you think the neglect at Walter Reed and the
publicity of this is going to have on the morale of our troops
out there?
General Kiley. I think if we don't fix it right away it has
the potential to negatively impact on the morale, which is why
I am committed to fixing it.
Ms. Sanchez. And how do we tell our families? Because I
know I am going to go home this weekend and I am going to meet
the families and they are going to tell me, ``How could you
have let this occur?''
What is the answer? Can someone on the board tell me how
could we have let this occur?
General Kiley. I think we have been very busy across the
Army Medical Department. I think, in this case, we just lost
sight of some of the issues that some of these soldiers were
dealing with, didn't respond quickly enough. And we have got to
fix it.
We understand what the problems are. We are going to
redouble our efforts not just at Walter Reed, but at bases and
posts around the nation.
Ms. Sanchez. Thank you, Mr. Chairman. And I see my time has
expired.
The Chairman. Thank you.
Before we go on, as I understand it, Dr. Kiley, you say the
$140 million is the Army's military hospitals' efficiency
wedge, which means that the Army has to find another $140
million in the budget. Am I correct?
General Kiley. I believe that is correct.
The Chairman. All right.
Now, as I understand, Dr. Winkenwerder said that he returns
money that was not needed. Now, it is not needed, then why
don't we give that money to the military hospitals and
eliminate the so-called efficiency wedge? This country lawyer
has a hard time understand that. Would somebody like to explain
that to me?
Dr. Winkenwerder? Anybody? Dr. Chu?
Dr. Chu. Let me, if I may, sir.
I think Dr. Winkenwerder's statement about returning funds
applied to fiscal 2006, the fiscal year already concluded. The
numbers that you cited, the $147 million, that is fiscal 2007.
It is different.
The Chairman. Was money returned in 2007?
Dr. Chu. We haven't finished executing 2007----
The Chairman. Will money be coming back? Or do you know?
Dr. Chu. I think it depends on execution.
Let me, however, explain how these numbers were derived. We
looked in detail at the efficacy of all our military treatment
facilities. In other words, if we pay them on the basis that we
pay our private sector providers, could they cover their costs?
Many of our facilities do very well on that kind of metric.
There are some facilities that perform very poorly. In other
words, they are not doing the level of work they need to do
given the level of resources we have.
So these figures came from a decision to challenge the
poor-performing facilities to come up not to the top, but to
the average over a period of years.
The Chairman. All right.
Dr. Chu. Now, as Dr. Winkenwerder said, it is something we
are going to look at year by year. This is relatively small in
the overall defense health program. I don't think we ought to
overdo it. And if these are not achievable, we will reverse
course.
The Chairman. Of course, the ones you need to explain all
this to--which is very difficult for this country boy to
understand--I am not sure that the patients sitting out there
in Building 18 would understand it.
Dr. Chu. It should be invisible to the patient. The
standard for the patient should be the same everywhere.
The Chairman. Thank you.
Mr. Jones.
Mr. Jones. Thank you, Mr. Chairman.
I guess my question is going to be to General Kiley, and
also to you, Dr. Chu.
Along the lines of Ms. Sanchez, what has amazed me, I do
not understand--General Kiley, I guess you would be called the
governor or the mayor of Walter Reed, because of your position.
Is there not some ongoing process of some individual or
some committee that goes through these facilities on a regular
basis to make sure that the maintenance is current and do the
things that normally people do around universities--they do it
around big businesses, they do it at homes?
I mean, there are people constantly--know, with any
facility, you have got to have an ongoing process to keep it
current. I mean, meaning the repairs, the paint, whatever it
is.
And I want to ask you this question. If it had not been for
Dana Priest and the article in The Washington Post, would you
have known there was a problem? I will ask General Kiley, I
will ask Dr. Chu, because time is limited: Would you have known
there was a problem with the substandard living conditions if
there were going to be heroes put in those conditions?
General Kiley. I would not. In my position as the commander
of MEDCOM and the surgeon general, I would not have.
And when I commanded Walter Reed, I had a colonel who was
the city mayor; I had a colonel who was the brigade commander;
I had a colonel who commanded the hospital facility, who
reported to me daily. They had subordinates that were charged
with the day-to-day maintenance of buildings. And, of course, I
did not have patients there.
But my successors also had those same command
relationships. I don't know if that answers your question.
Mr. Jones. Well, it does somewhat.
I guess, again, my question is, if these facilities are so
substandard, it just didn't happen overnight. It has been an
existing problem. Whether you had left the command at that
time, I don't know, and it doesn't really matter.
I am just trying to better understand the process that is
not working.
General Kiley. I think there are two factors, quickly.
I think that is an old building. We had renovated it
several times, had put in carpets, et cetera.
And then what I believe may have been part of the problem
is we failed to reprioritize the maintenance of that building
as a patient care area versus a standard administrative
building. And so the repairs that the NCO was requesting
weren't put into the queue like all the other repairs, and it
was just an error. We fixed that.
Of course, the building is empty now, but in retrospect, we
could have done a better job of that.
Mr. Jones. Dr. Chu, when did the Department of Defense make
a decision to privatize this construction work?
Dr. Chu. It wasn't Department of Defense. This was an Army
proposal within the larger effort to look at who should do
what.
I think you are speaking to the A-76 contract at Walter
Reed. Am I correct, sir?
Mr. Jones. I think this is right. My question is, can you
tell me who the IAP construction--who that business is that won
the contract?
Dr. Chu. Sir, could you repeat that? I couldn't hear over
the bells.
Mr. Jones. IAP is the group, the management group, that got
the contract. Do you know anything about them?
Dr. Chu. I would have to defer to the Army on the specific
contract.
Mr. Jones. Okay. When you put this out for private bid,
then I assume that the parameter is anyone that can do the work
can bid on the process. Is that right?
Dr. Chu. Again, I would have to turn to the Army on this
issue of the contract.
If you are referring to the A-76 process, as you know, sir,
it first starts as a comparison between in-house best
organization, which allows the in-house entity to reorganize
itself and rethink how it does business. And they receive,
actually, an edge in the competition in terms of the
calculation. So they are allowed to come in certain higher
because we do value the continuity that is there.
And then, yes, sir, under Federal contracting regulation
procedures, outside elements are allowed to bid, and the
decision is made which is the better value answer.
I can't speak to the specifics in this particular
competition. We will have to take that question for the record.
[The information referred to can be found in the Appendix
beginning on page 167.]
Mr. Jones. Mr. Chairman, could I submit a letter for the
record asking a couple more detailed questions about the
contractor process?
The Chairman. Certainly do it for the record, and hopefully
you get back to us within a week.
Mr. Jones. Thank you, sir.
The Chairman. Mr. Andrews from New Jersey.
Mr. Andrews. Thank you, Mr. Chairman.
General Kiley----
The Chairman. Excuse me. Just a second, Mr. Andrews.
There are two votes, and we will break shortly. We will ask
the witnesses to stay because this is terribly important that
we get through all of this. So bear with us, gentlemen.
Mr. Andrews.
Mr. Andrews. Thank you, Mr. Chairman.
General Kiley, I think I think I heard you just say a
minute ago to Congressman Jones that you would not have known
about some of the reports and conditions had you not read it in
The Washington Post. Is that what you said?
General Kiley. What I thought I was answering to
Congressman Jones was that I would not have been aware of some
of the maintenance challenges--specifically the mold, the holes
in the roof--if I hadn't seen that in The Washington Post.
Mr. Andrews. How about the rodents? Same----
General Kiley. Same thing.
Mr. Andrews. Okay.
Who down the line from you would have been aware of that?
If a soldier who is in that facility says, ``Hey, there was a
rat in my bathroom this morning,'' who does he tell? Where is
that person in the chain of command? How come you didn't know
that?
I have got to tell you, if I were managing a college--if I
were a college president, and one of my students said to me
that there are rats in the infirmary, and if my subordinates
did not know--A, know that, and B, tell me that was the case,
they wouldn't be my subordinates much longer.
Who is it that would know that? And why didn't they tell
you that? What was missing here?
General Kiley. There is a chain of command starting with
General Weightman, who manages that installation. There is a
colonel, the garrison commander, city manager, and a brigade
commander. Those soldiers answer to the brigade commander
through company commanders and first sergeants, who are charged
with the day-to-day health and safety of the soldiers, to
include inspecting their rooms. They should have known.
Certainly, any soldier that came to me and said, ``Hey,
sir, you know, you are the commanding general MEDCOM, and there
are rats in my rooms''--I would have acted on that immediately,
as would have General Weightman.
Mr. Andrews. And I take it on faith that you did not know,
or I am sure you would have done----
General Kiley. I did not know.
Mr. Andrews [continuing]. I know that is the case. I am
just deeply concerned that you didn't. And I am not suggesting
that that is necessarily your fault.
But based upon what you know here, where did the
information stop flowing upward? When someone found that there
were rodents in these rooms, where did that information stop so
it did not reach you?
General Kiley. Congressman, that is under investigation as
we speak, in a formal investigation, 15-6. I can tell you that
the commanding general relieved two first sergeants and a
company commander that were involved in MedHold and that
holdover. And that investigation should be closed soon.
Mr. Andrews. Okay.
General, I am not sure you are the right person to answer
this question. My information is that there are 1,055 soldiers
Army-wide who remain in medical hold-over (MHO) for more than
360 days at this point. I would like to know how many of them
are in the community-based program.
[The information referred to can be found in the Appendix
beginning on page 167.]
Mr. Andrews. With respect to those in the community-based
program, what quality assurances, provisions are in place now
so we can be sure that their treatment is appropriate and their
conditions are appropriate?
And then second, for those who are not in CBHCO--if someone
who is not in CBHCO was my constituent, and he or she called me
today and said, ``I am living in a facility here that is
subhuman,'' whom do I call to fix that?
General Kiley. You would call me right now, Congressman,
but----
Mr. Andrews. If I can just say, that doesn't work--and I
would call you--but not everyone has access to their
congressman to ask that question.
If this soldier told his or her spouse that problem, who
would he or she go to? And who would fix the problem?
General Kiley. Those soldiers that are not in the CBHCO are
still on our Army installations. And they have command and
control; they have a company commander and a first sergeant;
they have a MedHold Over commander; there is a hospital
commander, the Inspector General (IG). They could talk to a lot
of people if they had an issue that was not being answered.
Mr. Andrews. I want to go back to Mr. Smith's question of a
few minutes ago. Do you they have an ombudsman or an advocate
that is there for them that is not part of the chain of
command, but is their advocate? Do they have such a person?
General Kiley. I don't believe we have a formal ombudsman
program yet that is separate and distinct from either the
garrison or the Medical Command, but----
Mr. Andrews. Do you think that we should?
General Kiley. Yes, sir, I do. And we are going to.
Mr. Andrews. Thank you, Mr. Chairman. I appreciate it. I
would also appreciate an answer to my first question for the
record when it becomes available.
General Kiley. Yes, sir.
Mr. Andrews. Thank you.
The Chairman. We will take a few minutes' break. We have
two votes, and we will be back. I appreciate the witnesses
staying.
[Recess.]
The Chairman [presiding]. The committee will come back to
order.
Mr. Miller from Florida.
Mr. Miller of Florida. Thank you, Mr. Chairman.
Good afternoon, gentlemen. Thanks for being here and
staying through the extended delay for the votes.
Got several questions and issues that I am going to be
submitting to the acting secretary of the Army. And I will also
be asking some of the questions, particularly to General Kiley
today.
And we have talked about a wide variety of things, but one
of the things that is most important to me is traumatic brain
injury. I know it is to most everyone else in the health care
world. And the proper care and monitoring of those who suffer
from it is of particular concern, from ensuring our possible
traumatic brain injury (TBI) patients receive proper initial
cognitive screening to crafting legislation that changes the
International Statistical Classification of Diseases and
Related Health Problems (ICD) codes associated with TBI and
psychiatric disorders.
We as a government need to do all we can, and we need to do
it quick.
General Kiley, as many members say to our men and women in
uniform, I appreciate your service, certainly your patriotism,
and in no way do I doubt your dedication to the Army or to our
wounded soldiers.
However, it is important that we have trust and confidence
in our leaders. And I, along with many of my colleagues, have
lost that trust and confidence in you, sir.
And I think it is only fair before I begin questioning that
I inform you that I have written a letter to the secretary of
defense asking that he know my wishes that you should be
relieved of your command.
And, Mr. Chairman, with your permission, I would like to
enter that letter into the record.
The Chairman. Without objection.
[The information referred to can be found in the Appendix
on page 156.]
Mr. Miller of Florida. Frankly, I have been amazed even at
your public comments prior to this hearing and even some of
them here today.
And I want to associate myself with my colleague
Congressman Bill Young's comments and frustrations that he
made. I know in a hearing yesterday--I believe Mr. Young and
his wife are uniquely qualified to talk about the issues as
they relate particularly to Walter Reed.
And also, one of things you said in your opening statement,
that we had failed in the last few weeks--actually I know you
probably meant we failed for quite some time. I think it is the
last few weeks that it has actually been brought to our
attention by The Post.
Some of the questions that I have are, again, about the
codes that are currently being used. And I know you are
familiar--I think it is ICD-9 that is currently being used.
And please correct me if I am wrong, but it is my
understanding that that designation, without any other
description going along with it, medically translates to an
organic, psychiatric disorder, and that an IED victim who
suffers TBI and has obvious brain damage and neurological
issues is actually assigned that particular code.
My question is, is that true, and why are we still using
ICD-9? I understand that it may also be congressionally
required, but should we go to the ICD-11 that the private
medical fields are going to?
General Kiley. Congressman, to my knowledge, the ICD-9
codes for diagnosis--you are correct, as I understand it,
sitting here today. There is no specific code number for
traumatic brain injury, and so our medical personnel, as they
codify the health care that we are delivering, have to find a
code that is close.
And, frankly, that is not acceptable. I don't control ICD-9
coding. We have to find a solution to that right away.
Our TBI task force, which I launched last fall, I am sure
will be making recommendations to me in that regard.
Mr. Miller of Florida. Any other comments from anybody?
Dr. Winkenwerder.
Dr. Winkenwerder. I agree that that is a concern. As I
understand it, the ICD-9 and ICD-11 is managed by the American
Medical Association. I think we and others should be and will
be working with them to look at this issue.
