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



 
                    IMPLEMENTING THE WOUNDED WARRIOR

                   PROVISIONS OF THE NATIONAL DEFENSE

                 AUTHORIZATION ACT FOR FISCAL YEAR 2008

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


                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 11, 2008

                               __________

                           Serial No. 110-91

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio               STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana

                   Malcom A. Shorter, Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             June 11, 2008

                                                                   Page
Implementing the Wounded Warrior Provisions of the National 
  Defense Authorization Act for Fiscal Year 2008.................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    53
Hon. Steve Buyer, Ranking Republican Member......................     3
Hon. Steve Scalise...............................................     1
    Prepared statement of Congressman Scalise....................    55
Hon. Donald J. Cazayoux..........................................     2
Hon. Cliff Stearns...............................................     5
Hon. Stephanie Herseth Sandlin, prepared statement of............    54
Hon. Harry E. Mitchell, prepared statement of....................    54

                               WITNESSES

U.S. Department of Veterans Affairs, Hon. Patrick W. Dunne, RADM, 
  USN (Ret.), Acting Under Secretary for Benefits, and Assistant 
  Secretary for Policy and Planning, Veterans Benefits 
  Administration.................................................    29
    Prepared statement of Admiral Dunne..........................    68
U.S. Department of Defense, Hon. Michael L. Dominguez, Principal 
  Deputy Under Secretary of Defense for Personnel and Readiness..    31
    Prepared statement of Mr. Dominguez..........................    74

                                 ______

Jaycox, Lisa H., Ph.D., Senior Behavioral Scientist/Clinical 
  Psychologist, and Study Co-Director, Invisible Wounds of War 
  Study Team, RAND Corporation...................................     6
    Prepared statement of Dr. Jaycox.............................    56
Tanielian, Terri L., MA, Co-Director, Center for Military Health 
  Policy Research, and Study Co-Director, Invisible Wounds of War 
  Study Team, RAND Corporation...................................     8
    Prepared statement of Ms. Tanielian..........................    61

                       SUBMISSION FOR THE RECORD

Disabled American Veterans, Kerry Baker, Associate National 
  Legislative Director...........................................    79

                   MATERIAL SUBMITTED FOR THE RECORD

Background Letter and Departmental Report:
Hon. David S. C. Chu, Under Secretary of Defense, Personnel and 
  Readiness, U.S. Department of Defense, to Hon. Ike Skelton, 
  Chairman, Committee on Armed Services, letter dated June 9, 
  2008, transmitting the Department's report on ``Administrative 
  Separations Based on Personality Disorder,'' as required by 
  section 597 of the National Defense Authorization Act for 
  Fiscal Year 2008 (A similar letter was sent to the Chairman and 
  Ranking Member of Senate Armed Services Committee.)............    82

Post-Hearing Questions and Responses for the Record:
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Hon. James B. Peake, M.D., Secretary, U.S. Department of 
      Veterans Affairs, letter dated June 19, 2008, and VA 
      responses..................................................    89
    Hon. Bob Filner, Chairman, Committee on Veterans' Affairs, to 
      Hon. Robert M. Gates, Secretary, U.S. Department of 
      Defense, letter dated June 19, 2008, and DoD responses.....    96
    Hon. Steve Buyer, Ranking Republican Member, Committee on 
      Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary, 
      U.S. Department of Veterans Affairs, letter dated June 18, 
      2008, and VA responses.....................................    98
    Hon. Steve Buyer, Ranking Republican Member, Committee on 
      Veterans' Affairs, to Hon. Robert M. Gates, Secretary, U.S. 
      Department of Defense, letter dated June 18, 2008, and DoD 
      responses..................................................   104

Additional Post-Hearing Letters and Departmental Followup 
    Information:
    Hon. Steve Buyer, Ranking Republican Member, Committee on 
      Veterans' Affairs, to Hon. James B. Peake, M.D., Secretary, 
      U.S. Department of Veterans Affairs, letter dated July 16, 
      2008, and response letter dated August 8, 2008.............   113
    Hon. Michael L. Dominguez, Principal Deputy Under Secretary 
      of Defense, Personnel and Readiness, U.S. Department of 
      Defense, to Hon. Bob Filner, Chairman, Committee on 
      Veterans' Affairs, letter dated August 20, 2008, regarding 
      written testimony of Dr. Lisa Jaycox and Terri Tanielian, 
      both from RAND Corporation, on June 11, 2008...............   117
    Call Back Scripts for Both Phases, Care Management Candidate 
      Interview Call Script (Phase 1), and Combat Veteran 
      Interview Script (Phase 2), U.S. Department of Veterans 
      Affairs, April 24, 2008....................................   120
    Status of Congressionally Mandated Requirements for 
      Implementing the Wounded Warrior Provisions of the National 
      Defense Authorization Act 2008, as provided by the U.S. 
      Department of Defense on December 18, 2008.................   129


                    IMPLEMENTING THE WOUNDED WARRIOR



                   PROVISIONS OF THE NATIONAL DEFENSE



                 AUTHORIZATION ACT FOR FISCAL YEAR 2008

                              ----------                              


                        WEDNESDAY, JUNE 11, 2008


                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:21 a.m., in 
Room 334, Cannon House Office Building, Hon. Bob Filner 
[Chairman of the Committee] presiding.
    Present: Representatives Filner, Brown of Florida, Snyder, 
Michaud, Herseth Sandlin, Mitchell, Hall, Hare, Salazar, 
Rodriguez, Donnelly, Space, Walz, Cazayoux, Buyer, Stearns, 
Moran, Brown of South Carolina, Boozman, Brown-Waite, Lamborn, 
Bilirakis, Buchanan, Scalise.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. We are going to open our hearing on 
Implementing the Wounded Warrior Provisions of the National 
Defense Authorization Act (NDAA) for Fiscal Year 2008. The 
Committee will come to order.
    Mr. Scalise, it is customary for the new Members to be 
granted this opportunity to say a few words if you would like. 
We welcome you to our Committee and look forward to your 
participation.

            OPENING STATEMENT OF HON. STEVE SCALISE

    Mr. Scalise. Well, thank you, Chairman Filner and Ranking 
Member Buyer. I appreciate the honor to serve on the Veterans' 
Affairs Committee and as well as my colleague, Mr. Cazayoux, 
who I served on the Legislature with, specifically in the New 
Orleans region.
    All the parishes in my district were adversely affected by 
Hurricane Katrina, but our veterans hospital has been closed 
because of the damage that it took on from Hurricane Katrina. 
And so there are a number of issues I want to work on that 
involve all veterans across the country, but specifically the 
veterans in our region have been dealing with a number of extra 
problems because of the closure of that hospital.
    And looking forward to working through those issues with 
you and the rest of the Members of this Committee. Thank you.
    [The prepared statement of Congressman Scalise appears on
p. 55.]
    The Chairman. Thank you.
    Mr. Cazayoux.

       OPENING STATEMENT OF HON. DONALD J. CAZAYOUX, JR.

    Mr. Cazayoux. Thank you, Mr. Chairman, Members, Ranking 
Member Buyer. I, too, am delighted and honored to be on this 
Committee and look forward to working with each of you to make 
sure that we take care of our veterans in an honorable way and 
make sure that we take responsibility for our men and women as 
they come back from fighting our wars.
    And thank you very much, Mr. Chairman.
    The Chairman. We thank you and we welcome you to the 
Committee.
    I thank the witnesses for being in this hearing. 
Officially, we count that over 33,000 servicemembers have been 
wounded in Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF). I think we all know that due to the improvement 
in both battlefield medicine and incredible evacuation 
procedures and transportation, those who might have died in 
past conflicts are now surviving, many with multiple serious 
injuries such as amputations, traumatic brain injury (TBI) and, 
of course, post traumatic stress disorder (PTSD).
    We have seen a lot of publicity on this and our apparent 
inability to predict all of this and have the resources in 
place to deal with it. We are trying to catch up and do that.
    The Wounded Warrior provisions of the 2008 National Defense 
Authorization Act were intended to do just that. Many of them 
require the U.S. Department of Veterans Affairs (VA) and the 
U.S. Department of Defense (DoD) to collaborate to improve the 
care and management and transition of recovering 
servicemembers. The hearing today will explore the progress 
that the two Departments have made in implementing these 
provisions.
    Thirty-two warrior transition units have been established 
in the Army to try to improve care management. Injured soldiers 
are now assigned a primary care manager, nurse case manager, 
and a squad leader to guide them to their recovery.
    The rapid creation of these units appears to be a success. 
However, according to the U.S. Government Accountability Office 
(GAO), several challenges remain including hiring sufficient 
medical staff in a very competitive market, replacing 
temporarily borrowed personnel with permanent staff, and 
getting eligible servicemembers into those units.
    In December of last year, the VA, in cooperation with DoD 
and the U.S. Department of Health and Human Services (HHS), 
established the Federal Recovery Coordinator (FRC) Program to 
coordinate clinical and nonclinical care for severely injured 
and ill servicemembers.
    As of May of this year, there were only six field staff 
members working with the 85 patients at three sites. I want to 
look today at how effective this program has been and how it 
will be expanded to benefit more of our veterans.
    As these veterans transition from the military health 
system to the VA system, they face the difficulty of navigating 
through two different and cumbersome disability evaluation 
systems. The current system is a source of stress and 
frustration for many veterans.
    Last November, both DoD and VA jointly initiated a 1-year 
pilot program to evaluate a streamlined evaluation system. I 
hope they will be able to expand this program and today we will 
hear how that is going.
    We all know that PTSD and TBI are considered to be the 
Doctor, signature injuries of this war.
    According to a RAND Corporation report that came out in 
April, nearly 300,000 veterans of Afghanistan and Iraq are 
suffering from PTSD or major depression. Nearly 20 percent, 
according to the RAND figures and which, I think is a low 
number, reported a probable traumatic brain injury during 
deployment.
    By the way, compare the 300,000 estimate, which again I 
think is low, with the official casualty number of 33,000 and 
there is not just a minor discrepancy between the two figures. 
I think we are going to ask the Pentagon to deal with these 
casualty figures in far more realistic terms, and we want to 
get your thoughts on that.
    As we will hear, many veterans are not getting the care 
they need and deserve. Only 43 percent of those reporting 
probable TBI have been evaluated by a physician for brain 
injury. And only half of those who meet the criteria for PTSD 
or major depression sought help from a physician or mental 
health provider. This is simply not acceptable and we have to 
do better.
    Again, last year, the Department of Defense established a 
Center of Excellence for psychological health and traumatic 
brain injury and I want to see how the VA and DoD are working 
together to conduct research in these areas and develop best 
practices.
    Certainly an important component to improve continuity of 
care is development of an interoperable electronic health 
record, which would allow for the seamless transfer of medical 
information between the two Departments.
    I think we have made some significant progress toward 
improving care and transition, but a lot of work needs to be 
done and that is what this hearing is about today. We look 
forward to an informative hearing.
    Our first panel is from the RAND Corporation. Terri 
Tanielian and Lisa Jaycox will begin the discussion and then we 
will hear from the Department of Defense and Department of 
Veterans Affairs.
    I want to say, before we start our hearing, that no matter 
where we stand on the war, we are united in saying that every 
man or woman that comes back from the war should get all the 
healthcare--the seamless healthcare--that they need and the 
benefits they have earned.
    I will yield to Mr. Buyer, the Ranking Member, for his 
opening statement and any quick comments from the rest of our 
Members.
    [The prepared statement of Chairman Filner appears on p. 
53.]