You know, the whole matter of traumatic brain injury,
whether it is occurring in the context of our kinds of
experiences with warriors or in athletics or other, is really a
new, emerging field, under-recognized in the past.
And I just want to assure you, because I know that is
probably on the minds of others, that we are moving very
aggressively on that area. We have a field screening tool that
has been in place since last fall to screen people out on the
field when these events happen. We are beefing up our screening
afterwards. We are increasing our research. And I think the
overall awareness has gone way up, as it should.
But we need to do more. And there is just no question about
that. And we will be.
Mr. Miller of Florida. And certainly there are field tests
and other tests that are given to determine whether a person
suffers from a traumatic brain injury.
Is it true that if a person takes these cognitive tests and
receives anything in the average range, whether being above
average or below average in cognitive function, that they, in
fact, do not get designated as TBI, if they are still within
that average range? So if you are below average, you still
don't get told you have TBI?
Dr. Winkenwerder. Again, I am learning about this because
the disability system, again, is something that is driven out
of the personnel community, but from what I have learned it
sounds like that system is behind the times, so to speak, with
respect to how it looks at people with these kinds of injuries,
which are not--you know, they are not visible, and they are
subtle sometimes, and they may be varying in terms of their
symptoms.
And so I think--and Dr. Chu and I were just talking about
this recently--that we may need a new paradigm; we may need a
different way to think about how to look at disability for
somebody who has that kind of injury.
The Chairman. I thank the gentleman.
The subcommittee chairman of Personnel has a couple of
inquiries at this moment.
Dr. Snyder. Thank you, Mr. Chairman.
Mr. McHugh had to leave, but we still got a little confused
about case manager and case manager ratios.
General Kiley, maybe you can answer these questions here,
and then one for the record, if you need a bit more detail.
What is the current case manager ratio, system-wide, in the
Army? What is the current case manager ratio at Walter Reed?
And what should the case manager ratio be? And when I asked you
before about who paid the case managers, are they all
employees, or are any of those contracted out?
General Kiley. I believe the case ratio at Walter Reed is
approximately 1:30--25 to 30. And I will take all these
questions for the record.
I can't give you, as I sit here, a case manager-to-soldier
ratio across the MEDCOM. I do believe it varies, that some of
the data I have looked at--it can be as low as 1:17 to 1:35,
depending on the installation.
I will come back. I can give you those numbers.
[The information referred to can be found in the Appendix
beginning on page 166.]
Dr. Snyder. And what is your goal? What do you think it
ought to be?
General Kiley. Well, we thought our goal was 1:30, 1:25. We
are reassessing that now. It may be 1:15.
And at some point, you reach a point of potential
diminishing returns, in the sense that you are expending
resources and then, all of a sudden, the case managers don't
have much to do because they have taken care of the 10 or 15
soldiers. But we are not there yet. We don't have an answer for
that yet.
They are made up of GS employees. There are activated
reservists, case managers that work for us, also, at our
installations. I will take it for the record, to give you a
lay-down, across every installation.
Dr. Snyder. Thank you. If you can share that with----
General Kiley. And it would not surprise me, although I do
not know, sitting here, now, do I have some nurse case managers
at one of my installations that we have brought on board under
a contract? It could be all three combinations.
Dr. Snyder. If we could have that within a week, two?
General Kiley. Yes.
Dr. Snyder. Thank you.
Thank you, Mr. Chairman.
The Chairman. Ms. Bordallo, please.
Ms. Bordallo. Thank you very much, Mr. Chairman.
Mr. Secretary Winkenwerder and also Dr. Chu, I spoke to you
briefly during the recess. I want to thank you all for your
testimony.
Like my colleagues, I am concerned to learn that service
members who have been wounded as a result of their service in
Iraq and Afghanistan or elsewhere may not be receiving the
quality of care they need. And I trust that the DOD shares this
committee's concern and desire for prompt action to fix the
problems at Walter Reed.
I want to make sure that the Department is aware that
problems at Walter Reed are indicative of problems that exist
across the Department's entire health care system.
For example, many times in the past, including in committee
hearings and in meetings at my office, I have raised with you,
Mr. Secretary, and others in the Department--I have some of the
correspondence here with me here that I have inquired about
this, and you have written back--the health care needs of
retirees who are reliant on the TRICARE system for health care.
That is, a U.S., 20-year, military retiree who lives on Guam,
who are referred off-island for specialty care or emergency
care, are forced to travel to those locations at their own
expense.
These trips to access referred specialty care in Hawaii or
California cost in the thousands of dollars, unless, of course,
they are going military air travel. In 2005, the Department
suddenly changed policy to no longer reimburse retirees for
travel expenses.
On Guam, Mr. Secretary, and to the other witnesses here, we
cannot travel across the states to another hospital. We are the
only U.S. jurisdiction in the Pacific, thousands of miles away
from specialty care. So as a result, these costs are born
solely by the retiree.
Mr. Secretary, I have met with you, and I have written to
you, as I have said. And I have addressed this issue more than
once in hearings. The committee included report language on
this matter in 2005. The retirees deserve resolution. From what
I can gather, no measurable action has been taken by you or
anyone else on this matter since we met and discussed this
issue last year.
If my proposed legislative remedies continue to be
unacceptable to you or the Administration, then I respectfully
request that you propose alternative solutions for the
committee to consider if a fix cannot be made administratively.
So during this hearing, I will ask, once again, will you
work to rectify this problem to reassess your policy of
discontinuing reimbursement of travel for these 20-year U.S.
veterans?
Dr. Chu. Congresswoman, yes, we will look at it. And I will
take another look at it. And as I have said, I am sensitive to
that concern. We are sensitive to that concern.
It wasn't a discontinuance of payment for that. It related
to the fact that there had been, in the prior years, flights
that had occurred where people could go on those flights and
that it is no longer possible because of the flight schedules
and so forth.
But I think that deserves another look, and I promise that
we will do that and get back to you promptly.
Ms. Bordallo. Thank you. Thank you, Mr. Secretary.
And, Dr. Chu, I thank you for listening to me, as well,
this morning. I want to work together. I want to help our
veterans. Just recently I had a town hall meeting on Guam, and
this was a major concern among our veterans. And I hope that we
can come to some solution.
Dr. Chu. Thank you, ma'am.
Ms. Bordallo. Thank you, Mr. Chairman.
The Chairman. Mr. LoBiondo.
Mr. LoBiondo. Thank you, Mr. Chairman.
I want to thank the panel for being here today.
And, General Schoomaker, I had the opportunity to visit
earlier in the week. And I have to tell you I was very
impressed by the hands-on your brother demonstrated with where
we are with this.
But as a number of my colleagues have indicated, I am
having a hard time grasping how this came about.
In my visit, I listened to the frustration of a couple of
our soldiers who repeatedly attempted through their case worker
and then up the chain of command to have something done. Now,
whether there was frustration about the bureaucracy of the
paperwork that was a part of this, as was indicated--but the
reality is that those conditions were horrific, deplorable. And
repeatedly, over a long period of time, we had soldiers trying
to point this out.
I don't understand how this breakdown in the chain of
command could have happened. And I am concerned that there are
other situations where this chain of command is broken down in
other areas that we don't know about yet.
So I would like one more time to try to understand. Because
having been on this committee for a few years, there have been
isolated incidents--and I will say isolated--where I sense when
members of Congress ask questions we are almost dismissed from
just some level of the chain of command--the higher chain of
command that doesn't want to be asked any questions. And then
we have a situation like this where we are held responsible.
Yes, you are being held responsible, but we are being held
responsible.
So I am still failing to understand that through the whole
chain of command this thing was broken down. I mean, whoever
was in charge didn't have officers underneath that understood
the plight of the veterans who were in their care. The case
workers couldn't do anything about it. These rooms were on the
list and kept getting bumped off the list.
And what assurances do we have that there isn't something
else wrong in the system somewhere along the line? I am really
trying to understand this to work with you, but it is very
difficult.
I don't know who wants to take a stab at that.
General Schoomaker. Congressman, are you addressing me on
the issue? I assume by the end of your question you were
talking about Building 18 and how that occurred.
Mr. LoBiondo. Building 18 and how that occurred.
General Schoomaker. But, of course, there are also obvious
breakdowns in outpatient care in general and the medical
evaluation board (MEB)/physical evaluation board (PEB) process.
We have had reports of inpatient care concerns and all the rest
of it.
And the Building 18--those soldiers that were in there were
outpatients going through this process. Noncommissioned
officers were assigned over them. There was a company commander
over them, a first sergeant. And it goes on up through the, you
know, brigade that is there on Walter Reed that answers to the
commander of Walter Reed.
So that is precisely what we are investigating right now,
is how did we get to this? With all of the leadership present
that was at Walter Reed, how is it that something as simple as
this--when we were not constrained in resources to fix this,
and where we are fixing it throughout the Army in a very
aggressive way--why would this be a surprise to anybody? And
why would we be where we are today on it?
I think that--and so we are investigating it. As you know,
a couple of first sergeants and a company commander have been
relieved, and we have put in place a more robust structure with
a better span of control on it. And there is very aggressive
action being taken in making sure that the housing for the
barracks for soldiers are adequate. But we need to find out.
And, you know, the assurance is we have to reinforce the
chain of command. And the chain of command is based upon trust
and confidence in the people that are in that chain of command,
and it requires them to take action--of all of us.
So, you know, the assurance is that we are aggressively
pursuing, you know, what happened. We are going to fix whatever
the root causes of it are. And we are putting energy in the
system, putting the right leaders in place to make sure that,
you know, that it has continued to be an aggressive program and
we move onward.
There is no excuse. And I have consistently said that.
There is absolutely no excuse. But there are some reasons, and
we need to figure out what the reasons are and address them
properly.
Mr. LoBiondo. Mr. Chairman, can we on the committee expect
that we will have a follow-up to this to hear some of these
reasons or conclusions at some point in the future?
The Chairman. We could very well do that. It hasn't been
determined yet, but we could very well do that.
Mr. LoBiondo. And what about other facilities across that
country? I mean, I am assuming there is some aggressive action
being taken to make sure that nothing like this is taking place
anywhere else.
General Schoomaker. Well, you are correct, and at various
levels. We have a tiger team that is going out and looking at
it. Immediately upon learning this, we have asked everybody
to--the mission commanders out there, as well as the hospitals
and other facilities--it is not just limited, you know, to the
Medical Command. We have asked all of our commanders out there
to take a look at what they have and make sure that we know
what the challenges are, because we have been aggressively
working these issues.
And that is what is so frustrating. What angers me so much
is--I mean, we have been working now for at least three years
very aggressively, and have pursued the resources to do it,
have gotten the resources, have been applying the resources.
And there is really no reason for it.
Mr. LoBiondo. Well, that is the way we feel. And obviously,
over the last three years, with what you have done, some folks
below you on the chain of command don't quite understand it,
and I hope they do get the message.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Ms. Castor from Florida.
Ms. Castor. Thank you.
Gentlemen, let me start by saying that I am compelled to
convey to you the moral outrage of the folks I represent in the
treatment of our soldiers.
I represent a community that truly values the contribution
of our young, brave men and women. I represent the Tampa Bay
area. We have the largest VA hospital in Tampa, the Haley
Center. It also is one of the very unique polytrauma centers
that focuses on the critical brain injuries and spinal cord
injuries. And just across the bay, we have the great Bay Pines
veterans' center.
So, in our community, we truly value the service of these
young men and women and many veterans. In Florida, we have the
second highest number of veterans.
And, General, I agree with you. It is time for a
comprehensive solution, and I just wanted to point out a couple
of cases, in talking with soldiers there over the past few
weeks and, really, over the past few years, that you can build
into your comprehensive solution.
First is information provided to families. Before I was
elected to Congress, I served as a county commissioner, and I
was very surprised a year and a half ago to receive a call from
a family that could not get any information on an injured
soldier.
He was an Army specialist that was--his unit was attacked.
There were IEDs in the roadway outside Fallujah. He was caught
up in a firefight, shot in the neck, and could not communicate
himself. And, of course, flown to--provided excellent care,
flown to Germany and then to Walter Reed.
And very surprised as a local government official to get a
call, as a county commissioner. They didn't have anywhere else
to turn. You know, I was the closest elected official to them.
And, fortunately, Senator Bob Graham was on the Veterans
Committee then and provided entree.
And I happened to be going to Washington, just
happenstance, to be able to go to Walter Reed with folks from
Senator Graham's office, and we had to go to the hospital to
get information. We could not get information by calling anyone
in the chain of command, by calling doctors at Walter Reed.
And at that time, I believe, Senator Graham was a Ranking
Member on the Veterans' Committee.
We had to go to the hospital and track down the doctor and
find out what this soldier's condition and then phone the
family back home.
Now, I know since that time there have been improved
efforts to communicate with families, but that is a travesty
that you have to rely on those kind of efforts to get the
information back to the family.
And finally the soldier returned back home, and we had
said, ``If you need anything else, you know, don't hesitate to
call,'' thinking that certainly there would be no other issues
that they would have to call a county commissioner to get
through to the Army and to military health.
But sure enough, a few weeks later, this soldier called.
And I know it took a lot for him to call again and said, ``I
can't get my rehab appointments scheduled.'' He was shot
through the neck, injured his spinal cord, and he was back at
home but could not access the rehab system.
So this information, information-sharing to the families,
and being sure that these soldiers don't have to go through
that rigmarole to get their rehab appointments--another story:
Visiting a soldier just a couple of weeks ago at the Bay Pines
inpatient center, where they deal with drug rehabilitation and
post-traumatic stress disorder, a young soldier said, ``You
know, when we come back and we are going through discharge, we
are in such a hurry to get out that we get in the screening
that is done--the medical screening, especially psychological,
they hand us a checklist, and we go through, and we check it
off. And we are tough guys, and we don't have any physical
wounds, but we know something is not right, but we are in such
a hurry to get out, we just check all the boxes and then go.''
And he did that. And then all of the PTSD set in, and his
marriage went on the rocks. In discharge, did not have any
other prospects for employment. Eventually became homeless,
started drinking.
And he said, ``You know, if they had just been a little
more proactive with us upon discharge, that would have made all
the difference in the world.''
So being more active at the time of discharge.
And then let me also mention quickly: Dr. Scott at the
polytrauma center at the VA in Tampa said they are having a lot
of difficulty with residents in training--bringing in the
residents for these type of brain injuries and training the
rehab doctors. And this is at a place where we have a college
of medicine right across the street.