             OPENING STATEMENT OF HON. STEVE BUYER

    Mr. Buyer. Mr. Chairman, I want to thank the witnesses for 
being here today to discuss the implementation of the Wounded 
Warrior provisions of the 2008 Defense Bill.
    As you recall, these provisions, many of which were adopted 
in the Defense bill I drafted, received good input from Mr. 
Stearns and Mr. Miller, Mr. Brown, Mr. Boozman, along with Mr. 
Michaud, Stephanie Herseth Sandlin, and, once again, we leaned 
on Dr. Snyder for his good work with the Defense Bill.
    And, Mr. Chairman, you were also very supportive and spoke 
in support of them at the conference last year. So I want to 
thank you for your assistance.
    I also am very cognizant. One thing I have learned about 
you, Mr. Chairman, and myself, is that sometimes we are not 
very patient and we are eager to get out there and be 
aggressive. And I want to thank you. That is what you are 
trying to do here. But when we put these together, we put in 
progress reports for a reason.
    I almost cannot help but sense we are a month early with 
the hearing. I know that you are really eager to move out here, 
but there are eight DoD progress reports that were set forth in 
the Defense Bill.
    Section 16 of the Bill required GAO to provide an 
assessment of the implementation of the Wounded Warrior 
provisions 6 months after enactment. Since that deadline is 
next month, the GAO is unable to provide this assessment 
because it has only recently begun its review of the 
implementation provisions and it would not have been able to 
provide an in-depth analysis for the Committee.
    GAO did indicate that based on the initial assessment, VA 
and DoD have not finalized a policy nor have they begun 
implementation of many aspects of the Defense Bill's mandates.
    While this is of concern, I feel that it is really 
premature at this point to criticize the Departments' progress 
based on incomplete information submitted before the benchmark 
requirement.
    Therefore, my counsel during this hearing will be that the 
Wounded Warrior provisions must be implemented with a sense of 
urgency.
    Sixteen months have passed since the Washington Post news 
story revealed some of the instances of inadequate housing of 
soldiers at the Walter Reed Army Medical Center. While that 
moment was infamy for some, this Committee has had a 
longstanding concern that the current DoD and VA disability 
systems fail to provide a seamless transition, especially for 
those enduring the military's discharge process.
    Over the past 15 years, one commission and a task force 
report after another has called for measures to streamline the 
transition process, but such changes have not been implemented.
    Therefore, I was pleased that this year's Defense Bill 
contained these provisions that we had worked on together. That 
amendment in particular we were able to focus on the use of the 
uniform separation exam, an evaluation that VA could use for 
rating decisions.
    The electronic DD-214 is something we had talked about for 
years and I am glad they are finally moving toward that, the 
real-time access to the veteran's medical history by requiring 
electronic exchange of critical medical information between DoD 
and VA. The need for this electronic exchange of medical 
records was amplified during my many visits. And I am sure, Mr. 
Chairman, as you too are around, you see that necessity.
    While at Landstuhl, I had witnessed patients being 
transferred from the battlefield with the paper medical files 
taped to their chests and I was appalled that was being done.
    Now, obviously things were being done in transition of air 
medivac, but, you know, we talk about getting to the electronic 
medical record. We still have a long way to go.
    So, Mr. Chairman, I think what we are going to have to do 
is perhaps we are going to do this hearing and we are going to 
have to come back again in maybe September and have another one 
of these hearings keeping the pressure on, I guess, is what I 
am going to ask of you. And I think that is what you have done 
here by moving out here today. But we are going to need to come 
back and hold them to the timelines on their progress reports 
would be my counsel to you, Mr. Chairman.
    The Chairman. Thank you, Mr. Buyer.
    I will say that we are in the 6th year of the second 
longest war in American history and we are way too late on 
these things--not too early.
    Does anybody want to add any comments before we begin?
    Mr. Stearns.

            OPENING STATEMENT OF HON. CLIFF STEARNS

    Mr. Stearns. Mr. Chairman, thank you.
    As a Member from Florida with my other colleagues, we have 
a lot of veterans coming back from the war into Florida. It is 
one of the largest and fastest-growing veterans populations in 
the country.
    And I think, Mr. Chairman, as you pointed out, it is 
traumatic brain injury, if a veteran suffers from that, that in 
turn could create a high incidence of post traumatic stress 
disorder. So obviously Members want to know what is being done.
    I understand Title 17 of the ``Wounded Warriors Act'' 
specifically requires the Secretary of the VA to develop an 
individualized plan to help rehabilitate and reintegrate back 
into our community servicemembers who have received care at the 
VA for TBI.
    The Act also requires the VA to assign a case member for 
each veteran suffering from TBI while also explicitly stating 
the family members of the veteran with TBI should be involved 
in the development of this individualized plan. This is good. I 
would like to obviously hear how that is progressing.
    Just as a side note, Mr. Chairman, if, in fact, a person 
suffers from traumatic brain injury and this causes post 
traumatic stress disorder, if we could, through a blood test 
immediately administered on the field of battle or after the 
veteran comes back, through a blood test determine if there is 
this traumatic brain injury, that would indeed give us insight 
immediately on how to care for these individuals.
    There is a company in my congressional district called 
Banyon Biomarkers that we have helped fund for many years to 
develop this blood test, and they are on the cusp now of making 
this into a product that the military could carry into battle 
and actually test the blood samples of an individual to see if 
they have traumatic brain injury. And that in turn would give 
us a head start on post traumatic stress disorder.
    And I say that. I am obviously bragging about this company. 
We have funded it over the last 6, 7 years. And there are real 
possibilities, Mr. Chairman and my colleagues, that this will 
be made into a quantitative case and not into a qualitative 
case where we are trying to understand the veteran who comes 
back to fill out forms and things like that.
    But we need this urgently to be able to help the veteran 
even though perhaps he feels there is no problem. But this 
blood test is on the cusp of being made into a device that can 
be manufactured.
    So I look forward to the hearing. And I think as I pointed 
out in Title 17, the VA has a heavy responsibility to 
reintegrate these individuals and to help the family members 
develop this individual plan. So I look forward to the hearing.
    And thank you, Mr. Chairman.
    The Chairman. Thank you.
    We will start with the first panel. Lisa Jaycox is a Senior 
Behavioral Scientist and Terri Tanielian is a Senior Social 
Research Analyst with the RAND Corporation. They will discuss 
their recent report called ``The Invisible Wounds of War,'' 
which I think is an important contribution to our understanding 
of the issues.
    Dr. Jaycox will focus on the key findings on psychological 
cognitive injuries and Ms. Tanielian will focus on the 
recommendations for addressing these injuries.
    You are welcome to start. Thank you.

    STATEMENTS OF LISA H. JAYCOX, PH.D., SENIOR BEHAVIORAL 
    SCIENTIST/CLINICAL PSYCHOLOGIST, AND STUDY CO-DIRECTOR, 
INVISIBLE WOUNDS OF WAR STUDY TEAM, RAND CORPORATION; AND TERRI 
   L. TANIELIAN, MA, CO-DIRECTOR, CENTER FOR MILITARY HEALTH 
POLICY RESEARCH, AND STUDY CO-DIRECTOR, INVISIBLE WOUNDS OF WAR 
                  STUDY TEAM, RAND CORPORATION

               STATEMENT OF LISA H. JAYCOX, PH.D.

    Dr. Jaycox. Thank you, Chairman Filner, Representative 
Buyer, and distinguished Members of the Committee, thank you 
for inviting us here today to present on the RAND study, 
Invisible Wounds of War. It is an honor to be here.
    My testimony will present the results of the study which 
was conducted independently of the DoD and VA and takes a broad 
perspective on three consequences of war: post traumatic stress 
disorder or PTSD; depression; and traumatic brain injury or TBI 
among servicemembers returning from Iraq and Afghanistan.
    My colleague, Terri Tanielian, will follow with 
recommendations for addressing these conditions.
    Since October of 2001, approximately 1.6 million U.S. 
troops have deployed to these theaters at a pace unprecedented 
in the history of the all volunteer force.
    Advances in both medical technology and body armor mean 
that more servicemembers are surviving their combat experience. 
However, casualties of a different kind are beginning to 
emerge, invisible wounds such as mental health and cognitive 
impairments resulting from deployment experiences.
    First, I will discuss our findings relative to PTSD and 
depression. Our telephone survey representing all previously 
deployed individuals found substantial rates of mental health 
problems in the past 30 days with 14 percent screening positive 
for PTSD and 14 percent for major depression.
    Some specific groups previously under-studied including the 
Reserve components and those who have left military service may 
be at higher risk of suffering from these conditions, but the 
single best predictor of PTSD and depression is the number of 
combat traumas experienced while deployed.
    Only about half of those with current PTSD or major 
depression had sought help for a mental health problem in the 
past year and only about half of those that sought care 
received minimally adequate treatment. The number who received 
quality care would be even smaller.
    Many barriers inhibit veterans from getting help for their 
mental health problems including concerns about treatment 
leading to negative career repercussions and also concern that 
treatment might not be effective.
    Unless treated, both PTSD and depression have wide-ranging 
and negative implications that affect work, family, and social 
functioning including substance abuse, homelessness, and 
suicide. Thus, early intervention is needed to help stem this 
cascade of negative consequences.
    In dollar terms, the cost associated with PTSD and 
depression are substantial. We estimated costs incurred within 
the first 2 years after servicemembers return home to range 
from $4 to $6 billion.
    Our cost model assumes the status quo in which the minority 
of individuals with PTSD and depression actually get treatment 
and the minority of that care is acceptable quality of care. If 
we assume high-quality care goes to every person with PTSD or 
depression, we see that by increasing treatment costs, the 
societal costs are reduced by as much as $2 billion in just 2 
years.
    For active-duty personnel in particular, personal and 
cultural factors impede the use of services as do structural 
aspects of services such as wait times and availability of 
providers.
    We identified gaps in organizational tools and incentives 
that would support the delivery of high-quality mental 
healthcare to the active-duty population and to retired 
military who use TRICARE.
    The VA provides a promising model for the DoD in quality 
improvement in mental healthcare. However, it faces challenges 
in providing access to veterans, many of whom have difficulty 
securing appointments, particularly in facilities that have 
been resourced primarily to meet the needs of older veterans.
    Improving access to mental healthcare for veterans will 
require reaching beyond the DoD and VA healthcare systems, but 
it will be essential to ensure quality care in these systems.
    I am now going to turn to our results regarding TBI or 
traumatic brain injury. In our survey, we found 19 percent 
reported a probable TBI during deployment, although we do not 
know the severity of that injury or whether the injury caused 
functional impairment. Of those reporting probable TBI while 
deployed, 57 percent had not been evaluated by a physician for 
brain injury.
    In dollar terms, we estimate 1 year cost for mild TBI or 
concussion to be about $30,000 largely due to productivity 
losses. In contrast, for moderate to severe cases, costs are 
about ten times higher and are due mostly to mortality costs.
    The medical science for treating combat-related TBI is in 
its infancy. Research is urgently needed to develop effective 
screening tools as well as to document what treatment and 
rehabilitation will be most effective.
    In terms of the service systems for mild TBI, we found gaps 
in access to services stemming from poor documentation of blast 
exposures and failure to identify individuals with probable 
TBI. Servicemembers with more severe injuries face a different 
kind of access gap, lack of coordination across the continuum 
of care.
    Thank you for the opportunity to testify today and share 
our results. Additional research results are available in my 
written testimony and also available at veterans.rand.org. 
Thank you.
    [The prepared statement of Dr. Jaycox appears on p. 56.]
    The Chairman. Thank you very much.
    Ms. Tanielian.