Thank you.
The Chairman. Thank the gentlelady.
Mr. Kline.
Mr. Kline. Thank you, Mr. Chairman.
Thank you, gentlemen, for being here. I know all of us wish
the circumstances were a little bit different.
I, like everybody else, find it unexplainable and
inexcusable that we could have the kind of conditions that we
did have in Building 18. And I know that action is being taken.
We have seen some of it already pretty visibly. And I know that
you are working vigorously to get to the bottom of it and make
sure it doesn't exist elsewhere.
Having said that, I want to identify myself with the
remarks that some of my colleagues have already made--Mr.
Saxton, Mr. McHugh among them--and that is about the terrific
soldiers who work at Walter Reed.
One of my very, very best friends retired from the Marine
Corps about the same time I did, another Marine colonel. He
goes out to Walter Reed with his wife about three times a week.
They have gotten extensive care out there: vascular surgery and
other things.
And he called me day before yesterday in a rage, not about
the deplorable conditions, but about what the impact of all of
this coverage was on the morale of the personnel at Walter
Reed. My wife's last duty station as an Army nurse was in
Walter Reed. And I know not just because she worked there--but
I know that these are soldiers too and they care. And they give
their all.
And I know that this kind of publicity is damaging to the
morale. And as one of the doctors said to my friend, it is just
not fair because this looks to the world like we are a Third
World dump out here with substandard care and substandard
facilities everywhere. And we know that not to be the case.
So I just think it is important as we go through this that
we remember that it is not just the soldiers who are being
treated there that we need to care about, but it is those
working, in many cases very selflessly.
I am going to get to a question here, Dr. Chu.
The commandant of the Marine Corps was here testifying last
week or so, and we had a discussion about something that he
calls the wounded warrior regiment, a sort of formalized way of
making sure that Marines aren't falling through the cracks as
they go through this recovery process.
Some of them are being treated at Camp Lejeune or at Camp
Pendleton or something, and then some of them are being
discharged, they have being picked by the VA. And we know many,
many cases where we have had soldiers and Marines who have
dropped through the cracks as they go from defense care to
veterans care.
And to most of this country, gentlemen, let's face it, it
is all the same: It is how are we taking care of our wounded
soldiers, whether they are active duty or guard or been
discharged.
So my question, I guess to you, General Schoomaker, is, are
you looking at a wounded warrior--I know you have something,
sort of, called a wounded warrior program. But are you looking
at this concept that the Marine Corps has to, sort of,
formalize this? They have a regiment, a regimental commander.
They have brought an active duty colonel back from Hawaii to
command it. They have two separate battalions.
Are you looking at something like that to help keep
soldiers from falling through the cracks and taking care of
some of these case management questions we have been talking
about?
General Schoomaker. Well, we have, as you correctly stated,
in the Army the Wounded Warrior Program that we started in
2003. And it really got formalized in early 2004 for exactly
this purpose.
And we have had tremendous success with it. We have
integrated industry and jobs and the whole idea that this is a
soldier-for-life approach to things. And the purpose of it was
to ensure that soldiers didn't fall through the cracks on the
thing.
As you know, the load on this program has increased
significantly since 2003. And, you know, that approach that you
are talking about there may very well be something that we
ought to institute, you know, so that we distribute--kind of,
expand the control over it.
But the purpose of both programs is the same. And that is
that we have got a lifelong commitment to these young men and
women that have worn the Nation's uniform. And it is our
intention--our true intention to be dedicated to lifelong
support of them.
Mr. Kline. Well, I hope that the Army and the Marine
Corps--and it would be a model for other services--we kick
those programs into very high gear, so we have somebody serving
in uniform that the soldiers and marines know how to get in
touch with--you know how to get in touch with them and we know
how to get in touch with them--that is making sure we are not
losing these terrific young men and women.
Thank you, Mr. Chairman.
The Chairman. Thank you very much.
Ms. Davis.
Ms. Davis of California. Thank you, Mr. Chairman.
Thank you to all of you for being here. I know this is not
of your choosing, but on the other hand, we have to all be
accountable. And I think it is so important that we get to the
heart of this.
As you know, I represent also a great military community.
And we have some of the finest examples of patient care and
support for our service members there. But we also share in
those problems as well.
A number of people have discussed contracting out. And part
of that is for operations and maintenance at Walter Reed.
But I want you to take a look and help me understand the
impact of what some people would call the military-to-civilian
conversions, where you have service providers have to be
bought, really, in the civilian marketplace, and what impact
that is having on our service members and the care that they
receive.
One of the concerns, of course, is that there is not the
kind of continuity that we would hope for. Perhaps someone is
an advocate for many service members at one time, but we can't
keep those people in that job. And so, in fact, there are some
changes that occur.
If you could address that, I would appreciate it.
Dr. Chu. I think this is an opportunity for the Department
to ensure that there is the best possible care for our service
members.
The United States, as you appreciate, has a medical care
establishment second to none. People come from overseas to the
United States. This is a long tradition in the Department. Let
me take an example from a different military service, at
Newport, Rhode Island.
For some years, the Navy tried to operate its own inpatient
facility; decided that really wasn't the best way to provide
first-class care. The Navy continues to maintain a clinical
staff--internists, et cetera--at the Newport Naval Station.
But for inpatient care, they place the patients in the
civilian hospitals in that community. The military physicians
attend on those patients.
So mil-civ conversion, that bumper sticker, in my judgment,
is an opportunity, through the Department, and through each
military service, to rethink how it does business, to make sure
we have got the best possible set of ingredients.
So we use military personnel where it is essential.
The Department has been through a major review of what is
the military content we must have to deal with deployed
medicine, on the battlefield, bring the patients home for the
kind of care they get at Walter Reed. That does not mean we
have to staff everyplace else the same way.
There are examples all across the military that have been
used in the past. Take radiology as an example. It is not
necessarily the case that at a smaller installation we should
try to have our own radiologist. It is not professionally
satisfying for that person. And so many installations we have
gone to agreeing with a local radiology group, they will read
the films, we will reimburse them for the read, et cetera.
So this is an opportunity, in my judgment, to get it right,
to make sure that we are delivering care in a way that is most
effective.
Ms. Davis of California. And if I can interrupt, Dr. Chu,
in what areas, Secretary Chu, are these not working very well?
And let me just quickly--because we talked about the
advocate issue earlier, and one of the things that was said--
and ordinarily I would certainly support having volunteers in
positions, but we all know that we can't solve this problem
with short-term--whether it is short-term employment or
volunteers for that matter. I mean, if we are really going to
attack it, professionally and in the best way, we need to do it
right.
And so part of my concern is that perhaps there are some
areas in which this hasn't worked very well.
Dr. Chu. I am sure there are instances where people have
tried new arrangements where they have fallen short. And our
policy would be, let's back up and rethink those areas and do
it differently.
To your question about using volunteers as caseworkers, the
caseworkers that we are talking about here today are paid
personnel. These are professional staff members.
At the military injured center, we basically staffed at the
master's degree level, for example, to be sure we have the
right kind of backstop there for the service program. So we
understand you need a high level of professional competence to
do this job well. This is not straightforward.
Ms. Davis of California. Thank you. And if we can follow up
with that in the future and make sure that those people are
highly qualified and well trained, that would be helpful.
One very quick thing: In San Diego, they have developed a
one-stop center, which essentially provides employment
opportunities not just for the service member, but also for the
family member as well, housed with the California DOD and
educational opportunity center.
Is that a model that we should duplicate elsewhere, or are
there other models that you think are best practices?
Dr. Chu. On employment for both the member and the family,
we are experimenting with a wide variety of models, ma'am. Let
me send you something separately on that front.
Ms. Davis of California. Okay. Thank you.
The Chairman. Before I call on Ms. Drake, General Kiley,
General Weightman was recently in charge of Walter Reed.
General Kiley. Yes, sir.
The Chairman. Prior to him was a General Farmer.
General Kiley. Yes, sir.
The Chairman. Prior to that was you.
General Kiley. Yes, sir.
The Chairman. Did you have knowledge of any of the
shortcomings that have been reported regarding Building 18 when
you were there?
General Kiley. No, sir.
The Chairman. Was Building 18 being used when you were
there?
General Kiley. Yes, sir. We housed a permanent party and
transient student detachment, students that were soldiers that
came in for training at Walter Reed, some for short periods of
time.
The Chairman. So when you were there it was not being used
for patients?
General Kiley. That is correct.
The Chairman. And when did it begin being used for
patients?
General Kiley. If my memory serves me correctly, Mr.
Chairman, after about a $270,000 renovation to Building 18,
General Farmer in 2005 began using that, carefully selecting
patients who were ambulatory, getting toward the end of their
stay at Walter Reed, and began assigning them there, as I am
told.
The Chairman. Ms. Drake.
Mrs. Drake. Thank you, Mr. Chairman.
Gentlemen, thank you for being here. I am just going to get
all my questions out at once, and then we can get as many
answered as possible.
But I think we have heard overwhelmingly today that truly
we have a wonderful health care system within the military,
that it truly is quality. The problem is the long-term care.
And one of my questions for Secretary Chu and Dr.
Winkenwerder: Is there any process in place that you are having
discussions with the VA? Because, of course, these men and
women, some will be returned to active duty, some won't.
So what are doing? And can we use what has happened now to
make sure it is not happening over in the VA system just as
well?
I will tell you, I have never had a complaint in my office
about Walter Reed. I have had many complaints abut the VA
system. So if we can use this with all of you working together,
that could be helpful.
And I know I was encouraged in 2005, when we put the money
in for the seamless transition; we called it for better
information technology (IT) between VA and DOD.
And maybe, Mr. Chairman, we could do a joint hearing, if
that would be appropriate, with the Veterans Committee to look
at the VA system, as well.
The Chairman. The chairman of that committee and I have
already discussed this possibility.
Mrs. Drake. Good.
The Chairman. Thank you for mentioning it.
Mrs. Drake. Thank you.
And I think it is really good today to hear that we are
going to redefine the job of case managers, but I would also
encourage you--I know Duncan Hunter just called it a VIP
system. Maybe even if we had a hotline; that if they felt that
case manager wasn't listening to what they were saying--and,
obviously, they are overworked, as well, but not just for our
military men and women, but for their families.
If their families felt they had a way to communicate and
say, ``Something isn't right here.''
And, General Kiley, you have said it: It is complex. It is
confusing. And, you know, we are the hotline. When people call
us as their member of Congress, that is exactly the role that
we play. And, fortunately, we know who to call and are able to
get through.
But I would also like to ask specifically about Walter
Reed. Since that decision was made some time ago in the studies
that were done on Walter Reed and with a number of injured men
and women who are returning now from a global war on terror,
does it make sense to relook at Walter Reed, or is this just a
done deal?
And is it going to be BRACed? And if it is going to be
BRACed--we have talked a lot about uncertainty of funding.
Chairman Smith talked about it, not having our bills done by
October 1st.
And just an aside on that, two paralyzed veterans came to
see me yesterday. The only request they had of me was we get
our bills done by October 1st. And I thought, ``Boy, that is
not a lot for us. It doesn't cost us anything to do that.'' And
they were stressing what it meant to them that we don't get
those done on time.
But I am also curious about what is the uncertainty--if we
are BRACing Walter Reed, and we have just reduced, in the 2007
bill, the $3 billion for BRAC--what the uncertainty is for you
now. Are we moving ahead with Bethesda or do you have to wait
to see how we are going to address that issue?
So thank you for being there. And I know that was a lot,
but--thank you.
Dr. Chu. Let me try to answer them quickly within the
allotted time.
On your first question, yes, we have tried, in this
Administration, to try a new construct. We have a joint
executive council where I and the deputy secretary of the VA
and all the affected leaders meet once a quarter. We have had a
special meeting just this last week or so to start dealing with
these issues. We see it as an opportunity to do exactly what
you suggested.
On the hotline front, we do have a hotline that is at the
severely injured center. We do field calls there and we open
case files on those cases, just as you suggest----
Mrs. Drake. Well, maybe that needs to be more widely
public.
Dr. Chu. I think I am hearing you say it does need to be
widely publicized.
Mrs. Drake. Okay.
Dr. Chu. Although we do get lots of calls, so it is----
Mrs. Drake. And family members as well, because that is----
Dr. Chu. Anybody may call.
Mrs. Drake. Okay.
Dr. Chu. And we do not restrict what is ``severely
injured.'' If, in your perception, you are severely injured,
that is good enough for us; we will take that case. And as I
said, we have master's level counselors to work that system.
We fully support getting money by October 1st. You have
identified a very serious problem for the Department. This is a
game of large-scale musical chairs, unfortunately. If we do not
get the $2.3 billion that is at stake in the BRAC shortfall, we
have a big problem on our hands because those are statutory
deadlines.
In the specific case of Walter Reed, Bethesda--also Brooke
and Wilford Hall--the Department is aiming to put at these two
premier locations a first-class, 21st-century facility.
Both Walter Reed and, on a slightly longer timescale,
Bethesda as buildings need to be replaced. We should not wait
on this issue. In fact, I was pleased, in the hearing on the
Senate, Tuesday, that Senator Warner urged us to go faster, not
slower.
But we do need the funding. And I would urge that members
of this committee join their colleagues in ensuring that
funding is in the supplemental, so we correct this issue as
quickly as possible.
So we would like to get on with it. We would like to make
sure it is first-class; it has the capacity and the modernity
of facilities to serve our people well.
Mrs. Drake. And do we think that we will re-look at Walter
Reed, or is it going to remain BRACed by 2011?
Dr. Chu. Well, it is a statutory decision, as I--I am not a
lawyer, but I understand the statutory decision. We have no
real desire to reopen this decision.
We want a first-class facility. I don't think anyone would
argue, though, two tertiary care facilities within five miles
of each other--we should have one first-class space.
The advantage of the Bethesda location is it is the same
campus as our medical school. And it is, as you know, across
the street from the National Institutes of Health (NIH).
And Bill Winkenwerder and I have charged the medical school
dean, as a prelude to this event, to build a stronger
relationship between DOD and NIH, so we bring to bear on our
problems the talent in that institution.
Mrs. Drake. Thank you.
And, Mr. Chairman, I would just like to reiterate what
Chairman Snyder said. If you could tell us if we have a
constituent that is there. I think even just contacting them
and letting them know we know that they were injured and thank
them for what they have done for our country.
Dr. Chu. Thank you, ma'am.
Mr. Larsen [presiding]. Thank you, Ms. Drake.
Actually, I am next in line, so I will--I don't know that I
have a question, but just a comment. Sometimes I show up at
these hearings with a set of questions I really need to ask.
Sometimes I need to come and listen in and hear what I need to
hear and develop some thoughts.
I first just want to underscore Mr. Miller from Florida's
comments earlier about traumatic brain injury, combat traumatic
brain injury. That is something of great importance who have
contacted my office--ensuring that we don't wait too long
before we try to screen some of these folks--not wait till
something shows up. But if, you know, the science needs to
advance faster than it has, let us know what we can do to help
out with that so we can screen faster and catch it sooner.
As you leave at some point today, I do not want you to
think that the morale issue at Walter Reed is a function of
media exposure, okay? It is a function of, from my perspective,
a disastrous and horrendous failure in leadership; not because
it got covered in some newspaper and is being covered all over
the country now. It wouldn't have happened--it wouldn't be
covered unless things weren't getting taken care of. And so I
really have to emphasize that from my perspective.
Let me tell you a fun story, a high school football story.
We got shellacked one game. And we didn't get beat by a lot,
but we had done pretty well all year except this one game. Our
defense--all the gaps showed up, all the weaknesses showed up.
We hung in there, but all the weaknesses showed up. We ended up
losing the game.
And our football coaches asked after the game, he said,
``What do you think of the execution of your defense?'' He
said, ``Well, I think it might be a little too early for that
extreme of an action. We will see how they do next week.''
The point I am making is that--and Dr. Chu, you talked
about execution, how things were done--the execution on this
has been terrible as well. And not just how you have handled it
since it has been covered, but we are here because we need to
ask: Why did this happen in the first place? Why did this occur
in the first place?
Now, Secretary Gates, to his credit, has come down like a
ton of bricks on this issue. And, frankly, I hope he has a few
more tons of bricks to bring on this issue as well--before,
during or after the independent review group is done. Because
this is a problem that is going to--it is costing us now.
But we debate about Iraq. We debate about Afghanistan. If
we lose hearts and minds of the folks who are coming home,
people who are active duty and become veterans, if we lose
hearts and minds of the families because we aren't treating
those folks well when they come home, that is when we lose, in
the minds of the American people, what we are doing overseas.
And that is a great frustration of mine.
If we aren't taking care of these folks when they are
coming home, if we aren't taking care of these folks as active
duty in our military health care system, and then--as they
become veterans--then it doesn't matter how well we do
sometimes overseas, because the people who have fought are
going to be critical of how they were treated when they got
home.
So on the positive side, we want to help improve that. We
have to. We can't be fighting this one 30 years from now. We
can't be fighting how we treated our veterans today 30 years
from now like we are fighting another war 30 years ago because
how we treated veterans then. We got to get it right.
And that is why we are here today. And if we are
frustrated, if I am frustrated, if some of us are frustrated,
it is because we have got enough work ahead of us. We have
enough work ahead of us. We have to get this right.
So with that, I will end my comments.
And Mr. Turner from Ohio.
Mr. Turner. Thank you, Mr. Chairman.
General Schoomaker, General Kiley, as you will recall, I
participated in the Government Reform hearing on Monday at
Walter Reed. General Kiley, at that point you were asked
several questions that were similar to Ms. Sanchez's questions
of how could this happen.
Today you answered, ``We have been busy.'' Monday you
answered--because I wrote it down, and I asked you about it
later, and I asked General Schoomaker--you said, ``The
complexity of the injuries of these soldiers was not fully
realized.''
And my question to you, General Schoomaker, was: Did you
find that an acceptable answer? Because it wasn't an acceptable
answer to me or the Government Reform, Subcommittee of National
Security.
Because I think we could easily have anticipated the type
and level of injuries that were described to us in the hearing
or that were described to the patients. I understand you have
371 outpatient rooms at Walter Reed. That was part of the
testimony on Monday.
And, General Schoomaker, you told me that you were not
aware of General Kiley having made that statement and that you
would check on that statement and what he meant by it and get
back to me.
And now I am back in front of you, and you are back in
front of us, so I would like to know your comments on whether
or not you think that General Kiley's statement is an
acceptable answer of, ``The complexities of these soldiers'
injuries were not fully realized,'' as an answer to how this
could have happened.
General Schoomaker. Well, I am not sure I remember the
context in which this was--as I listened to this, what you just
described, I take it we are talking about the complexity of the
injuries that we are seeing come off the battlefield today.
Mr. Turner. We were asking the question as to how this
could have happened. And just like General Kiley today said to
Congresswoman Sanchez, ``We have been busy,'' his answer on
Monday was, ``The complexities of these soldiers' injuries were
not fully realized.''
And what I asked you on Monday was, it would seem to me and
the other members of the Committee of Government Reform that
when we heard that, that that was not acceptable; that in fact
the injuries could easily be anticipated and the complexity of
their injuries would have been very easily anticipated. And we
asked General Kiley, ``Well, what type of injuries did you
prepare for then, if it wasn't these?''
Because what we saw in that hearing, the three individuals
we had testify, a family member and two soldiers, we had a
machine-gun wound, an explosion and a vehicular accident, which
don't seem to me to be very unexpected in a conflict.
And you indicated when I asked you the question that you
would check with General Kiley about that answer and get back
to me. I wonder what your thoughts were today.
General Schoomaker. My thoughts today are that I think we
are seeing soldiers survive injuries in combat we haven't seen
before. And I think things like TBI and PTSD and the multiple
things that we had, that is the context in which I understood
the question.
Mr. Turner. Okay. They are surviving, though, as a result--
General, they are surviving, though, as a result of the actions
that you have taken and others have taken----
General Schoomaker. That is correct.
Mr. Turner [continuing]. On the battlefield that clearly--I
mean, it is not an unexpected result--if you are taking action
to increase the survivability, certainly your expectation would
be that the medical system would be receiving these individuals
and be required to step to the plate for their care.
General Schoomaker. As a non-medical person, my
understanding is that what we are seeing, though, are injuries
that aren't visible injuries; that we understand differently
today than we understood even two or three years ago in terms
of TBI, PTSD, some of these kinds of things that--yes, soldiers
survive an IED attack and they may not even be wounded in the
typical sense----
Mr. Turner. General, I understand that. My time is just
expiring soon, so I want to ask you--because I asked you that
then. I understand your further explanation of that, that it
has taken a while for you guys to understand what you are going
to be receiving.
But this problem arose in the past couple weeks. It came to
light in the last couple weeks, but it has been ongoing.
So at what point was it--because it wouldn't have been just
when The Washington Post started the article of the difficulty
that soldiers are having. At what point was it that the
complexities of these injuries were fully realized? Because it
wouldn't have been two weeks ago.
General Schoomaker. From my standpoint, I think we have
been learning every day. Every day we learn something
different--I certainly do--in the soldiers that I visit and the
things that I hear on this. And so I don't know. I think it has
been a learning process, a process of adaptation all along.
And, again, I am not a medical professional. I think that
the complexity that I am talking about is the results of
survivability rates and unseen injuries that we are starting to
understand now that are a lot different than anything I have
experienced in my career.
Mr. Turner. Thank you, Mr. Chairman.
The Chairman [presiding]. Thank the gentleman.
Before I call Ms. Shea-Porter, do I understand correctly,
Dr. Winkenwerder, that you must leave? We have three----
Dr. Winkenwerder. Yes, sir----
The Chairman [continuing]. Four members----
Dr. Winkenwerder. Yes, sir. I am going to try to stay
another 15 or so minutes----
The Chairman. I think we will get everybody in if we stick
by the five-minute rule well.
Ms. Shea-Porter.
Ms. Shea-Porter. Thank you, Mr. Chairman.
I have several questions. At first I want to preface those
questions by telling you that I was at Fitzsimons Army Medical
Center with my husband during the 1970's. And it is so
discouraging to see the same kinds of issues and the same
problems and the same surprise that things aren't going so
well.
And I wonder where the breakdown is. And it is hard for me
to buy into any of this, because my feeling is that you know
that these soldiers are going into combat. You know that some
of them are going to have their bodies and their spirits
broken. And who has been looking out for them? And I can't
answer that. And I am going to ask you a couple questions to
see if you could answer that for me.
The first one I wanted to ask was General Kiley, please.
I have it that you said when you did the initial review of
Walter Reed, ``I do not consider Building 18 to be substandard.
We needed to do a better job on some of those rooms, and those
of you that got in today saw that we, frankly, fixed all those
problems. They weren't serious and there weren't a lot of
them.''
Is that accurate?
General Kiley. Well, obviously, the rooms that had the mold
and the holes in them were clearly below standard. And
subsequent to those comments, I have said that.
It is an old building. It requires constant maintenance. We
have failed to do that. So, as an organization, we have failed,
but recognize that and we are fixing that now.
Ms. Shea-Porter. Well, I even want to get past the
buildings, although I do believe that any time you are in
command of anything for anyone, part of your responsibility is
to make sure that you talk to people on the bottom of the rung
and not just on the top, and that you walk around your
facilities and you look for yourselves.
You must never, ever lose that hands-on, have-a-look touch.
Because this is what happens when we do this.
But what about the people in those rooms? Even if the rooms
looked okay to you, at that point, you must have heard
something about the people who were occupying those rooms, and
the problems they were having?
General Kiley. No, ma'am. When I made rounds and talked to
soldiers at Walter Reed, I was never approached that there was
a problem in Building 18--``Hey, sir, you should see my room;
it has mold.'' I would have taken immediate action.
And subsequently to that, talking to soldiers, the ones
that were in those rooms were asking to get those repaired, and
we failed to do that. We screwed that up, and we need to fix
it.
And it is not just Building 18. I take your point. We need
to make sure that is not happening anywhere else in MEDCOM.
Ms. Shea-Porter. Well, you know, when my husband was a
lowly lieutenant, I am not sure that I would have walked up to
a four-star general--although I might have--or a three-star
general or even a colonel and said anything about it. It is
really your responsibility to have a look, instead of expecting
that.
Now I would like to talk to Secretary Chu for a moment,
please.
You are the undersecretary of defense for personnel and
readiness. Did you ever go out to visit any of these
facilities? Have you talked to any of those who have these
brain injuries and other horrific injuries? Who do you depend
on to find out if we are doing what we need to do for these
troops?
Dr. Chu. I depend both on the top and the bottom. Wherever
possible, I do try to visit our various facilities, although I
have not been to Building 18, I should acknowledge. But I also
depend on the Department's various reporting sources to look
at, overall, how are we doing on this front.
And I do think, as several members have said, the clinical
care that the Department delivers to these individuals is
first-rate. And I do think we do want to make sure we thank the
commissions and the clinical staff at places like Walter Reed
for what they are doing.
As General Kiley has testified, the Department did not do a
good enough job in terms of the billeting for these troops. We
accept that responsibility.
We accept the responsibility for the complexity of the
Disability Evaluation System. I think this debate is a terrific
opportunity to reconsider that entire system.
And we are at the beginning stages of doing that. I think
we would like to have a different kind of system for the
future; one that, from the family's perspective, from the
injured's perspective, is simple to use, even if the back
office elements, the statutory foundations, are complex.
Let's let the specialists deal with that; present the
family with a simpler and more easily explained set of choices
so that they understand what their selection might be and how
they might best proceed in the next stages of their lives.
So, yes, ma'am, we do understand that we did not perform
well, in terms of how we cared for some of these troops. We do
set a higher standard for our people. I accept my
responsibility in that regard.
What we are dedicated to is changing the system, changing
the outcomes that we get for these individuals. These are
terrific Americans, and they deserve good outcomes.
Ms. Shea-Porter. I would like to say that I have nothing
but admiration for those clinicians and others who work to help
our troops. And this has absolutely nothing to do with them,
but it really has a lot to do with the leadership right here.
And so I want to ask you again, where have you gone to
visit the troops that are injured?
And do you have plans, now--because you are relying on
layers and layers and layers of bureaucracy, whereas, since it
is your job, how are you going to reach out and actually--I
realize you are very busy, but at some point during the year,
you have to go out and actually talk to a couple of families to
get the stories.
Have you done that, and do you have any plans to do that?
Dr. Chu. When I visit an installation, I make it a point to
visit a barracks, to visit the housing for families, to sit
down, if possible, and have lunch with a few of our soldiers or
sailors or airmen or Marines, or junior officers, whatever the
case might be----
Ms. Shea-Porter. Injured ones--have you gone and----
Dr. Chu. And I have, in my career, ma'am, visited, I think,
every major military medical installation in this Department.
Now, have I done every one in the last week? No, of course
not. But I do make it a point to visit the bottom as well.
Because I agree with you: It is up to us to take a look, on a
random basis, as to how the program is actually working, as the
Navy would phrase it, at the deck-plate level.
Ms. Shea-Porter. Well, I think the only way you are ever
going to really know is to actually talk to those--is that it?
I thank you.
The Chairman. Thank you very much.
Mr. Wilson.
Mr. Wilson. Thank you, Mr. Chairman.
And, Secretaries, Generals, thank you for being here today.
I have actually seen the good. I have visited the casualty
hospital in Baghdad. I have been to Landstuhl, seen the
dedicated people there. I have been to Bethesda, seen the
dedicated personnel. I am really grateful we have the highest
survivability rate in history.
There have been advances in prosthetics that are history-
making. In fact, I have got two sons that were born at Bethesda
National Hospital. So I know the military medical system. But
that makes it even more of a disappointment that people could
fall through the cracks.
The Washington Post article was actually pretty explanatory
that--in terms of a military unit--that there are two
companies, one for active duty and one for reserve components.
And then it is divided into platoons, with sergeants. And,
indeed, I have such faith in the NCOs of our military, it was
described that sergeants know everything about soldiers: vices
and talents, moods and bad habits, even family stresses.
Then I was reading about the military supervisors and case
managers, and that there has been an extraordinary increase in
the number of these. How do the case managers and the sergeants
and the military structure and the civilian structure--how do
they work together, or do they not? Because it seems like
people have fallen through the crack, through this system.