              STATEMENT OF TERRI L. TANIELIAN, MA

    Ms. Tanielian. Chairman Filner, Representative Buyer, and 
distinguished Members of the Committee. Thank you for inviting 
me to testify today. It is an honor and pleasure to be here.
    My testimony will briefly discuss several recommendations 
for addressing the psychological and cognitive injuries among 
servicemembers returning from Afghanistan and Iraq.
    The purpose of these recommendations is to close the gaps 
in access and quality for our Nation's veterans that Dr. Jaycox 
described.
    Our report offers four recommendations that would improve 
the understanding and treatment of PTSD, depression, and TBI 
among combat veterans.
    First, our report recommends an increase in the number of 
providers who are trained and certified to deliver proven or 
what we call evidence-based care. There is a substantial unmet 
need for treatment of PTSD and depression among military 
servicemembers following deployment.
    Both DoD and the VA have had difficulty in recruiting and 
retaining appropriately trained mental health professionals to 
fill existing or new slots. With the possibility of more than 
300,000 new cases of mental health conditions among Iraq and 
Afghanistan vets, a commensurate increase in treatment capacity 
is needed.
    Since there is already an increased need for services, the 
expansion of trained providers is already several years 
overdue. With an existing shortage of mental health 
professionals in the U.S. healthcare system more broadly, this 
has become a critical pipeline issue.
    Such investment could be facilitated by several strategies 
including adjusting financial reimbursement for providers to 
offer appropriate compensation and incentives, developing 
certification processes to document the qualifications of 
providers, and establishing regional training centers for joint 
training of DoD, VA, and civilian providers in evidence-based 
care for PTSD and depression.
    Our second recommendation is to change policies that would 
encourage active-duty personnel and veterans to seek needed 
care. Many servicemembers are reluctant to seek services for 
fear of negative career repercussions. Policies must be changed 
so that there are no perceived or real adverse career 
consequences for individuals who seek treatment except when 
functional impairment compromises fitness for duty.
    Such policies will require creating new ways for 
servicemembers and veterans to obtain treatments that are 
confidential, off the record, off base, and during off-duty 
hours. Currently information about being in treatment is 
available to command staff even though treatment itself is not 
a sign of dysfunction or poor job performance, providing an 
option for confidential treatment has the potential to increase 
total force readiness by encouraging individuals to seek 
healthcare before problems accrue to a critical level.
    Third, to close the gap in quality, our study recommends 
delivering evidence-based care to servicemembers and veterans 
wherever and whenever they are served. Treatments for PTSD and 
depression vary substantially in their effectiveness and while 
the most effective treatments are being delivered in some 
sectors of the care system for military personnel and veterans, 
system-wide implementation remains a problem.
    Delivery of evidence-based care to all veterans with PTSD 
or depression would pay for itself or even save money by 
improving productivity and reducing medical and mortality costs 
within only 2 years.
    The VA is at the forefront of trying to ensure that 
evidence-based care is delivered to all of its patients, but it 
has yet to evaluate its success at these efforts across the 
entire system nor will the VA serve all veterans.
    Transformations are required to achieve the needed 
improvement in quality of care for our veterans. For example, 
providers delivering treatments to veterans must be held 
accountable for the services they are providing.
    TRICARE and the VA could require that all patients be 
treated by therapists who are certified to handle the diagnosed 
disorders of that patient and use varying payment systems to 
incentivize the delivery of evidence-based care. Monitoring 
systems should also be used to ensure quality and coordination 
of care.
    Our final recommendation calls for investing in research to 
close information gaps and plan effectively for the future. 
Better understanding is needed of the full range of problems 
that confront individuals with post-combat PTSD, depression, 
and TBI. Greater knowledge is also needed to understand who is 
at risk for developing mental health problems and who is most 
vulnerable to relapse.
    At the same time, policymakers need to be able to 
accurately measure the costs and benefits of different 
treatment options so that fiscally responsible investments in 
care can be made. A coordinated Federal research agenda on 
these issues within the veterans population is sorely needed.
    Such a program would likely require resources in excess of 
that currently devoted to PTSD and TBI through DoD and the VA 
and could extend to the National Institutes of Health (NIH), 
the Substance Abuse and Mental Health Services Administration, 
the Centers for Disease Control and Prevention, and the Agency 
for Healthcare Research and Quality.
    Addressing PTSD and depression as well as TBI among those 
deployed to Afghanistan and Iraq should be a national priority, 
but it is not an easy undertaking. The prevalence of these 
injuries is relatively high and may grow as these conflicts 
continue. And the long-term consequences associated with these 
injuries if left untreated without evidence-based care can be 
severe.
    The systems of care available to address these conditions 
have been improved significantly, but critical gaps remain. 
System-level changes across the entire U.S. healthcare system 
are essential if the Nation is to meet not only its 
responsibility to recruit, prepare, and sustain a military 
force but also its responsibility to address service-connected 
injuries and disabilities.
    Thank you again for the opportunity to testify today and to 
share our research findings and recommendations.
    [The prepared statement of Ms. Tanielian appears on p. 61.]
    The Chairman. Thank you both very much.
    Mr. Snyder, if you have any questions, you are recognized.
    Mr. Snyder. Is it Tanielian? Am I saying that right? The 
issue of training, you are very clear multiple times in here 
talking about evidence-based treatment and that people need to 
be trained in that.
    If I today decided to quit this job and I wanted to become 
that kind of a trainer, where would I go and how long would it 
take me?
    Ms. Tanielian. That is an excellent question. And we 
recommend actually that regional training centers be developed 
that would offer this type of training in evidence-based care. 
Currently, availability of such training is sparse in different 
locations around the country and we would need additional 
training centers.
    I would also ask Dr. Jaycox who is trained in some of these 
evidence-based therapies to comment.
    Dr. Jaycox. I think one part of your question is who can be 
trained. And normally some degree of clinical training be 
before you get training in evidence-based treatments is 
required.
    But that does not necessarily mean just psychiatrists and 
psychologists. Social workers, marriage and family therapists, 
etc., there are many different people with degrees who would be 
ready to take up this kind of training.
    And the DoD is rolling out a number of training programs 
among and providers within their systems. So there is, you 
know, a number of different efforts to bring these kinds of 
treatments into both the DoD settings and the VA.
    Mr. Snyder. Is not one of the problems there, I mean, my 
impression is we have a lack of general mental health providers 
in this country anyway already, right? Do you agree with that?
    Dr. Jaycox. Yes.
    Mr. Snyder. And so if what we are talking about is trying 
to take this pool that we think is inadequate for the country 
and get some of them to take additional training at these 
regional training centers and these specific treatment 
modalities for PTSD and the depression and the kind of thing 
you are talking about, we are still going to have the same 
shortage of providers; are we not?
    Ms. Tanielian. We have a current shortage of providers in 
the U.S. mental healthcare system. That is why we identified 
this as a pipeline issue. We do need to think about the 
pipeline of individuals going into mental health professions as 
well as those paraprofessionals that Dr. Jaycox described and 
how they could be trained as well in these particular types of 
approaches.
    We need to think broadly because we need a large investment 
to get the required expansion as soon as possible.
    Mr. Snyder. One of the issues that comes up sometimes is 
that there is an interest to meet this need and having probably 
people with quite limited mental health treatment background, 
you know, but who may be veterans themselves or have been in 
combat themselves.
    I do not see anywhere in your writing that you are 
suggesting that we omit step one which is some basic background 
and education and clinical experience in providing treatment to 
patients and folks with mental health issues.
    Would you elaborate on that?
    Ms. Tanielian. Yes, I agree that there needs to be some 
baseline clinical training, but there are also roles for other 
types of people in the treatment process. We know that support 
and help with transitions is extremely important for reducing 
PTSD and depression symptoms.
    So, for instance, in the Vet Centers, that role of helping 
people work out their financial problems, their employment 
problems, their family problems is important as well.
    And in addition, there are some new models that integrate 
care, for instance in primary care, where the primary care 
physician can serve as sort of the point of contact that then 
would help decide, which patients need to go into the more 
intensive psychotherapy approaches, for instance.
    And the primary care physicians can be trained to deliver 
the medications with psychiatric consult so that individuals 
would not have to see a psychiatrist directly, but could also 
work with their primary care physician.
    Mr. Snyder. One of the things that happens, it seems to me, 
in mental health services is a person goes to see, and you 
talked about this, I think, Ms. Tanielian, a person goes to see 
their mental health provider. They spend time with them. Then 
they come out with their slip that says counseling or just 
something, and I think it is deliberate, you do not know what 
happened in the room.
    The problem is, it seems, is that part of the issue that 
makes it difficult to evaluate what has been effective or not 
effective or if the person is being paid, Federal dollars is 
providing the kind of what you call evidence-based therapy.
    Would you comment on that?
    Ms. Tanielian. Absolutely. Our healthcare system is 
designed on a reimbursement system that only asks providers to 
record the number of minutes that they saw the patients.
    Our analyses suggests that we need to break down the black 
box of what is happening in these sessions and require 
accountability so it would be more informative for both 
evaluating the types of care that are being delivered as well 
as incentivizing the delivery of evidence-based care, to 
understand what types of therapies or treatments are being 
delivered in that 30, 45, or 90 minute session.
    Mr. Snyder. Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Snyder.
    Mr. Stearns.
    Mr. Stearns. Thank you, Mr. Chairman.
    Just to put this in perspective, how many, and this is a 
question each of you can answer separately, how many, if any, 
of your recommendations were already addressed in the Wounded 
Warrior provisions of Public Law 110-181? Start with you.
    Dr. Jaycox. You know, our report is complementary to the 
Wounded Warrior provisions in that we are focusing on 
depression, PTSD, and----
    Mr. Stearns. No. But that is not the question. The question 
is, how many of the Wounded Warrior provisions of these 
recommendations are already being done?
    Dr. Jaycox. Those really focus on the severely wounded 
individuals so that it is a different system of care that we 
are looking at, by and large, except for in terms of moderate 
to severe TBI. So I do not have an exact answer for you.
    Mr. Stearns. Do you?
    Ms. Tanielian. It is an excellent question. I think that we 
could look a little bit more closely at the specific provisions 
in the legislation and provide you with a more detailed 
response about the exact overlap.
    We are suggesting that the issues for raising the level of 
quality of care that is provided really extend beyond the DoD 
and the VA and go across the entire U.S. healthcare system in 
terms of the pipeline issues for providers who are going into 
these professions as well as the systems that would need to be 
in place to ensure appropriate quality in terms of the 
evidence-based care that is being delivered to the veterans.
    Mr. Stearns. So you are also talking about the private 
sector too?
    Ms. Tanielian. Absolutely. A number of veterans will be 
seeking care outside of the DoD and the VA healthcare systems 
in the private sector as well as the publicly funded healthcare 
sector.
    Mr. Stearns. Maybe it is difficult for you to answer. But 
if you took the VA, the DoD, and the private sector and if you 
could rank them into a professional opinion in terms of the 
quality of mental healthcare and traumatic brain injury care 
provided services, is the private sector way ahead of the DoD? 
I mean, if you took VA and DoD and the private sector, could 
you give me sort of a ranking here or just a feel for this?
    Dr. Jaycox. I will give you my opinion on that.
    Mr. Stearns. Yes. Just your personal opinion after you have 
done this.
    Dr. Jaycox. Yes.
    Mr. Stearns. You are the analyst and you are the experts.
    Dr. Jaycox. As we said earlier, the VA is really at the 
forefront for monitoring quality and rolling out----
    Mr. Stearns. The VA is ahead of the private sector?
    Dr. Jaycox. Yes.
    Mr. Stearns. And ahead of DoD?
    Dr. Jaycox. Yes, in that it is both conscientiously 
monitoring and trying to enhance quality both for PTSD and 
depression. The DoD is rolling out a lot of programs, but is 
not yet monitoring the quality of those programs. And the 
civilian sector, I would say, is behind both of them.
    Mr. Stearns. Is that your opinion also that the Veterans 
Administration is way ahead of the private sector as well as 
DoD?
    Ms. Tanielian. Yes. The VA has a number of tools in place 
that they are using already, as Dr. Jaycox described, to 
increase the level of evidence-based care that is delivered to 
its patients as well as to monitor and incentivize the delivery 
of that type of care.
    The DoD also has similar tools that they are now able to 
roll out. The civilian sector, while there are some models out 
there, for decades, the veterans healthcare systems as well as 
the military health systems have led the field, particularly 
around the treatment of PTSD.
    Mr. Stearns. You probably heard my opening statement in 
which Banyan Biomarkers, which is affiliated with the 
University of Florida, which I represent, has done research to 
identify in the battlefield from a blood test whether there is 
traumatic brain injury.
    Have you ever heard of that or have you been aware of that 
kind of advancement?
    Dr. Jaycox. I am not aware of that, but we really focused 
on post-deployment PTSD, TBI and depression, so not during 
deployment.
    Mr. Stearns. What does RAND define as minimally adequate 
care for mental health conditions? Do the different policies 
and procedures among the services and the VA impact the 