General Kiley. Sir, the relationship between the case
managers and platoon sergeants is an important one. The platoon
sergeants have official military accountability for the
soldiers, know where they are, make sure--or should be making
sure that their health and safety on a day-to-day basis is met
to include the condition of their rooms. And the case managers
worry about the medical conditions, the recovery from medical
conditions, the coordination for examinations and for
appointments.
There is a third piece of this that closes out the episode
of a soldier being at Walter Reed, which is the medical board
process. And in some cases it appears that records have been
lost. That is totally unacceptable--very frustrating, both to
the case managers and the soldiers. And that is a Patient
Administration Division and a Physical Evaluation Board liaison
responsibility.
And all of those are being very vigorously examined under
another AR 15-6 investigation at Walter Reed to try to
determine exactly where the breakdowns were.
It is a very complex process, as I was asked a little
earlier. And working your way through the medical board process
with these complex, multiple, often unseen injuries--TBI,
PTSD--sometimes the PTSD starts to manifest itself a month or
two after some of the other injuries have started to heal. In a
MEB and PEB system that goes back not only to the 1970's, but
to the 1950's, it can be very trying and very daunting for the
soldiers.
Mr. Wilson. And I am glad you brought up about the
paperwork, because that seems to be the next step: how these
different layers of persons work together. But Secretary Chu
has identified the complexity in med boards; I am familiar how
difficult that can be.
I indeed am happy to hear that this is being studied,
because the thought that young people would be lost in some
kind of bureaucratic system----
General Kiley. Yes, sir.
Mr. Wilson [continuing]. For month after month is just
really not at all what we as veterans, as members of Congress,
as parents would anticipate for the treatment of our young
people.
General Kiley. Yes, sir.
And given the complexity of the medical board process, as
the chief has referenced, we have made iterative improvements,
attempted to improve it; for example, designating physicians
whose only job is to do the MEB for soldiers rather than have
10 or 15 or 20 physicians in a facility all trying to figure
out how to do the one medical board they are going to do this
year.
We learned the hard way years ago in this process that that
wasn't working. And so, for example, Walter Reed, there are, I
am told, three and a half fully dedicated physicians in the med
board process. That is the physician piece.
But we have got to keep getting at this. We need to reduce
the paper work. If we could make the entire process an
electronic process, we are looking for these kinds of solutions
right now. No lanes or boundaries on getting this thing fixed.
Mr. Wilson. Well, I, again, just have to tell you that
those of us who so much support our troops and so much support
our military are deeply concerned.
General Kiley. Yes, sir.
Mr. Wilson. We appreciate your efforts very, very much.
And I know we have the best in the world, but we want to
make sure our troops do understand that. I want our families to
understand that.
General Kiley. So do I.
Mr. Wilson. Thank you.
General Kiley. Yes, sir, thank you. So do I.
The Chairman. Doctor.
Dr. Winkenwerder. Yes, sir.
I was just going to say if you would allow--it would be
possible to excuse myself. I am glad to take any question for
me for the record or even call back personally if that would be
better for the member.
The Chairman. We appreciate you being with us. We noticed
you have stretched your deadline 15 minutes, and thank you----
Dr. Winkenwerder. Thank you very much. Thank you.
The Chairman. Mr. Hayes.
Mr. Hayes. Thank you, Mr. Chairman.
General Schoomaker, it pains me a great deal to ask the
following question--a lot of criticism leveled. You have got a
management problem: Should not General Kiley be relieved from
duty because of what has happened here?
General Schoomaker. Well, I will make my recommendations as
appropriate to the authority that has that deal. And I prefer
not to say it here.
As you know, I have officially been recused from dealing
with this because my brother is in the mix. But I can promise
you that this is being investigated, and I can assure you that
the proper action will be taken as a result of this
investigation in terms of accountability.
Mr. Hayes. And, again, that is not a question I want to
ask, but as a manager in the private sector, it all ends up in
my lap.
At Fort Bragg we have a very active town hall, kind of, a
format to air these kinds of concerns. There is a very
aggressive action plan that has been outlined for Walter Reed.
Is that a part of, again, gathering information to make sure
that this doesn't happen?
General Schoomaker. Well, actually, I had a meeting with
other General Schoomaker and General Kiley this week out at
Walter Reed, addressing and listening to what some of their
thoughts are on how to approach this. And that is clearly part
of not only town hall meetings, but selective meetings with
people at various levels in a personal setting to really have
very candid discussions and get their buy-in and understanding
of where we might best improve things.
But I will tell you, it is very distressing to me that with
the amount of direct contact, hundreds and hundreds of visits
all over our medical facilities, from Landstuhl to Brooke to
Walter Reed to Tripler and everywhere out there, talking to
families and talking to soldiers--which I truly believe are
candid discussions where people are not afraid to walk up to a
four-star general, where we are sitting in their room, talking
to families, ``Are you being cared for properly? What are your
concerns? What do you think about things?'' unanimously,
without question, it has been thumbs up on the kind of care
that they are been receiving.
General Schoomaker. Yes, there have been issues that have
been raised, and we fixed them, because they raised the issues.
But to have something like this occur with all of this
truly is a surprise to me, and we are going to find out why.
And when we find out why, we will hold those accountable that
are the problem.
Mr. Hayes. Thank you.
Again, to reiterate, Walter Reed is a premier institution.
The good that has been provided is incredible. My brother-in-
law 35 years ago went there for some--he was a Marine; even let
a Marine in--for serious cancer surgery.
So, again, hopefully we are past the turning point and we
can get back to focusing on care for the soldiers, which is
what we do day-in and day-out.
But, again, I thank you for your efforts, and sorry we are
here. But, as you say, anybody that didn't get the job done,
make sure that that is taken care of.
Mr. Chairman, thank you. I yield back.
The Chairman. Thank you so much.
General Kiley, how many rooms are there in Building 18?
General Kiley. Mr. Chairman, I believe there are 54.
The Chairman. How many rooms are we talking about that are
subject to the inquiry?
General Kiley. Sir, I believe there were a total of seven
rooms that had evidence of mold. Two of them had mold on the
walls. The other four or five had mold around the bathtub and
the sinks. And then there were another 19 or 20 that had some
other issue: They had a leaky faucet, a leaking toilet, a
switch that didn't work, as I understand.
The Chairman. Mice?
General Kiley. Sir?
The Chairman. Mice?
General Kiley. Sir, there had been a problem with some mice
and cockroaches last year, in 2006. This was brought to the
attention of the command at Walter Reed. The preventive
medicine teams went in. They did an assessment of the extent of
it.
The Chairman. Did they assess cockroaches and mice?
General Kiley. Sir, what they did was take a look through
the rooms and take a look at the condition of the building and
determined that they could, one, set mouse traps and roach
traps. They asked----
The Chairman. They catch them all?
General Kiley [continuing]. Asked the soldiers to clean up
any food that might be in their rooms.
The Chairman. Did they catch them all?
General Kiley. Sir?
The Chairman. Did they catch them all?
General Kiley. Sir, as far as I know, they did. They
haven't seen mice, I am told, for months. I think they policed
that up, yes, sir, in an area where you are in a city, urban
area, yes, sir.
The Chairman. What else, besides the mice, cockroaches and
mold?
General Kiley. Well, some leaky toilets, a leaking faucet
here or there, a couple switches that didn't work, as I
understand it. I can take that for the record and give you a
whole list of the findings.
The Chairman. No, no. I just want to know, were complaints
made?
General Kiley. Sir, I believe the process at the time was
that soldiers would make their concerns----
The Chairman. No, no, no. Just answer the question: Were
complaints made?
General Kiley. Yes, sir.
The Chairman. To whom?
General Kiley. To the barracks noncommissioned officer.
The Chairman. And then what happened after that?
General Kiley. He would submit work orders to repair them.
The Chairman. And were they done?
General Kiley. Some were done last year. I am told that up
to 200 of these were fixed over last year. But there were
repair work orders outstanding.
The Chairman. Are there conditions such as this in
hospitals elsewhere in the United States?
General Kiley. Inside the hospitals, it is a challenge with
some of our older facilities.
The Chairman. The answer to your question is yes?
General Kiley. I think it is. Yes, sir.
The Chairman. Now the answer to your question is yes. Would
you then explain where they are, if you know?
General Kiley. Sir, I have to take that for the record. I
have got an SRM project list of things to fix and improve
across all of our hospitals.
[The information referred to can be found in the Appendix
beginning on page 161.]
The Chairman. Right.
Dr. Gingrey.
Dr. Gingrey. Mr. Chairman, thank you.
And I want to thank the witnesses, Secretary Chu, General
Schoomaker, General Kiley. I am sorry that Dr. Winkenwerder had
to leave, but I appreciate you being here for so long.
And, you know, I want to say for the record, Mr. Chairman,
that I have been to Building 18, I have been to Walter Reed on
a number of occasions. But specifically in regard to this issue
I went to take a look firsthand, having grown up in a motel
when I was going to medical school and living in one of the
rooms.
When I saw this old Walter Reed Motor Inn, it really
reminded me a lot, Mr. Chairman, of the motel that my parents
had in Augusta, Georgia. It is not a five-star hotel, make no
mistake about it, but it is not a flop house. It is not a dump.
It is not a dive. It needs some work, no question about it. I
am not making excuses, of course.
And when I read The Washington Post report, I was glad to
know that those cockroaches were belly up. It suggested to me
that at least somebody was spraying for them, Mr. Chairman.
And, of course, if you leave food around in a motel room or
a dorm room at a college, you are going to get some mice to
show up at some point in time.
But there is no question that there is a problem. I have
heard some of my colleagues on both sides of the aisle suggest
that specific heads should roll. I was a little bit shocked,
quite honestly, that the secretary of the Army was relieved of
his command, and the commander at Walter Reed, General
Weightman, was relieved of his command, and a change has been
made there.
I don't know what comes next, but I would guess if you
ask--since General Schoomaker has had to recuse himself--ask
The Washington Post whose head should roll, I think it probably
would be the commander in chief--would be the only
satisfaction. And that would be President Bush.
But here again--and let's try to take the politics aside,
and some of the rhetoric, and try to solve the problem.
As a physician member, I think that we need a lot of things
that would help in regard to, let's say, going to a complete
electronic medical records system, where these soldiers that
are injured, and the families where they have traumatic brain
injury or missing limbs don't have to worry about filling out
22 forms and repeating it four times because somebody has lost
it.
I think the impression that I get--and hopefully I won't
use my entire 5 minutes so you can respond--is that when you
have a soldier recovering, whether he or she is at the Mologne
House on the main campus or just across the street at Walter
Reed Motor Inn, Building 18, and they have no mobility problems
at that point, wherever you have them, if you keep them too
long--and 360 days is too long--at some point they are going to
be so frustrated over a missed appointment or a long queue or
lost paperwork, maybe a little unhappy about adjudicating their
disability claim, either getting back with their troops or
rotating back into civilian life, that they are going to start
noticing the mold and the cobwebs and the dead cockroaches and
the rats. And that is part of the problem.
So I would like to suggest to the witnesses that maybe if
we can move in that direction, we will go a long way toward
solving this problem.
Dr. Chu. Let me speak to----
The Chairman. Does someone have an answer to that--
Secretary?
Dr. Chu. Delighted to, sir.
To the electronic record challenge, that is where we are.
We have deployed--I am sorry Dr. Winkenwerder had to leave
because I think he was very proud of it--we have deployed ALTA,
as I think you are aware, which is an electronic outpatient
record system, worldwide availability, so basically your
records on a server--actually, more than one--and you can call
it up wherever you are.
We have agreed with the Veterans Affairs Department that,
for the future, we should have a common inpatient electronic
record.
We have already started what we call bi-directional
electronic exchange at certain installations, but that is with
the existing systems. And as you appreciate, we have got two
different systems designed from different I.T. perspectives for
the future, which will take some years. I don't want to mislead
you.
We are aiming at a common system for the two enterprises,
which will facilitate the long-term care of those who have
significant injuries.
I take your point about the length of time that is involved
here. I do think part of it is that the Army, specifically,
tries very hard to allow those soldiers who can continue to
serve and wish to continue to serve to recuperate.
And that does take some time, given the nature of these
injuries, as you appreciate--a considerable period of time. And
that may lead to some of the frustrations that you have
described.
And I accept your advice that, if we can find ways to
shorten that, consistent with the medical situation, we would
be importantly advantaged.
General Schoomaker. Mr. Chair, I would like to say just a
couple things here.
First of all, I am no expert at all in the system, but I
have had explained to me--and I have some experience from
previous commands and frustrations--with the length of time it
takes to process people through this MEB/PEB process.
And I think a lot of people get confused at the
recuperation period, which can go on for as much as a year for
some of these soldiers--is not part of the MEB/PEB process.
And it is until the healing is done that the process of
going through the evaluation--there is no use to do it.
If you assume that somebody took an entire year to heal and
then went through the rest of the process as fast as,
administratively, you can go through it, it would take another
180 days.
If they never missed an appointment, never appealed a
decision, never did anything, it would take another 140 days
plus--180 days plus 40 days--so 220 more days on top of the
healing thing.
And I am exactly in your camp. I think that the bureaucracy
and the length of time it takes to go through this thing is a
huge factor in terms of the frustration level and the
opportunity for misunderstanding and all of the stuff that we
are so frustrated about on this.
And I really do believe that we have got to figure out a
way that we can, kind of, multi-task and figure out how to get
this kind of a process to appropriately move at a speed that
protects the soldiers' interests, which is what this is about,
as well as the institution's interests, in terms of reconciling
what they have.
Second, as I said earlier in the hearing, in my opening
statement, I am concerned that we have different public laws
that regulate what DOD does in terms of disability ratings,
which are different--you know, Title 10 is different than Title
38, which the VA goes under. And then I guess Social Security
has got a different one.
And so part of the distrust in the system is the fact that
somebody may get 40 percent in DOD and turn right around and VA
gives them 70 percent.
And so there is a fundamental inconsistency in it that
tends to lead one to believe that there are some shenanigans in
the deal, combined with the frustration of length of time.
So I think, again, as we have been talking about all day,
there is an opportunity here to come down comprehensively and
reconcile this system. Because this is not going to go away. We
are in a long war. We are going to continue to see and learn
more about what we are doing. And we must fix this thing
comprehensively. And I think that is the opportunity we have.
Dr. Gingrey. Mr. Chairman, thank you. You have been most
generous with allowing me extra time, and I really appreciate
your allowing----
The Chairman. I thank the gentleman. Let me follow through
on your inquiry.
Regarding electronic medical records--I am not sure who to
address the question to, probably Dr. Kiley.
General Kiley. I will take a stab at it, Mr. Chairman.
The Chairman. We funded this some years ago. Is that
correct?
General Kiley. Yes, sir. This has actually been going since
1983.
The Chairman. Since when?
General Kiley. Sir, since I was a physician at William
Beaumont, on the hospital information system in 1983, we were
building new prototypes.
The Chairman. The outpatient care has been complete. Am I
correct? Medical records for outpatient care has been complete.
General Kiley. It is close. There are still some modules we
would like to put in, but it is pretty close, yes, Mr.
Chairman.
The Chairman. The inpatient care has just begun----
General Kiley. That is correct.
The Chairman [continuing]. With the exception of some
specialized cases, as I understand it.
General Kiley. There are some specialized----
The Chairman. What in the world has taken so long, since
1983?
General Kiley. Well, sir, that was a prototype back in
1983. I think Dr. Winkenwerder----
The Chairman. When was it funded?
General Kiley. Sir?
The Chairman. When was it fully funded?
General Kiley. I will have to take that for the record. I
don't know. It has been 10 to 12 years, Mr. Chairman----
The Chairman. Dr. Chu, do you know?
Dr. Chu. If I could, Mr. Chairman. This is actually the
second generation. ALTA is the second-generation system the
Department has deployed in this regard.
The Chairman. When was it funded?
Dr. Chu. Over the last several years. I would have to get
you the numbers for the record.
[The information referred to can be found in the Appendix
beginning on page 161.]
The Chairman. Would you be kind enough to do that----
Dr. Chu. Delighted to.
The Chairman [continuing]. As to how much and at what
dates?
Dr. Chu. Yes, sir.
The Chairman. Or at least what years?
Dr. Chu. Yes, sir.
The Chairman. That would help.
Dr. Chu, the other day, during the Navy presentation, the
Navy is proposing to cut an additional 900 medical providers
out in 2008, 100 of which are doctors. And as I understand it,
the Navy medical system is being challenged quite a bit.
At what point was this approved in the Pentagon?
Dr. Chu. Sir, I presume you are referring to the Navy's
military-civilian conversion plan.
The Chairman. No, no, no.
Dr. Chu. I am sorry.
The Chairman. No. It is just old-fashioned Navy--it was
spelled out for us: Navy medical providers.
Dr. Chu. The Navy as a whole is shrinking in terms of
personnel.
The Chairman. We know that. We know that.
Dr. Chu. The Navy medical establishment is taking
significant steps to rebalance its staffing between uniform
personnel and civil personnel; the issue that Congresswoman
Davis raised.
That came out of a broad-scale review for the Department as
a whole as to what is the size of the uniformed establishment
we need to have in order to sustain deployed operations now and
in the future.
But beyond that, I am not familiar with the specific
numbers that you just read.
The Chairman. Those are the Navy numbers that were provided
to us recently.
Without objection, my statement at the beginning, which I
was unable to deliver, will be put--Dr. Kiley, does the Army
inform members of Congress when there is a wounded soldier from
his or her district?
[The prepared statement of Mr. Skelton can be found in the
Appendix on page 67.]
General Kiley. Mr. Chairman, I am going to have to take the
question for the record.
But if my memory serves me, we ask each soldier if they
would like their representative to be notified. And I believe
that we pull a roster together once a week to notify. But I
will have to double-check that; I don't want to go on the
record incorrectly.
The Chairman. We would appreciate that. I know full well
that we are notified if there is a death or a casualty----
General Kiley. Yes, sir.
The Chairman [continuing]. Like that.
Yes?
General Schoomaker. Sir, I believe that there is a weekly
notification made to Congress on soldiers----
The Chairman. On wounding?
General Schoomaker. On wounded soldiers. But the soldier
must agree to have his name----
The Chairman. Oh, I see.
General Kiley. Right. Yes, sir, that is the privacy thing.
The Chairman. Yes, I understand. Thank you.
I might mention, it has been a little while ago, but I was
able to see one of your medical facilities from the inside out.
Congressman Tim Murphy and I were in a vehicle mishap just
outside Baghdad and we were taken by ambulance to the Baghdad
Army hospital, where we received excellent treatment and then
medevaced to Landstuhl hospital.
And I cannot say--I know Congressman Murphy would agree
with me--I cannot say enough good things about the people who
treated us there.
As a matter of fact, with Speaker Pelosi--it has been about
a month ago, Secretary Chu, six of us were in the Middle East.
We came back. But we were at Ramstein and Landstuhl hospital.
And I was able to thank, in an upright position, the four
nurses who were so kind to me there. It is a first-class
facility, and I can't do anything but brag about them.
Dr. Chu. Well, thank you, sir, for saying that. And I know
they deeply appreciate it.
General Kiley. Yes, sir, very much.
The Chairman. And you went by room number seven in the ICU
unit, where I lingered for over three days. [Laughter.]
Well, gentlemen, thank you.
Dr. Gingrey, do you have any further questions?
Thank you so much for being with us.
This is a major challenge for us. I believe there will be a
follow-through hearing at the subcommittee level. That is my
understanding, in visiting with these subcommittee chairmen.
Thank you for being with us. And do your best to fix it.
General Kiley. Yes, sir.
The Chairman. Thank you.
Dr. Chu. Thank you, Mr. Chairman.
General Kiley. Thank you, sir.
[Whereupon, at 1:37 p.m., the committee was adjourned.]
=======================================================================
A P P E N D I X
March 8, 2007
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
March 8, 2007
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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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DOCUMENTS SUBMITTED FOR THE RECORD
March 8, 2007
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[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD
March 8, 2007
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QUESTIONS SUBMITTED BY MR. SKELTON
The Chairman. What else, besides the mice, cockroaches and mold?
Are there conditions such as this in hospitals elsewhere in the United
States?
General Kiley. US Army Medical Command currently lists $183,832,000
of unfinanced requirements for sustainment, repair and maintenance of
medical facilities that directly impact the delivery of healthcare to
Army beneficiaries. These projects are listed in the chart below.
Additionally, Army Medical Command has unfinanced requirements for non-
healthcare delivery projects totaling $42,878,000. Those projects
support medical research, force protection, quality of life, and
preventive and veterinary medicine across the Army.
------------------------------------------------------------------------
Location/ Project Title/
State Installation Description Cost $000
------------------------------------------------------------------------
AZ Yuma Renew Yuma Proving $1,700
Grounds Health
Clinic
------------------------------------------------------------------------
CA Ft. Irwin Renovate ER & Main $1,670
Entrance-Weed ACH
------------------------------------------------------------------------
CA Ft. Irwin Modify Mary Walker $400
Clinic
------------------------------------------------------------------------
CA Monterey Presidio of Monterey $7,500
Health Clinic
Renewal
------------------------------------------------------------------------
CO Ft. Carson Smith Dental $3,000
Transition
------------------------------------------------------------------------
CO Ft. Carson Repair Floor Heaving $7,500
Phase 1
------------------------------------------------------------------------
DC Walter Reed Army Renovate Intensive $2,500
MEDCEN Care Unit
------------------------------------------------------------------------
DC Walter Reed Army Install HVAC return $350
MEDCEN air system
------------------------------------------------------------------------
DC Walter Reed Army Repair Lab Pneumatic $210
MEDCEN Tube System in
------------------------------------------------------------------------
DC Walter Reed Army Repair Non-Compliant $400
MEDCEN Fire Stop/Smoke
Barriers
------------------------------------------------------------------------
DC Walter Reed Army Repair 34 of 38 Hot $950
MEDCEN water converters
------------------------------------------------------------------------
DC Walter Reed Army Upgrade restrooms to $2,540
MEDCEN ADA compliance
------------------------------------------------------------------------
DC Walter Reed Army HVAC Controls and $450
MEDCEN Balancing
------------------------------------------------------------------------
DC Walter Reed Army Signage--Improve $1,200
MEDCEN patient travel in
facility
------------------------------------------------------------------------
DC Walter Reed Army Replace the worn and $120
MEDCEN torn base cove
------------------------------------------------------------------------
DC Walter Reed Army Paint Interior $200
MEDCEN Stairwells and
handrails
------------------------------------------------------------------------
DC Walter Reed Army Modify sprinklers to $275
MEDCEN meet NFPA
Requirements
------------------------------------------------------------------------
DC Walter Reed Army Repair Chiller Plant $1,300
MEDCEN Systems and Valves
------------------------------------------------------------------------
DC Walter Reed Army Bldg. 82, Roof $20
MEDCEN Repair
------------------------------------------------------------------------
DC Walter Reed Army Replace electrical $377
MEDCEN distribution panels
------------------------------------------------------------------------
DC Walter Reed Army Convert Delano Hall $403
MEDCEN to Barracks
------------------------------------------------------------------------
DC Walter Reed Army Modify Soldier $450
MEDCEN Family Assistance
Center/SFAC
------------------------------------------------------------------------
DC Walter Reed Army Emergency Riser in $523
MEDCEN Heaton Pavilion
South
------------------------------------------------------------------------
DC Walter Reed Army Install revolving $250
MEDCEN door to maintain
climate control
------------------------------------------------------------------------
DC Walter Reed Army Repair/Replace Fire $250
MEDCEN Doors/Frames Phase
II
------------------------------------------------------------------------
DC Walter Reed Army Repair Bldg 178 $920
MEDCEN
------------------------------------------------------------------------
GA Ft. Benning Patient Tower $4,500
Perimeter Heating
------------------------------------------------------------------------
GA Ft. Benning Repair Roof, Paint $4,200
Exterior, Replace
Windows
------------------------------------------------------------------------
GA Ft. Benning Replace Operating $450
Room Reheat
------------------------------------------------------------------------
GA Ft. Benning Repair Radioloy Dept $3,300
------------------------------------------------------------------------
GA Ft. Gordon Repair Lightning $500
Protection/
Grounding System
------------------------------------------------------------------------
GA Ft. Gordon Modernize Elevators $449
Building 300
------------------------------------------------------------------------
GA Ft. Stewart Warfighter $2,500
Refractive Eye
Surgery Program
------------------------------------------------------------------------
German Hohenfels Hohenfels Health $604
Clinic Exterior
Repair
------------------------------------------------------------------------
German Illsheim Renovate Illsheim $200
Health Clinic
------------------------------------------------------------------------
German Landstuhl Install direct $1,200
digital control in
Critical Care Tower
------------------------------------------------------------------------
German Landstuhl Renovate Wing 2A/C $2,200
of the Medical
Center
------------------------------------------------------------------------
German Stuttgart Renew Dental Clinic $450
------------------------------------------------------------------------
German Stuttgart Renew Stuttgart $3,750
Dental Clinic
------------------------------------------------------------------------
German Vilseck Dental Clinic $1,050
Interior Repair
------------------------------------------------------------------------
HI Schofield Bldg 681, Repairs $7,300
Barracks and Renovation
------------------------------------------------------------------------
HI Tripler Army Correct boiler $375
MEDCEN deficiencies to
ASME standards
------------------------------------------------------------------------
HI Tripler Army Optimize Optometry $575
MEDCEN Clinic
------------------------------------------------------------------------
HI Tripler Army Optimize Orthopedic $841
MEDCEN Clinic
------------------------------------------------------------------------
HI Tripler Army Bldg 137, Repair $950
MEDCEN Emergency Generator
------------------------------------------------------------------------
HI Tripler Army Bldg 161, Repair $350
MEDCEN Fire Sprinkler
System
------------------------------------------------------------------------
HI Tripler Army Clinic Ergonomics, $680
MEDCEN 10 Areas
------------------------------------------------------------------------
HI Tripler Army Bldg 161, Install $550
MEDCEN Emergency Generator
------------------------------------------------------------------------
HI Tripler Army Expand Pathology lab $1,080
MEDCEN capacity
------------------------------------------------------------------------
HI Tripler Army Combine functions in $1,000
MEDCEN specialty clinics
to reduce need for
additional staff
------------------------------------------------------------------------
HI Tripler Army Renovate Neonatal $700
MEDCEN Intensive Care Unit
------------------------------------------------------------------------
KS Ft. Leavenworth Central Patient $1,000
Records Area
------------------------------------------------------------------------
KS Ft. Leavenworth Physical Therapy/ $4,050
Ortho Add/Alt
------------------------------------------------------------------------
KS Ft. Riley Riley Same Day $11,000
Surgery Clinic
------------------------------------------------------------------------
KY Ft. Campbell Renovate Bldg 2730 $985
to Satellite
Pharmacy
------------------------------------------------------------------------
KY Ft. Campbell Red and Blue Clinic $2,500
Renovations
------------------------------------------------------------------------
KY Ft. Knox Repair Jordan Dental $9,000
Clinic
------------------------------------------------------------------------
KY Ft. Knox Repair deficient $1,000
Sprinkler System
and Standpipe
------------------------------------------------------------------------
LA Ft. Polk Renovate and $8,000
reconfigure
Perioperative
Services
------------------------------------------------------------------------
MD Aberdeen E2100 Renewal-- $99
Electrical
Feasibility Study
------------------------------------------------------------------------
MD Ft. Meade Renew Patholoy Lab $5,000
------------------------------------------------------------------------
MO Ft. Leonard Wood Site Pre for Modular $750
Troop Medical
Clinic
------------------------------------------------------------------------
NC Ft. Bragg Build out Attic $1,700
Space to free up
ward space
------------------------------------------------------------------------
NC Ft. Bragg MASCAL DECON $1,000
Facility
------------------------------------------------------------------------
NC Ft. Bragg EDIS Building $1,000
------------------------------------------------------------------------
OK Ft. Sill Repair Interstitial $404
Lighting
------------------------------------------------------------------------
OK Ft. Sill Repair Bleak Troop $700
Medical Center
------------------------------------------------------------------------
OK Ft. Sill Warehouse/Records $1,300
Conversion for
clinical space
------------------------------------------------------------------------
OK Ft. Sill Allen Dental $6,000
Addition/Alteration
------------------------------------------------------------------------
SC Ft. Jackson Hospital Structural $2,900
Foundation Repair--
East Win
------------------------------------------------------------------------
SC Ft. Jackson Renewal Troop $5,400
Medical Clinic
Optimization
------------------------------------------------------------------------
TX Ft. Bliss Warfighter $3,000
Refractive Eye
Surgery Program
------------------------------------------------------------------------
TX Ft. Bliss Construct Social $700
Work Services
Building
------------------------------------------------------------------------
TX Ft. Bliss Medical Resident $2,800
Village
------------------------------------------------------------------------
TX Ft. Bliss Repair outlying $350
Building Roof on
medical building
------------------------------------------------------------------------
TX Ft. Hood Upgrade Elevators 1- $1209
7
------------------------------------------------------------------------
TX Ft. Hood Replace Emergency $2,900
Generators
------------------------------------------------------------------------
TX Ft. Sam Houston Renew McWethy Troop $2,990
Medical Clinic
------------------------------------------------------------------------
TX Ft. Sam Houston Construct temp admin $3,750
facilities so
hospital can be
used for clinical
requirements
------------------------------------------------------------------------
TX Ft. Sam Houston Hospital Orthopedic $350
Clinic Expansion
------------------------------------------------------------------------
TX Ft. Sam Houston Repair/renovate $7,500
Budge Dental
------------------------------------------------------------------------
VA Ft. Lee Repair 2nd Floor, $1,186
``A'' Wing
------------------------------------------------------------------------
VA Ft. Lee Renew Bull Dental $5,000
Clinic
------------------------------------------------------------------------
VA Ft. Lee Renew Kenner Clinic $5,000
------------------------------------------------------------------------
VA Ft. Lee Site work for $1,800
interim Troop
Medical and Dental
Clinics
------------------------------------------------------------------------
VA Ft. Myer Rader Clinic $3,000
Transition Space
------------------------------------------------------------------------
WA Ft. Lewis Construct LDR #8 for $750
Women's Health
Program
------------------------------------------------------------------------
WA Ft. Lewis Expand Madigan $700
Pediatric Clinic
------------------------------------------------------------------------
WA Ft. Lewis Renew Labor and $600
Delivery area;
recovery area
------------------------------------------------------------------------
WA Ft. Lewis Renovate Wing 2A/C $1,000
of the Medical
Center
------------------------------------------------------------------------
WA Ft. Lewis Renovate Labor & $450
Deliver Nursing
Team Center
------------------------------------------------------------------------
WA Ft. Lewis Addition to Women's $750
Health Clinic
------------------------------------------------------------------------
TOTAL $183,832
------------------------------------------------------------------------
The Chairman. Regarding electronic medical records. We funded this
some years ago. The outpatient care has been complete. Medical records
for outpatient care has been complete. The inpatient care has just
begun with the exception of some specialized cases. What has taken so
long, since 1983? When was it fully funded?