delivery of mental healthcare and TBI care? If so, in what way? 
And does Public Law 110-181 address any of these issues?
    Dr. Jaycox. We talked about the definition of minimally 
adequate care. First, we defined it in a way that is similar to 
the way researchers are doing so in the civilian sector and 
that is that if people reported having counseling or 
psychotherapy that they have at least eight sessions of 
psychotherapy that lasted at least 30 minutes each in the last 
year.
    So really it is just talking about an amount of time in 
therapy. And for medication that you visited a doctor at least 
four times and stayed on the medication as long as your doctor 
wanted you to.
    So, again, it is sort of a dose of therapy rather than just 
talking about the specific type of therapy or the type of 
medication provided.
    Mr. Stearns. Anything you would like to add?
    Ms. Tanielian. No, thank you.
    Mr. Stearns. Okay. Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Stearns.
    We will now hear from the Chairman of our Health 
Subcommittee, Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Doctor, you had mentioned, I believe at the beginning of 
your remarks that societal costs actually could go down by as 
much as $2 billion if they received treatment earlier.
    Is that for the veteran themselves or does that include 
their families, the cost to society because of the families 
affected as well?
    Dr. Jaycox. Thank you for letting me elaborate a little bit 
on that.
    The costs in our model included lost productivity at work, 
so both presenteeism and absenteeism, being able to function 
less well on the job, lives lost to suicide, and treatment 
costs, that is direct treatment costs.
    We were not able to factor in things that we know exist 
like difficulty with family members, divorce, substance use 
because there are not good dollar figures to attach to those 
and in order to be able to put them as assumptions into the 
model.
    So really the gains with treatment have to do with 
increased productivity at work and fewer suicides. Productivity 
is the biggest cost driver for both PTSD and depression.
    Mr. Michaud. Do those figures include, for example, if 
someone comes back who has PTSD, which ultimately might lead to 
alcoholism or drug abuse and incarceration, is the cost of 
incarceration put onto the county or State?
    Is the cost of incarceration incorporated in that as well?
    Dr. Jaycox. No. So that kind of cost is not incorporated, 
just work productivity, suicide, and treatment costs. And they 
are very conservative estimates because, as you point out, 
there are many other costs that we are aware of.
    Mr. Michaud. Okay. You mentioned that the VA does a better 
job compared to the DoD as well as in the private sector.
    What do you attribute that to? Do you attribute it to the 
VA does not have to worry about cost reimbursement and they can 
do a better job?
    Ms. Tanielian. It is not necessarily that it is about 
reimbursement, rather it is that there has been an investment 
in research as well as in training and rolling out evidence-
based practice guidelines to train providers in the delivery of 
evidence-based care as well as the use of tools that they have 
within the system, such as the electronic medical record that 
would enable them to kind of monitor care.
    Mr. Michaud. You had mentioned that there were actually 
regional training teams, facilities where you can actually 
train.
    Where are those located? And the second part of that 
question is, if you look at the demographics of our military 
today, I believe 40 percent are from rural areas, and do you 
see a disparity between urban versus rural in getting the help 
that individual military or veterans need?
    Ms. Tanielian. Sure. We recommend the establishment of 
regional training centers to train providers in this type of 
care. It is not that they exist already.
    And there is a lot of variation in accessibility of care 
between urban and rural areas. Those that may be further away 
from military installations and VA healthcare facilities will 
have greater difficulty in getting services in those types of 
settings and will turn to their community-based setting and 
sector for care.
    And that is why civilian providers would also need to be 
trained in delivering evidence-based therapy as well as be 
trained in the military culture and being sensitive to the 
special issues in treating military servicemembers and 
veterans.
    Mr. Michaud. And where would you suggest that these 
facilities be located when you look at the demographics of our 
veterans?
    Dr. Jaycox. That is a great question. We are hoping to do 
some further work on that. And I think there is some work 
underway also to actually map out where servicemembers and 
veterans are and where the facilities are and figure out the 
areas of need. But we did not analyze that in this report.
    Mr. Michaud. And my last question is, when you look at the 
Department of Defense and you look at the VA system and what is 
happening out there in the private sector, there definitely is 
a shortage of healthcare professionals.
    Have you looked at, and it would probably be hard to judge, 
but right now when you look at the war as it continues on, 
there is definitely a need in DoD for those type of healthcare 
professionals as well as in the VA system, but as the war winds 
down, there will probably be less need in DoD but more need 
actually in the VA system? Have you looked how those two can 
kind of meld together to work more cooperatively?
    Ms. Tanielian. That is a critical kind of study that would 
need to be done. We were not able to examine the data that 
would be required to look at that and project demand over time 
and to look at the capacity that would be required in 5, 10 
years and where that capacity would be best placed.
    We have heard anecdotally that there is a shifting of 
providers from our community-based mental health sectors to 
either the DoD or VA now because they are hiring. And so we are 
taking providers from what is a shortage area already. And so 
that is why we identify this as a major pipeline issue for the 
entire U.S. healthcare system.
    Mr. Michaud. Thank you very much. Appreciate it.
    The Chairman. Thank you.
    Mr. Boozman, you are recognized.
    Mr. Boozman. Thank you very much.
    I was wondering. You talked about evidence-based care as in 
contrast to what? Will you discuss, you know, some of the 
things that are going on that you are concerned about versus 
the evidence-based care?
    Dr. Jaycox. Well, we contrast it with the usual care, which 
is not necessarily a bad thing, but does not have the higher 
recovery rates that we find with evidence-based care. And to be 
frank, we do not know exactly what is going on in usual care. 
There have been some studies of it, but it is more diffuse 
supportive type of therapy without using the specific 
techniques that we know to be effective.
    We have a whole section in our report that discusses the 
evidence-based care for PTSD, depression, and TBI and compares 
it with--gives a level of evidence for the DoD and VA 
guidelines for healthcare for those conditions.
    And so really when we talk about evidence-based care, we 
are talking about offering the best that we know is available 
which offers higher recovery rates, but is not perfect either.
    Mr. Boozman. You mentioned, I think, 18\1/2\ percent PTSD 
and depression. How is that in contrast to just the general 
service, the people that have not deployed or do you have any 
figures as far as what that represents?
    Dr. Jaycox. We used similar measures to what have been used 
in other studies, but we do not have good estimates for the 
nondeployed population.
    I can tell you in our sample, everyone had been deployed, 
but we had a group of people who had not been exposed to any 
combat exposures while deployed, so no experiences of loss or 
traumatic events.
    And we found very low rates of PTSD and depression there. 
One percent for PTSD and three percent for depression. So that 
gives you an idea.
    Mr. Boozman. Okay. I guess I think it probably is important 
to find that out and then, too, just the general population, 
you know, what kind of depression.
    Ms. Tanielian. Sure. In the general civilian population, 
about 7 percent will experience depression in a year and only 
about 3\1/2\ percent will experience PTSD in a year.
    Mr. Boozman. The other problem that you mentioned was, you 
know, people not reporting, you know, the fact that they were 
having a problem.
    Can you talk to us about specific things that you feel like 
we can do a better job of?
    Dr. Jaycox. Sure. We asked servicemembers what would get in 
the way of getting treatment and, as we mentioned, three of the 
top five barriers had to do with concerns about negative 
repercussions on career, security clearance----
    Mr. Boozman. And, yet, I think you also said that the rate 
of reporting was about the same as the general population.
    Dr. Jaycox. The rate of reporting, that service use was 
about the same as in the general population?
    Mr. Boozman. Yes.
    Dr. Jaycox. Yes. That is true. We do have difficulty 
getting individuals with mental health problems in the civilian 
sector into care as well.
    Here, though, the types of barriers are very different. In 
the civilian population, it really has to do more with access 
and here everybody has access to some type of care. And it is 
really about concern around negative career repercussions. So 
that was a striking difference.
    Mr. Boozman. Good. Thank you very much, Mr. Chairman. I 
yield back.
    Thank you for your testimony.
    The Chairman. Thank you.
    Mr. Snyder. Mr. Chairman, that report, we do not have that.
    The Chairman. Mr. Snyder would like to look at that book if 
you would not mind passing it around. And if he does not pay 
for it, we will get him for it. Thank you.
    Mr. Mitchell. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman.
    I just have two questions. Ms. Tanielian, you mentioned in 
your testimony that slightly more than half of those that are 
suffering from PTSD and depression are receiving minimally 
adequate care.
    Can you describe what you mean by that and also what are 
the long-term effects of the inadequate care? What might they 
be and what are we looking at here?
    Ms. Tanielian. Sure. Only about half of those who had 
sought care from a professional in the past year received what 
we define as minimally adequate care, which really was about 
the amount of time they spent in either therapy or the number 
of times that they visited the doctor.
    So if they were getting medications, it was four visits to 
a physician in the past year and taking the medication as long 
as they were recommended to. If they were in therapy or 
counseling, it was visiting a therapist for at least eight 
visits of 30 minutes in duration.
    So this is really just a minimum dose of therapy. Without 
treatment or with under-treatment, we know that there are long-
term negative consequences associated with having PTSD, 
depression, and TBI including impairments in relationship, 
homelessness, increased risk for suicide, problems with 
employment, et cetera.
    Mr. Hare. So what kind of care? I mean, okay, we know what 
minimum care here is, minimally. So what would you advocate for 
that?
    Ms. Tanielian. We are recommending that veterans and 
servicemembers, wherever they are treated, wherever, in 
whichever sector, they be offered the latest evidence-based 
therapies, treatments that have been demonstrated through 
research to yield higher recovery rates. So faster recovery as 
well as more time without symptoms.
    Mr. Hare. Okay. And, Dr. Jaycox, just a quick question for 
you. How could both the VA and the DoD improve the methods for 
identifying and bringing in soldiers who may be suffering from 
PTSD, major depression, or TBI to improve their care?
    Dr. Jaycox. That is a really good question. There are a 
number of screening efforts underway. Unfortunately, you know, 
there is some concern that servicemembers and veterans do not 
want a PTSD or depression diagnosis on the record in their 
personnel file.
    And so it is tricky to figure out a way to screen them in a 
way that will benefit them and get them into care without the 
concerns about negative career repercussions.
    I think the more that the military can do to encourage 
care, to make it acceptable and seen as a sign of strength to 
receive mental health treatment post deployment, the more 
servicemembers would be willing to seek out those services and 
admit to symptoms when they are screened.
    Mr. Hare. The Chairman has advocated for a long time, and I 
completely agree with him, that we ought to be screening 
everybody so that person does not have to identify themselves 
as having a problem and then there is the whether or not it is 
going to affect whether or not they are going to be able to 
advance in rank or whether it is going to affect them in their 
jobs.
    So would you concur that what we should be looking at doing 
is screening everybody that comes back with no exceptions and 
also then monitoring them for a longer period of time because a 
lot of times, as I understand it, and I have a Vet Center close 
to my Congressional district office, a lot of this does not 
just happen in a matter of weeks or months? It could be down 
the road. Plus, you know these are things that affect not just 
the service person but their entire family.
    Dr. Jaycox. There are mandatory screenings post deployment 
and now 3 to 6 months after return, but those, again, are 
imperfect in that servicemembers might not be willing to admit 
to symptoms when screened.
    But I agree that long-term follow-up is necessary. Research 
is necessary to follow individuals over time and track and see 
how they are doing and particularly around traumatic brain 
injury where we know so little about the functional impairment, 
the long-term course, and the types of treatments that are 
needed, that there really is a strong need to identify and 
follow individuals over time.
    Mr. Hare. How long would you recommend we monitor?
    Dr. Jaycox. I think it needs to be a long-term study. We 
are still seeing Vietnam veterans who are having new diagnoses 
of PTSD and they are in their sixties, fifties and sixties. So 
I think we need to be ready to monitor them for a very long 
time.
    Mr. Hare. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Moran.
    Mr. Moran. Mr. Chairman, thank you.
    In regard to PTSD, are there studies that demonstrate a 
cause and effect that certain circumstances that a member of 
the military encounters are more likely to cause symptoms of 
PTSD or other mental health issues?
    And the reason I ask this question is, can we get to the 
point in which we know a cause for the symptoms so that we can 
attempt to eliminate the cause? Are there studies that show 
number of deployments, length of deployment, or physical or 
mental issues, characteristics of a particular individual cause 
a greater propensity to encounter PTSD?
    Dr. Jaycox. We were able to look at that in our study. We 
have data on the kinds of experiences they had, number of 
deployments, length of deployments. And we found a number of 
predictors of heightened risk for PTSD and depression including 
enlisted versus officers, Marines and Army versus Navy and Air 
Force. Women and Hispanics are at higher risk in our data. We 
also have Reserves and those who have left military service as 
higher risk.
    Length of deployment is related, but the single best 
predictor is the number of combat traumas experienced. So if 
you control for everything together, really it is that that 
drives the rates of PTSD and depression.
    Combat trauma is a very common experience. We only had 
about 10 or 15 percent in our sample who have not experienced 