Dr. Chu. Funding for the Armed Forces Health Longitudinal
Technology Application (AHLTA) covering the period fiscal year (FY)
1997 through FY 2013 is $1.9 billion. This funding includes both
acquisition and sustainment costs. The $1.2 billion acquisition costs
of AHLTA include the development, integration, initial procurement, and
deployment of the system. Sustainment costs include activities such as
software maintenance, program management, and information assurance.
This funding chart shows funding by fiscal year covering the period
FY 1997 through FY 2013. AHLTA (formerly known as Composite Health Care
System II) received Milestone Zero Approval in FY 1997. (In other
words, funding to build AHLTA began in FY 1997). Therefore, the FY 1997
through FY 2005 shows actual funds spent on AHLTA by fiscal year.
Each year a budget request (President's Budget) is submitted to
Congress. This budget is the biennial budget submission and covers two
years. However, the Department of Defense (DoD) builds a budget that is
called the Future Years Defense Plan (FYDP). The FYDP for the latest FY
2008 President's Budget covers FY 2006 through FY 2013. The chart shows
the funding budgeted for AHLTA in the FY 2008 President's Budget for FY
2006 through FY 2013.
FY 1997 through FY 2005 reflect actual funds spent and the FY 2006
through FY 2013 reflects the budget request (FY 2006 and FY 2007 are
years that still have active appropriations and therefore are still
considered in the budget submission).
[The chart referred to can be found in the Appendix on page 158.]
______
QUESTIONS SUBMITTED BY MR. ORTIZ
Mr. Ortiz. Do you think that you can give us a list of your worst
facilities so that a group of members here can go see it so that we can
be in a position where we can help you fix those facilities?
General Kiley. At all but one Army installation with Medical
Holdover Soldiers, the Army Installation Management Command is
responsible for the command and control of Medical Holdover Soldiers,
including billeting. The Army Medical Command (MEDCOM) is responsible
for providing healthcare at those installations. The sole exception is
Walter Reed Army Medical Center, where MEDCOM is responsible for both
installation management and healthcare delivery.
From a medical facilities assessment, the hospitals at Fort Knox,
Kentucky, Fort Benning, Georgia, Fort Riley, Kansas, and Fort Hood,
Texas, are all more than 40 years old and have significant
infrastructure concerns. Each of these facilities is in need of
replacement. Tripler Army Medical Center, Hawaii, is also in need of
significant renovation or replacement. In the next few years, the
inpatient tower at Landstuhl Regional Medical Center, Germany, will
need replacement as will the health clinic at Fort Rucker, Alabama.
MEDCOM is able to maintain these facilities in accordance with the
Life Safety Standards of the Joint Commission on Accreditation of
Healthcare Organizations through sustainment, repair and maintenance
funds. However, a long-term strategy within the Medical Military
Construction appropriation is required to ensure Army medical treatment
facilities are capable of supporting the Army into the future.
______
QUESTIONS SUBMITTED BY MR. MCHUGH
Mr. McHugh. As more information comes to light about the widely
publicized problems at Walter Reed Army Medical Center, it appears that
private-public job competition, referred to by many as the ``A-76
process,'' sapped the facility of needed workers at a time when a
demand for their skills, based on inpatient and outpatient population,
was growing. Please provide for me the data in a chart form, that (1)
shows month by month how the numbers of workers on hand in functions
covered by the A-76 process changed over time, and (2) how the WRAMC
inpatient and outpatient (medical hold and medical holdover)
populations changed month to month over the same period. The period I
am interested in begins two months before the A-76 process was
announced and continues through the month when the A-76 contractor was
awarded the contract and ends with the month of January 2007.
General Kiley. The requested data is provided below. It shows that
personnel strength levels remained relatively stable throughout the
competition. It also shows that considerable resources continued to be
devoted to maintenance during the short transition period.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
05 05 06 06 06 06 06 06 06 06 06 06 06 06 07
--------------------------------------------------------------------------------------------------------------------------------------------------------
Med Hold/Med * * * * * * * 667 * * * * 617 640 625
Holdover
--------------------------------------------------------------------------------------------------------------------------------------------------------
BASOPS Staff 296 292 292 289 293 294 294 294 250 244 228 228 232 224 209
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Data not
available
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mr. McHugh. How many other installations involving medical hold and
medical holdovers since 2001 have undergone A-76 competitions? Please
provide me with the same trend data from the time the A-76 was awarded
through the time a contract may have been awarded versus patient
workloads.
General Kiley. Below are the titles and associated sites where the
Army Medical Command has conducted A-76 competitions since 2001. None
of these competitions had any impact on patient care. All but two of
the conversions occurred after the start of Operation Iraqi Freedom.
Unlike the Walter Reed A-76 competition, none of these studies involved
base operations that effected the sustainment, repair, or maintenance
of medical facilities or billeting of patients.
----------------------------------------------------------------------------------------------------------------
Title Affected Site(s) Status Patient Care Impact
----------------------------------------------------------------------------------------------------------------
Automation Riley 3 Sep. 01 Contract Award Pre-OIF
Management
----------------------------------------------------------------------------------------------------------------
Hospital Riley 1 Oct. 01 (Government Start Pre-OIF
Housekeeping Date)
----------------------------------------------------------------------------------------------------------------
Ambulance Polk 1 Nov. 01 Contract Award Pre-OIF
Services
----------------------------------------------------------------------------------------------------------------
Hospital Huachuca 3 Dec. 02 In-House Start Date Pre-OIF
Housekeeping
----------------------------------------------------------------------------------------------------------------
Hospital Benning 19 Dec. 03 Contract Awar332 Soldiers in
Housekeeping Medical
Holdover
----------------------------------------------------------------------------------------------------------------
Base Support Detrick 25 Jan. 04 In-House Start Date No patients
Services
----------------------------------------------------------------------------------------------------------------
______
QUESTIONS SUBMITTED BY DR. SNYDER
Dr. Snyder. How many people today do we think systemwide are in a
medical hold or holdover status?
General Kiley. On March 8, 2007, there were 901 Active Component
Soldiers assigned to Army Medical Treatment Facilities for Medical Hold
Care and 670 attached. There were 1,895 Reserve Component Soldiers
assigned to installation-based Medical Holdover Units and 1,321 Reserve
Component Soldiers assigned to Community Based Healthcare
Organizations.
Dr. Snyder. What is the current case manager ratio, system-wide, in
the Army? What is the current case manager ratio at Walter Reed? What
should the case manager ratio be? And when I asked you before about who
paid the case managers, are they all employees, or are any of those
contracted out?
General Kiley. As of March 8, 2007, US Army Medical Command has one
Case Manager for every 30 Soldiers across the Army. The ratio varies
based on the complexity of patients at any particular location.
Currently, the ratio ranges from 1:18 at Walter Reed Army Medical
Center to 1:36 at smaller community hospitals. This is 116 case
managers for approximately 3,400 Soldiers assigned to Medical Holdover
Units. Community Based Health Care Organizations average one case
manager for every 16 Soldiers (81 case managers for 1,294 Soldiers
assigned). The case manager ratio at Walter Reed Army Medical Center is
one case manager per 17 Soldiers. The total number of case managers
across the Army includes 158 military and 51 civilian case managers.
______
QUESTIONS SUBMITTED BY MR. SMITH
Mr. Smith. I want to hear what you are doing for the challenges for
guard and reserve, particularly on the mental health piece, if they
don't necessarily get the same care, don't have the same community,
making sure that they are drawn in.
I am very interested in electronic medical records. As part of
this, also as you are moving patients around the system, do the records
follow them? Do we have electronic medical records (EMRs) within the
military, so that we are not losing track of records?
And last, just to make it really complicated, how system-wide is
this?
General Kiley. For National Guard Soldiers, the Post-Deployment
Health Reassessment (PDHRA) tool offers both physical and mental well-
being screening. The Army National Guard implementation continues as
states and territories incorporate PDHRA into training schedules. On
average, there are 20 on-site screening teams available each weekend.
Some of the issues facing the PDHRA screening teams include (1)
Geographic dispersion of Soldiers impacts utilization of the teams; (2)
Mobilizations of National Guard units have not maintained unit
integrity resulting in wide dispersal of eligible Soldiers, and (3)
Units do not train on every weekend of every month. The Army National
Guard will continue to focus on on-site events as the primary method to
achieve screening. Call Center processes are being refined to reduce
wait time and increase viability of the screening method. The Army
National Guard is also advocating for an automated method for tracking
referral completion.
For the Army Reserve, there are similar challenges. We determined
that the previous method of contacting Soldiers for 100% PDHRA
screening, via the Call Center, proved less effective than on-site
events. Limited staff availability to schedule PDHRA screening events
was problematic. With the hiring of PDHRA Coordinators and scheduling
more PDHRA on-site events, the Army Reserve projects meeting its goal
of 3,000 monthly screens by March 2007. Funding has been received to
hire a PDHRA Coordinator at each Direct Reporting Command. Monitoring
of mobilization and demobilization dates is being undertaken to
proactively schedule units within the 90-180 day window.
We do have an Electronic Medical Record (EMR) under development
within the Military Health System (MHS). Over the past several years,
the Army, in conjunction with the MHS, has deployed AHLTA, an
outpatient EMR that uses one centralized clinical data repository. By
the end of Fiscal Year 2007, AHLTA will make outpatient medical records
available across MEDCOM and at combat support hospitals in Iraq and
Afghanistan. What the MHS still lacks is an inpatient EMR that enables
the same visibility of inpatient information as AHLTA. We also need to
develop an updated system for pharmacy, laboratory, and radiology
orders and results. These two remaining components are under
development, but still several years away. Until they are complete, the
Composite Health Care System, originally developed and deployed in the
late 1980's remains the backbone of the ancillary and inpatient EMR for
the MHS.
Many of the problems with the Physical Disability Evaluation System
(PDES) discovered at Walter Reed Army Medical Center exist across the
Army. The PDES is clearly an outdated system that does not meet the
21st century needs of the Army or our Soldiers. All too often, this
system places the Soldier in an adversarial position with the medical
and personnel systems. We are working to streamline this system,
improve the Soldier's understanding of the system, and ensure every
Soldier receives a thorough and fair evaluation of their disability.
______
QUESTIONS SUBMITTED BY MR. JONES
Mr. Jones. IAP is the group, the management group, that got the
contract. Do you know anything about them?
When you put this out for private bid, then I assume that the
parameter is anyone that can do the work can bid on the process. Is
that right?
Dr. Chu. There was no decision to ``privatize'' the base support
services at Walter Reed Army Medical Center (WRAMC), nor was there a
pre-decision to ``privatize.'' Privatization is a decision to exit a
business line, terminate an activity, or sell government-owned assets
to the private sector. Public-private competition subjects recurring,
commercial activity type work performed by government personnel to
competition with the private sector to determine if the government or
contractor is the most efficient and cost effective source. The Army
made a decision to conduct such a public-private A-76 competition for
the base support services at WRAMC under OMB Circular A-76 procedures.
The competition was to determine the lowest-cost, technically
acceptable service provider that could provide base support services at
WRAMC.
The public-private competition was for base support services, not
construction. The outcome of the competition was the private sector
offeror, International American Products Worldwide Services, Inc.
(iAP). The timeline for the public-private competition process of the
base support services at WRAMC (functions included all public works-
related functions, hospital logistics--hospital warehouse functions,
and administrative/logistics functions) follows:
May 19, 2000--the United States Army Medical Command Assistant
Chief of Staff for Resource Management notified the Assistant Chief of
Staff for Installation Management that the WRAMC Commander intended to
compete base support services at WRAMC.
June 13, 2000--WRAMC competition began upon Congressional
notification and public announcement.
September 29, 2004--WRAMC made a tentative decision, which provides
due process for affected parties to dispute the outcome (e.g., appeals
and protests).