anything like that while deployed. Particularly in these 
conflicts, it is quite common to be exposed to an explosion or 
have a life-threatening situation regardless of whether you 
have combat-duty military occupational skills or not.
    Mr. Moran. And because of unwillingness to report or lack 
of statistics, are those studies scientifically based? Is there 
valid, sufficient data to reach those conclusions?
    Dr. Jaycox. Well, we believe our study is. It has been 
subject to a fair amount of peer review and is able for the 
first time to kind of look across the different sectors. Many 
of the prior studies focus on one combat unit, for instance, at 
a particular point in time and ours is a cross-section of a 
wide variety of individuals who have been deployed.
    So that offers something new. And also we were able to 
promise complete confidentiality to everyone we interviewed, so 
it is unlinked to any personnel records.
    Mr. Moran. Are these traumas that are the most common 
denominator, are they things that are experienced by everyone? 
That is not the right word. Are they experiences that are 
common in military service such that they could not be 
eliminated and it is just part of military service, so you 
could not eliminate that to eliminate PTSD and depression?
    Dr. Jaycox. Yes. The most common are things like having a 
friend seriously wounded or injured or killed, witnessing an 
accident or life-threatening event, personally experiencing 
those types of events. So they are part of military experience.
    Mr. Moran. For events that are more controllable, is there 
a causal relationship to PTSD and depression?
    Dr. Jaycox. We did not see that.
    Mr. Moran. Okay. And in regard to your review of where we 
are, structurally how we deliver services, and you may have 
answered this question with Mr. Michaud's question, is there a 
differential in services available and quantitatively and 
qualitatively in rural versus other settings? Are we short-
changing rural veterans?
    Ms. Tanielian. There is wide variability in the 
accessibility of services across the country in each of these 
systems. We do know that those that have a harder time getting 
access to military installations or VA facilities will turn to 
community-based providers where they could also get care down 
the street.
    And so there may be a more difficult time for veterans in 
rural areas to find providers that have been trained in the 
evidence-based approaches by either the DoD or the VA.
    Mr. Moran. My time is 30 seconds from expiring, but this is 
one of the issues that I want to explore further. I have had 
several meetings.
    In Kansas, we have mental health centers that are really 
the public sector providing mental health services. And they 
tell me that they have the willingness and the desire to treat 
veterans but have no particular relationship with the VA.
    And so just structurally, I want to see how we combine the 
Department of Veterans Affairs and their outpatient clinics, 
their hospital settings and Vet Centers with the community-
based services that are really what we have in rural America.
    There is no Vet Center, no VA hospital in the Congressional 
district I represent. There are community mental health centers 
and, yet, they would like the opportunity to better avail 
themselves in cooperating with the VA. And if you have thoughts 
about that, I would be glad to hear from you aside from this 
setting.
    Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. If I could just clarify what Mr. Moran 
stated. Were there any controllable things, Doctor, I know you 
had said no, but you also said earlier that length of 
deployment and number of tours is controllable, right?
    Dr. Jaycox. Yes. But those are not predictive of PTSD or 
depression once you control for it. It is the combat traumas 
that are the largest predictor.
    The Chairman. And, of course, you will join me in the 
ultimate control, which would be ending the war.
    Ms. Herseth Sandlin.
    Ms. Herseth Sandlin. Thank you, Mr. Chairman.
    I would actually like to hear your response to Mr. Moran's 
question. I represent the entire State of South Dakota and we 
have vast rural areas. And I recently was in Aberdeen, South 
Dakota in the northeastern part of the state visiting a 
Community Based Outpatient Clinic (CBOC) where a local 
psychiatrist has entered into a contract with the CBOC.
    And you both had good things to say about what the VA is 
doing and I certainly agree, but did you specifically look at 
the outreach to the rural veterans through the community-based 
outpatient clinics?
    I do agree with Mr. Moran that whether we have CBOCs or 
medical centers, we also have community mental health centers 
that are, I think, ready and willing to work with the VA.
    Could you specifically talk about any analysis you did with 
the CBOCs?
    Ms. Tanielian. We did not do any specific analysis with the 
CBOCs. However, mental health clinics as well as private 
providers in our community settings, do provide another avenue 
for veterans to get care.
    And our recommendations would call for ensuring that even 
those providers be trained in delivering evidence-based care so 
that wherever our Nation's veterans seek care, they can be 
afforded the best care available.
    Ms. Herseth Sandlin. And that is consistent with what I 
have heard from veterans as well and veterans service 
organizations, that concern that there is some specific 
training if indeed we are looking to contract with people 
outside of the VA system to provide that level of care.
    A couple of other areas I would like to follow-up on based 
on your response to earlier questions. Could you discuss why 
women are at greater risk for PTSD and if there are any 
different barriers to women veterans getting access to care 
than what you found in the maybe five different barriers you 
had referenced earlier?
    Dr. Jaycox. Yes. Women are more at risk for PTSD and 
depression nationally. They are more likely to develop those 
and there are many different theories about why that might be, 
but it is not specific to the military life.
    In terms of specific differences in barriers and such, we 
have not broken it out that way. Women only comprise about 14 
percent of the military force and in our sample, that is the 
same. So we are not able to really break out the numbers.
    We would like to look at that. It is a very important 
question to look at the specific kinds of traumas they 
experienced in addition to whether or not they experienced 
military sexual trauma, for instance. But we have not done that 
in this study.
    Ms. Herseth Sandlin. Well, I appreciate your desire to want 
to look at that closer. Ms. Brown-Waite and I have introduced a 
bill specifically working with the Disabled American Veterans 
and others to address the issues of barriers to access to 
healthcare across-the-board for women veterans. So we hope to 
continue to get more information not only in the provisions and 
our legislation that we hope to advance but also in the work 
that RAND and others will be doing.
    One other question as it relates to the avoidance issues 
and the stigma that we know continues to exist as it relates to 
servicemembers and, you know, the civilian public as a whole 
seeking access to mental healthcare.
    One of your recommendations is to ``change policies to 
encourage active-duty personnel and veterans to seek needed 
care.'' So the VA has done a terrific job trying to get a grasp 
of this problem. The DoD is rolling out these programs.
    But what specifically? Can you talk a little bit more about 
your recommendations as to, you know, who carries what level of 
responsibility to seek the care and do the outreach to 
veterans, to get them across these avoidance issues not just in 
the initial access to the care but then, as you mentioned, 
Doctor, admitting to the symptoms during the treatment?
    Ms. Tanielian. Sure. We know that stigma is a problem in 
the general population. But for military servicemembers, active 
duty in particular, concerns about the impact that getting 
mental healthcare may have on their career were paramount in 
terms of the barriers to getting healthcare.
    So required disclosures about getting mental health 
counseling or service, policies that require that you report 
mental health counseling would be those that could be amended 
such that there would be no perceived or real adverse career 
consequences associated with getting mental healthcare.
    Ms. Herseth Sandlin. Dr. Jaycox, anything to add?
    Dr. Jaycox. I just would add that there is a concern about 
the large number of people who have separated from the military 
but have not yet crossed into the VA and that is to that 
population that the VA is doing outreach efforts, but it is 
kind of unclear who is responsible for them. They may be 
seeking care from a variety of different sectors and we need to 
worry about how to draw them into care more effectively.
    Ms. Herseth Sandlin. That is a good point. And one of the 
things that we have been working on with our Subcommittee and 
the full Committee is sort of that group that separated from 
service.
    You know, they also are now qualified for those in the 
National Guard and Reserve that separated for education 
benefits based on their deployment. They may not even know they 
have those education benefits because we are not able to easily 
connect with them.
    But certainly I think that the State Adjutants General and 
some of our States have developed good working relationships in 
which we are trying to share best practices to be able to not 
lose track of these veterans and allow them to fall through the 
cracks as we know that they have.
    And so, again, we appreciate your testimony and your 
recommendations.
    The Chairman. Thank you.
    I want to assure you and other Members we are going to 
devote significant chunks of time to the two issues you raised. 
The first is access for rural veterans and the second is 
specifically, care for women veterans. We are going to do a 
series of field hearings and also hearings here in DC. So those 
are two important areas.
    I appreciate your leadership, Ms. Herseth Sandlin.
    Mr. Buyer.
    Mr. Buyer. Thank you, Mr. Chairman.
    What I have in front of me is last year's Defense Bill and 
the Wounded Warrior provisions that we worked on with the 
Senate and with the Armed Services Committees of the House and 
the Senate.
    In Section 1618, we have asked that the Secretaries of both 
of these Departments work together to develop a joint plan. And 
they are going to get that to us in July.
    Now, part of this joint planning between the two 
Departments, what we wanted to focus in on is prevention, 
diagnosis, mitigation, treatment, and rehabilitation of and the 
research on traumatic brain injury, post traumatic stress 
disorder, and other mental health conditions in members of the 
Armed Forces including planning for seamless transition of such 
members from care through the Department of Defense and care 
through to the VA.
    Then we asked for a comprehensive plan. We wanted the 
assessment of current capabilities, the identification of gaps 
in current capabilities, and then the identification of the 
resources.
    Then we went with specificity and identified twelve 
elements that we also were looking for. So we went in with 
great specificity because we want to be able to be responsive 
then to what you have referred to as one of the leaders then in 
mental health and the delivery of these services.
    Now, while this is going on, you then have conducted your 
own piece of research. So part of today's hearing is about 
implementation not of this, of what you have done, but of this, 
what we have done.
    So what you can be very helpful here to us is by saying, 
okay, based on your research in this and what we have done in 
the Defense Bill, are we on the right track? That is my 
question to you.
    Ms. Tanielian. I would say that I think we are on the right 
track. I think the increased attention and the investment in 
improving the services and the programs that are available in 
both the DoD and the VA with specific focus on PTSD, TBI, and 
depression will bring about positive change to improving the 
care systems for these populations.
    Mr. Buyer. So in your review, what we are doing, will this 
address the gaps in services that you have identified in your 
study?
    Ms. Tanielian. It will address the gaps in services within 
the DoD and the VA. There are gaps that extend beyond these two 
healthcare systems. There is a pipeline issue for the training 
of providers that go into these particular professions. It 
extends well beyond these two agencies. There are also concerns 
about the quality of care that is provided in the civilian 
sector and in these community-based settings as well.
    And so one of our major conclusions is that these issues 
extend beyond the DoD and the VA and will require 
transformation and system-level changes across the entire U.S. 
healthcare system.
    Mr. Buyer. I agree with you. It is one of the reasons we 
wanted to focus on the case manager because we learned quickly 
that the case manager was becoming the individual that was in 
close proximity to the wounded servicemember. Could have been a 
wife, husband, or it could have been a father. You know, it is 
someone who is probably outside the medical profession. They 
are trying to figure out how do they best manage that 
particular person's health.
    And we have, whether it is into the DoD, the polytrauma 
center, back to DoD, to TRICARE, then upon discharge, VA and 
whether it was a medical discharge or not a medical discharge 
and now they are out of the private sector, maybe on contract-
based care, whether it was an approved provider.
    I mean, you get into all these complexities and so I can 
understand those challenges in the subacute care system for us 
to be able to deliver the care that not only does that 
servicemember believe but also the close loved one also 
believe.
    And so that case manager, Mr. Chairman, you know, becomes 
that patient advocate and that is extremely important.
    So I appreciate that in your testimony.
    Earlier you had mentioned about how, and you were 
absolutely right, whenever you throw out a number, you also 
invite scrutiny. So all of a sudden, this number, 300,000, 
since you had interviewed or took a survey of 1,965 
servicemembers from 24 communities across the country, it 
appears that from this that you have concluded that 300,000 of 
the 1.6 million who served in Iraq and Afghanistan then have 
symptoms of post traumatic stress disorder or major depression.
    The 300,000, is that a possibility or a fact?
    Dr. Jaycox. That is a possibility. That is an estimate 
based on our numbers. We were able to use state-of-the-art 
statistical techniques----
    Mr. Buyer. All right. Let----
    Dr. Jaycox [continuing]. To weight our sample to the 
deployed population.
    Mr. Buyer. All right. And when you were doing your 
sampling, obviously you were talking to servicemembers.
    Dr. Jaycox. Yes.
    Mr. Buyer. And the servicemembers when you would ask them a 
question, are you depressed or do you have post traumatic 
stress disorder or TBI, were these, when they would say I have 
either of those, is this a self-diagnosis or is this actually 
my doctor says I have?
    Dr. Jaycox. It is neither of those. We actually assess all 
the symptoms. So we ask them have you had trouble sleeping in 
the past 30 days, have you had nightmares, all of those 
questions that then----
    Mr. Buyer. So you are being the doctor over the phone?
    Dr. Jaycox. Well, there are standard surveys that are used 
that map very well on to a clinical diagnosis. So we used ones 
with good psychometric properties that map on to a clinician 
diagnosis with reasonable probability.
    Mr. Buyer. Wow. I yield back.
    The Chairman. Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    And thank you both for being here and tackling this tough 
issue.
    I think the Ranking Member brought up a very valid point on 
this issue of case manager or patient advocates is something 
that I would really like to see us tackle because I think that 
getting them into the system and having someone help manage 
that is critical. And I would applaud Secretary Peake and his 
staff for addressing that issue.
    One of the things we have seen in the State of Minnesota is 
one of 22 States that has county veterans service officers that 
are used as the point of contact and something we have asked 
for is what the State of Minnesota does with National Guard 
soldiers they have captured all of them--their returning 
soldiers--because they have that data on 99 percent of them.
    And some of the preliminary data seems to show that by 
capturing them early, getting them in the system early, we see 
a lower occurrence of PTSD and some of these things which I 
think is a positive and I applaud them because there are some 
institutional barriers here, Health Insurance Portability and 
Accountability Act (HIPAA) laws, those types of things of 
trying to get there. But I agree that is the way to go.
    The question I am going to ask you is a bit subjective, I 
know, but I am just trying to get at this. You heard it from 
Representative Herseth Sandlin, Mr. Moran.
    I, too, like many of these reps have sprawling districts 
with very rural areas and the issue in these areas is not being 
able to go down and choose another provider. There is simply no 
one that provides mental healthcare at all in the region. Forty 
percent of these Iraq, Afghanistan veterans fall into that 
category.
    My question to you is, there was a lot of talk last year 
and in the requirements we put in of using teleconferencing, 
telepsychology and telemedicine and those types of things of 
counseling, telecounseling on this. My question to you is that 
I want to know, evidence-based-wise, is there anything out 
there that is showing that works? Is it the way to go? Is it a 
cost-effective as well as an outcome-based, effective way to do 
this?
    Dr. Jaycox. There are a number models like that that are 
under study, but we do not have the answer yet. But there are 
things funded by NIH, for instance, that are really trying to 
bring these kinds of services to people in rural settings using 
Telehealth models.
    And so we should know that in the coming years, but there 
is not good evidence yet.
    Mr. Walz. Your advice would be just we need to just wait 
and see as that comes out? And, I mean, I am wondering, is 
there anything out there, any other studies, and any other way 
from the civilian sector that this type of, you know, 
teletherapy is working?
    Dr. Jaycox. I think that these kinds of cognitive 
behavioral treatments that are the evidence-based treatments 
for PTSD and depression lend themselves well to internet-based 
and therapist-supported telephone services. So I think there 
are models that could be begun to roll out, although the 
evidence is not fully in.
    Mr. Walz. Very good. Thank you.
    And I yield back, Mr. Chairman.
    The Chairman. Thank you, Mr. Walz.
    Mr. Space, any questions?
    Mr. Space. I yield back my time, Mr. Chairman.
    The Chairman. Mr. Hall.
    Mr. Hall. Thank you, Mr. Chairman.
    And thank you to our witnesses. I am sorry I missed your 
opening statements, but I have been perusing them during other 
questions.
    Based on what you said about stressors, Ms. Tanielian, for 
VA compensation purposes, should the VA use a broader 
definition of engaged in combat with the enemy that goes beyond 
infantry activity or direct participation in an attack?
    I am thinking about the incoming rounds in the green zone 
where I slept last October, where people never know when they 
hear a shell coming down or a round coming down if it is going 
to hit them or land right next door or, for instance, somebody 
traveling in a convoy and witnessing the vehicle in front of 
them being hit or civilians being hit. We have heard stories of 
nightmares and depression and so on from people like this who 
have not themselves been engaged in what is conventionally 
called combat.
    Ms. Tanielian. Yes. The nature of exposures on the 
battlefield has really changed quite dramatically with these 
particular conflicts because the risk is more disperse. And so 
we are seeing individuals who are not in typical infantry roles 
or military combat roles that are being exposed to traumatic 
events while they are deployed.
    And so our data did show that the types of exposures that 
are predicting PTSD are relatively common in those who have 
been deployed.
    Mr. Hall. That is good to hear because we have a bill that 
this full Committee reported favorably out to the House that 
would, among other things, do that.
    I notice, Dr. Jaycox, in your testimony that you estimate 
the PTSD related and depression related costs could range from 
$4 to $6.2 billion over 2 years in 2007 dollars. We do not know 
yet what the Congressional Budget Office estimate will be on 
this ``Claims Modernization Act'' which we passed out of 
Committee, but assuming that it does pass and that the numbers 
are anything like what we hear, they are a fraction of what it 
would cost to treat PTSD and to give a presumption of PTSD to 
those who served in Iraq and Afghanistan or similar conflicts 
in the future, is a small fraction of what the cost to society 
is from lost productivity and other causes that you mention 
here.
    I am not asking you for an answer to that. I am just 
interested that you are putting a number on untreated PTSD that 
runs well into the billions of dollars.
    Regarding women's health and mental health, what I have 
heard and not just from the services but from the service 
academies is that women's experience in combat is not just the 
same type of trauma that men have but also the problems of 
sexual harassment and the change from an all male or mostly 
male force to--it is only 17 percent now, but it is still the 
largest percentage of women, I think, serving ever in our 
country's history in our Armed Forces, and that many of them 
when they come home cannot or do not want to take part in a 
discussion group or an encounter session with a bunch of guys 
who are veterans because their experience is so different.
    Is that something you have encountered?
    Dr. Jaycox. Unfortunately, we did not look at women 
separately in this study and we did not ask different questions 
of the women than the men. So we do not have good data on that 
to offer.
    Ms. Tanielian. I would say it is an absolutely critical 
issue to try and understand the experiences of women. To do 
that would require a different study than we did. You would 
need to kind of over-sample and look at much larger groups of 
women.
    Our study was designed to look at the entire representative 
population of the deployed force. And as Dr. Jaycox said, it is 
only about 12 to 14 percent women.
    Mr. Hall. Okay. Thank you.
    And the concept of telecounseling and teletherapy based on 
what limited knowledge I have of counseling and therapy in 
general, my guess is that it would probably work to the extent 
that it works for the milder cases of depression and PTSD, but 
that for many veterans--a lot of veterans that I have heard 
testifying before the Committees or Subcommittees who were 
veterans in our district that I have spoken to, they not only 
want to talk to a human being, they want to talk to a veteran, 
you know, who they feel understands them and having a voice on 
the other end of the phone is helpful probably in some 
instances.
    Having somebody under the computer screen, I think, is 
probably less helpful unless it is dispensing medication or 
something like that, which in some cases, may be appropriate as 
a temporary measure at least.
    But does that sound accurate?
    Dr. Jaycox. Yes. I agree. Even with these Telehealth 
models, there needs to be psychiatric backup locally so that 
for emergencies and all those kinds of things. And it may serve 
a certain purpose, but it is not going to solve everything.
    Mr. Hall. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Rodriguez.
    Mr. Rodriguez. I apologize. I am on the Homeland Security 
Committee.
    Let me just do one brief question and then we can go to the 
next panel. Your data shows that you are indicating roughly of 
the 800,000 that have gone to Iraq and Afghanistan that 300,000 
might suffer from post traumatic stress disorder. That is a 
significant number from what we have been told--I do not recall 
the figure. I think the VA might have had 100,000 maybe 
potential. So that is about a 300 percent increase.
    Do you have any comments?
    Dr. Jaycox. Well, that is based on a survey that we did 
with representing the whole deployed force, so it is a cross-
section of everyone. That data has not yet been available. And 
it is a cross-section, so it is how many people are currently 
suffering and an estimate then based on the whole deployed 
force.
    We hear some people think that it is an underestimate as 
well. The numbers come in around the same as many of the DoD 
studies, so our rate of 18\1/2\ percent sort of corroborates 
the DoD studies and is not vastly different.
    Mr. Rodriguez. Come again. You said it is not vastly 
different in terms of--now, do you know the approach that they 
are utilizing to make that determination versus yours?
    Dr. Jaycox. Sir, the DoD has conducted a number of studies 
on specific groups of individuals at a particular point in time 
post deployment. So, for instance, a brigade or a combat unit 
either 1 month or 3 months after they have gotten back. And 
they have also found rates in the high teens similar to ours.
    Mr. Rodriguez. Okay. Thank you very much.
    Thank you, sir.
    The Chairman. I thank you both. Your report has had wide 
visibility and is quoted. Your expertise to these questions is 
much appreciated and gives added weight to your study.
    Let me just ask a couple questions along the lines that 
some of the other Members have asked. I personally think these 
are low estimates based on my own studies. But if you take even 
the 300,000, and I assume the TBI, there is an overlap with the 
PTSD, I mean, that again is ten times the official casualty 
statistics from the Pentagon.
    Shouldn't these 300,000 be included in number?
    Dr. Jaycox. Well, they are an injury condition resulting 
from combat deployment and so it is a different kind of 
casualty. But, yes, they are very important numbers.
    The Chairman. Again, a 300,000 casualty figure versus 
30,000 is very, very different and I think we in America should 
understand what has happened. That is a significant number of 
casualties and again, I think it is on the low side.
    You told us about the scientific sampling and you had 
roughly 2,000 or just slightly less than 2,000 telephone 
interviews, right? Is that correct?
    Dr. Jaycox. Yes, that is correct. Let me point out one 
other thing which is that this is a cross-section at a 
particular point in time. So this is the number of people who 
we interviewed who said I am currently suffering from PTSD or 
depression by virtue of the symptoms they endorsed.
    There are more people who may have been suffering earlier 
when they got back from deployment and who may develop these 
disorders later.
    The Chairman. Right. But, just as a brainstorming idea, if 
one of the elements of depression was refusal to answer the 
phone, the numbers could be vastly under-reported. I can see 
something like that occurring.
    Also, the stigma and the screenings that you referred to 
could also apply to the telephone interviews. That is, people 
are smart enough to know that if they say this, it shows that 
they are weak.
    So, even in a so-called confidential setting, which I doubt 
anybody would really believe in a telephone conversation--I 
certainly would not--they may also be under-reporting their 
symptoms. It is part of the whole problem that you referred to.
    So, I think for a lot of reasons it is still on the low 
side, even though it is ten times higher than the military 
would like to admit.
    Another Member pointed out that I had been trying to talk 
about mandatory evaluations, I use that word differently than 
screenings. I know, you said there are mandatory screenings, 
however, I am not sure that is true in terms of the Guard and 
Reserve units.
    Those screenings, as I understand them, and tell me if you 
have a different understanding, are usually self-administered 
questionnaires. There is no qualified provider there actually 
observing the soldier or exploring other things. Is that 
correct?
    Ms. Tanielian. Correct. We learned a lot about a lot of 
variability in the way that those screenings are being 
implemented across the services.
    The Chairman. I think we have to say that there are no 
mandatory evaluations. When I mean evaluation, I mean spending 
an hour with a qualified mental health professional who could--
we had one Member refer to blood tests, administer brain scans, 
and conduct interviews.
    I think the best approach that we can do and the simplest 
thing is that while on active duty we can provide a mandatory 
evaluation, not screen, for all of our soldiers because we are 
letting them out with PTSD and brain injury which, as we all 
know, causes enormous problems for themselves, their families, 
and their communities.
    And, you know, the VA always says, ``Well, we screen 
everybody who comes in.'' Well, first of all, not everybody 
comes in. You know, it is probably fewer than 20 percent. The 
screening, and the VA should be able to answer this on the next 
panel, is a couple of questions from a clerk.
    A psychiatrist told me there are 15 predictors or factors 
in PTSD or suicide risk. If you are asking two questions, as I 
believe the VA does, you are not getting at hardly any of the 
risk factors.
    I think we have a long way to go. Your report has helped us 
because it has shown that the need is so great. I agree that 
while on active duty, every soldier should be evaluated and 
provided follow-ups, as you point out. I mean, the very title 
of your report, the Hidden--is it Hidden Wounds?
    Ms. Tanielian. Invisible.
    The Chairman. The Invisible Wounds. Clearly they are both 
invisible because of denial and invisible because of stigma. 
But it is also invisible because it might not have manifested 
itself yet.
    So we have to look at people 3 months, a year, and, as you 
said, maybe 30 years later. We have to keep doing that.
    But this problem is a matter of life and death for so many 
individuals. You said suicide several times in your answers. We 
are talking about significant numbers and we have to get these 
evaluations. Your work has helped us toward that and I 
appreciate it.
    You have a chance for any last minute comments or words. 
Again, your expertise is well-evident and we appreciate it so 
much.
    Dr. Jaycox. Thank you.
    Ms. Tanielian. Thank you.
    The Chairman. I thank the first panel for testifying.
    We will call the second panel. Both the Department of 
Defense and the Department of Veterans Affairs are here with us 
today. We thank you. We thank both Departments.
    As the Ranking Member said, we are a little bit ahead of 
your official reporting period. But, given all the publicity on 
suicides, homelessness, and other issues, we thought we needed, 
as a service to our veterans, and our Nation to know more about 
what is going on now.
    Representing the Department of Defense is Michael Dominguez 
who is the Principal Deputy Under Secretary of Defense for 
Personnel and Readiness. Representing VA is Admiral Patrick 
Dunne, the Acting Under Secretary for Benefits and the 
Assistant Secretary for Policy and Planning.
    Admiral Dunne, if you would proceed and introduce those who 
have accompanied you today?