June 5, 2006--Congressional notification was made via the Final
Decision Report identifying the selected private sector source, iAP.
November 7, 2006--The 90-day transition period (phase-in period)
began.
February 4, 2007--iAP contract performance period (first period of
full performance) began.
International American Products Worldwide Services, Inc. is one of
the largest facility management companies doing business with the
Department of Defense (DoD). iAP purchased Johnson Controls World
Services, which was the successful offeror during the public-private
competition process due to their long and successful history of
competing for DoD contracts to provide base support services.
As part of the acquisition process, under Federal Acquisition
Regulations, Defense Acquisition Regulations, and Army Acquisition
Regulations, private sector offerors are subjected to a source
selection process where a government source Selection Evaluation Team
evaluates them and the Source Selection Authority determines the
lowest-priced, technically qualified private sector offeror to perform
the work. Such competitions are performed in accordance with
regulations, and, when appropriate, OMB Circular A-76. iAP was selected
for the base support services at WRAMC under these regulations.
______
QUESTIONS SUBMITTED BY MR. ANDREWS
Mr. Andrews. My information is that there are 1,055 soldiers Army-
wide who remain in MHO for more than 360 days at this point. I would
like to know how many of them are in the community-based program.
General Kiley. There are 1,134 Reserve Component Soldiers who had
been assigned to installation-based Medical Holdover units and
Community Based Healthcare Organizations for longer 360 days as of
March 8, 2007. 695 of these Soldiers are assigned the Community Based
Healthcare Organizations.
______
QUESTIONS SUBMITTED BY MR. MILLER
Mr. Miller. I'm sure you are familiar with the ICD-9 designation.
It is my understanding that an ICD-9 designation without any
accompanying description medically translates to ``an organic
psychiatric disorder'' and that IED victims who suffer TBI and have
obvious brain damage and neurological issues are given this
designation.
Dr. Winkenwerder. The application of the 9th revision of the
International Classification of Diseases (ICD)-9 codes to a person's
medical situation is an attempt to classify, in a standardized manner,
each of the individual's medical conditions or reasons for seeking
care. Every ICD-9 code is associated with a text description of the
diagnosis. There are no codes without such descriptions. In the context
of traumatic brain injury TBI, there are numerous ICD-9 codes which may
be appropriate for specifying the patient's condition. They include:
310.2 Post-concussion syndrome
800 Fracture of vault of skull
801 Fracture of base of skull
802 Fracture of face bones
803 Other and unqualified skull fractures
804 Multiple fractures involving skull or face with other bones
850 Concussion
Fourth digits from .0 to .5 and .9 specify whether or not there was
loss of consciousness and, if so, the duration of that loss of
consciousness.
851 Cerebral laceration and contusion
852 Subarachnoid, subdural, and extradural hemorrhage, following injury
853 Other and unspecified intracranial hemorrhage following injury
854 Intracranial injury of other and unspecified nature
925 Crushing injury of face, scalp, and neck
959.0 Injury, other and unspecified, of the head, face, and neck
Code 310.2 refers to the presence of impaired mental (i.e.,
intellectual) function following a concussion, not to a psychological
disease. It is a mental disorder, not a psychiatric disorder. The
category 310 as a whole is specifically for ``non-psychotic mental
disorders due to organic brain damage.''
The list of ICD-9 codes above includes those traditionally used for
potential (TBI) cases. They do not cover the full clinical spectrum
such as the non-specific symptoms for which the codes are in the 780.xx
series. Unique codes for military external causes of injury have been
proposed and are being coordinated now with the TRICARE Management
Activity coding office for incorporation into Armed Forces Health
Longitudinal Technology Application and other systems. These codes, if
used consistently and accurately, would add some details and may
improve our ability to study TBI from a clinical perspective.
Mr. Miller. Why would the Army assign a combat wounded TBI patient
with a psychiatric disorder? Can we in Congress help you to create a
new designation specifically for TBI and one that does not carry the
stigma some believe exists with having a ``documented psychiatric
disorder?''
Dr. Winkenwerder. The International Classification of Diseases
(ICD)-9 refers to the 9th revision of the ICD, a system promulgated by
the World Health Organization. It is not a Department of Defense (DoD)
or United States Army system. Changes are made to the disease
classification codes every year, but it takes time and must reflect
international acceptance. Traumatic Brain Injury TBI is a recently
introduced medical term that is not used extensively around the world,
nor is there full agreement in the scientific community regarding
precise definitions for various types of TBI, such as mild, moderate,
or severe. Consequently, at this time, there is no specific ICD code
for TBI. The closest match is ICD-9 code 310.2, entitled ``post-
concussion syndrome.''
In the ICD rubric, this particular code falls under the major
diagnostic classification grouping of ``mental disorders,'' a reference
to dysfunction of the brain from any cause, including organic diseases,
dysfunction due to injury or chemicals, behavioral issues, and various
psychological conditions. Examples of non-psychiatric disorders in the
``mental disorders'' category include mental disorders induced by drugs
(i.e., medications), acute alcohol intoxication, tobacco dependence,
tension headaches, and dyslexia.
Code 310.2 refers to the presence of impaired mental (i.e.,
intellectual) function following a concussion, not to psychological
disease. Combined with the other specific ICD-9 codes that depict the
anatomical extent of head injuries, there should be no stigma
associated with 310.2, any more than with the other mental disorders in
the list above. Accurate coding of an individual with a post-concussive
syndrome (also known as TBI), falls in the mental disorders category of
codes, but it is not a code associated with a psychiatric disorder.
Recognizing the limitations of the ICD-9 system, the DoD developed
a set of militarily unique codes for external causes of injury related
to TBI. This list is in coordination with the TRICARE Management
Activity coding office for incorporation into Armed Forces Health
Longitudinal Technology Application and other systems. These new codes,
if used consistently and accurately, will add some details and should
improve our ability to study TBI from a clinical perspective.
Mr. Miller. Is it true that while waiting for the results of a
medical board, a soldier cannot have any needed surgeries because a
surgery would change his medical status? If so, what are you doing to
remedy this obviously problematic regulation?
Dr. Winkenwerder. A medical board is the process of gathering the
medical testing and evaluation information on a patient that addresses
all of the medical symptoms, concerns, complaints or diagnoses the
patient has. After an analysis of this medical information, the board
decides if the Service member meets medical retention standards.
If a patient develops a new medical problem or has a surgery before
the medical analysis is done, then the medical board process is
interrupted and the new information needs to be completed and added to
the other information.
It is not true that a patient cannot undergo surgery or receive any
other needed medical attention. The health of the patient always comes
first, and the processing time for the medical board will, of
necessity, be extended.
The Department of Defense is working with the Department of
Veterans Affairs to re-evaluate the medical disability evaluation
systems that are currently in place. Even with improvements in
developing a single, overall process, determination of disability
cannot be accurately made until the patient's medical condition is
fully evaluated and is stable.
Mr. Miller. Is it true that all outpatients at Walter Reed are
bureaucratically and administratively transferred from one system or
database to another so that if I were to call the WR switchboard today
and ask for a constituent that is an outpatient, the operator would not
know if that individual was there or not? Can outpatients receive mail
at WR once they are transferred?
Dr. Winkenwerder. As patients are discharged from inpatient status
to outpatient status, the medical center brigade assumes accountability
for them. Walter Reed Army Medical Center (WRAMC) personnel located at
the information desk and other places at WRAMC do not have a personnel
roster or database of outpatients. Outpatients are currently assigned
to the medical center brigade and will soon be assigned to the warrior
transition brigade. Outpatient rosters are maintained by the brigade
and can be made available to the WRAMC personnel. The hospital and
brigade are partnering together for an optimal solution to this issue.
Outpatients do receive mail once they are in-processed to WRAMC.
Our newly approved hospitality services will include a much more
robust information desk and information system for customer service.
Mr. Miller. What is currently in Building 40? What are it's future
plans and do you believe there is a better way to use this building?
Dr. Winkenwerder. Building 40 is the old WRAIR building. This
building has been vacant since 1998. In October 04, HQDA approved and
signed a EUL (Enhanced Use Lease) on this property. The original plan
was to renovate this historic structure to create a modern and
efficient multiple purpose building capable of providing the
Installation adequate and efficient space to support the overall WRAMC
mission. The projected end state was 200,000 square feet of modern
office, or lodging space. The renovation cost was estimated at $62
million, all funded by a private developer. This plan was suspended
after the official BRAC announcement.
Mr. Miller. I'm sure you are familiar with the ICD-9 designation.
It is my understanding that an ICD-9 designation without any
accompanying description medically translates to ``an organic
psychiatric disorder'' and that IED victims who suffer TBI and have
obvious brain damage and neurological issues are given this
designation.
General Kiley. The International Classification of Diseases-9 (ICD)
codes all known diseases. There area wide variety of codes which cover
different types of head trauma. These include fractures, intracranial
injuries, including concussion, and unspecified head injuries. The ICD
codes which cover head trauma are 800.0-801.9, 803.0-804.9, 850-854.1
and 959.0.
It is not true that an ICD-9 designation without any accompanying
description medically translates to ``an organic psychiatric disorder''
and that IED victims who suffer TBI and have obvious brain damage and
neurological issues are given this designation. Those patients'
conditions should be coded according to the correct diagnosis. However,
the term ``organic psychiatric disorders'' covers a wide range of
conditions. Organic psychiatric disorders are those with demonstrable
pathology or etiology, or which arise directly from a medical disorder.
Therefore a patient with traumatic brain injury could present as an
organic psychiatric condition, and could receive several diagnoses.
There are also many separate diagnostic codes for organic psychiatric
disorders. For example, organic psychotic conditions are coded as 290-
294.
Mr. Miller. Why would the Army assign a combat wounded TBI patient
with a psychiatric disorder? Can we in Congress help you to create a
new designation specifically for TBI and one that does not carry the
stigma some believe exists with having a ``documented psychiatric
disorder?''
General Kiley. The primary diagnosis for a combat wounded TBI
patient should be one of the ICD-9 codes specific for head trauma.
These include fractures, intracranial injuries, including concussion,
and unspecified head injuries. However, a patient may also have an
organic psychiatric disorder, psychiatric symptoms related to his or
her injury, or a separate psychiatric disorder. For example: (1) the
head trauma may cause depression directly; (2) they may be very
depressed and anxious over their injuries, or (3) they may have
symptoms of post-traumatic stress disorder or other anxiety unrelated
to their injury.
It is part of the task of the clinician to evaluate, diagnose, and
treat both the patient's physical and psychological wounds. In some
cases, this evaluation may take time as the clinical picture changes.
As the war has progressed and the extent of the head injuries
became more apparent, our clinicians have received more training in
evaluation and diagnosis of mild traumatic brain injury. Certainly a
mild TBI may be confounded with a psychiatric condition. Part of the
current challenge is to ensure that civilian practitioners also receive
training how to perform this evaluation and diagnosis.
Mr. Miller. Is it true that while waiting for the results of a
medical board, a soldier cannot have any needed surgeries because a
surgery would change his medical status? If so, what are you doing to
remedy this obviously problematic regulation?
General Kiley. Clearly, if there is a medical consequence (i.e., a
threat to life, limb or survival) to the timing of the surgery, it will
be done at the right time regardless of the administrative process. In
short, medically-necessary surgeries are always performed even if the
Medical Evaluation Board (MEB)/Physical Evaluation Board (PEB)
processes must be stopped and subsequently reinitiated.
If the surgery is not going to change the ability to meet retention
standards, if it is associated with prolonged rehabilitation, and it
will not change one's functional status, then a thorough medical review
is performed to see which surgeries are ``elective''. An ``elective
surgery'' is defined is one that is not life-or-limb threatening nor
required for survival.
Elective surgeries are not performed during a MEB during which the
fitness for duty determination is begun nor during the PEB which is the
sole forum within the Army to determine a Soldier's unfitness for duty
as a result of a physical impairment.
The MEB's mission is to determine if the physically-impaired
Soldier meets retention standards in accordance with AR 40-501,
Standards of Medical Fitness. The MEB process documents the Solder's
medical history, current physical status and recommended duty
limitations. The Solder's Command prepares a memorandum on the
Commander's position on the Soldier's physical abilities to perform
his/her primary military occupation specialty (PMOS) or officer
specialty (OS). If it is found that the Soldier does not meet retention
standards, the MEB findings are then forwarded to the PEB for
adjudication.
The PEB's underlying mission is to determine whether the Solder can
reasonably perform the duties of his/her primary MOS/OS and grade; and,
if not, to determine the present severity of the Soldier's physical or
mental disability and rate it accordingly.
If the Soldier non-concurs with the decision of the PEB, the case
is forwarded to the Physical Disability Agency (PDA) which may modify
the PEB's findings and recommendations if it concludes that the PEB
made an error.
Mr. Miller. Is it true that all outpatients at Walter Reed are
bureaucratically and administratively transferred from one system or
database to another so that if I were to call the WR switchboard today
and ask for a constituent that is an outpatient, the operator would not
know if that individual was there or not? Can outpatients receive mail
at WR once they are transferred?
General Kiley. As patients are discharged from inpatient status to
outpatient status, the Medical Center Brigade assumes accountability
for them. Walter Reed Army Medical Center (WRAMC) personnel located at
the Information Desk and other places at WRAMC that are called do not
have a personnel roster or database of outpatients. Outpatients are
currently assigned to the Medical Center Brigade and will soon be
assigned to the Warrior Transition Brigade. Outpatient rosters are
maintained by the Brigade and can be made available to the WRAMC
personnel. The Hospital and Brigade are partnering together for an
optimal solution to this issue. Finally, outpatients do receive mail
once they are inprocessed to WRAMC. For the long term, our newly
approved hospitality services will include a much more robust
information desk and information system for customer service. We fully
expect much better information management regarding these issues.
Mr. Miller. What is currently in Building 40? What are it's future
plans and do you believe there is a better way to use this building?
General Kiley. Building 40 is the old WRAIR building. This building
has been vacant since 1998. In October 04, HQDA approved and signed a
EUL (Enhanced Use Lease) on this property. The original plan was to
renovate this historic structure to create a modern and efficient
multiple purpose building capable of providing the Installation
adequate and efficient space to support the overall WRAMC mission. The
projected end state was 200,000 square feet of modern office, or
lodging space. The renovation cost was estimated at $62 million, all
funded by a private developer. This plan was suspended after the
official BRAC announcement.