 STATEMENTS OF HON. PATRICK W. DUNNE, RADM, USN (RET.), ACTING 
   UNDER SECRETARY FOR BENEFITS, AND ASSISTANT SECRETARY FOR 
  POLICY AND PLANNING, VETERANS BENEFITS ADMINISTRATION, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MADHULIKA 
 AGARWAL, M.D., CHIEF PATIENT CARE SERVICES OFFICER, VETERANS 
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
PAUL A. TIBBITS, M.D., DEPUTY CHIEF INFORMATION OFFICER, OFFICE 
     OF ENTERPRISE DEVELOPMENT, OFFICE OF INFORMATION AND 
   TECHNOLOGY, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND HON. 
   MICHAEL L. DOMINGUEZ, PRINCIPAL DEPUTY UNDER SECRETARY OF 
DEFENSE FOR PERSONNEL AND READINESS, U.S. DEPARTMENT OF DEFENSE

      STATEMENT OF HON. PATRICK W. DUNNE, RADM, USN (RET.)

    Admiral Dunne. Thank you, Mr. Chairman. Good morning, 
Members of the Committee. Thank you for the opportunity to 
update the Committee today on VA's progress in implementing the 
Wounded Warrior provisions in the fiscal year 2008 National 
Defense Authorization Act.
    I would like to thank the Committee for its work in passing 
this important legislation and I am pleased to report VA and 
DoD are making demonstrable progress.
    I am accompanied this morning by Dr. Madhulika Agarwal, 
Chief Patient Care Services Officer for the Veterans Health 
Administration, and Dr. Paul Tibbits, Deputy Chief Information 
Officer, Office of Enterprise Development.
    In January, VA awarded a contract for two studies on 
disability benefits. The first study will examine the nature 
and feasibility of making long-term transition payments to 
veterans undergoing rehabilitation. The second study concerns 
appropriate compensation for loss in earnings capacity and 
information on potential quality of life payments.
    The reports are due by August and will inform our efforts 
regarding disability benefits, policies, and procedures.
    VA is working on two handbooks, one for our Federal 
Recovery Coordinators and another for transition assistance and 
case management of OEF and OIF veterans.
    The Federal Recovery Coordinator handbook will guide the 
FRCs in the delivery of all needed programs and services to 
recovering servicemembers and veterans. The target date for 
completion is this summer.
    VA completed a separate handbook on the transition 
assistance and case management of OEF and OIF veterans in May 
of 2007. And we will continue to review and update this 
handbook as necessary.
    A charter group comprised of Specialty Care Managers to 
include OEF/OIF teams. Spinal cord, blind rehabilitation, 
mental health, trauma, and others will be making 
recommendations in July for a system-wide approach to care 
management with emphasis on the coordination between programs. 
This charter group will also assist in the development of VA 
policy for care management.
    We are currently piloting a single joint VA/DoD medical 
examination process for servicemembers from Walter Reed Army 
Medical Center, National Naval Medical Center at Bethesda, and 
Malcolm Grow Medical Center enrolled in the disability 
evaluation system. The Senior Oversight Committee will be 
briefed in July regarding the expansion of this proposal.
    Last August, the Deputy Secretaries of Defense and Veterans 
Affairs signed an Memorandum of Understanding establishing the 
Federal Recovery Coordination Program.
    In January, the newly identified FRCs completed a 
comprehensive VA and DoD training program. FRCs are already 
developing individual recovery plans for severely injured 
servicemembers and veterans.
    As of June 1st, this program has enrolled and is currently 
serving 80 servicemembers and veterans.
    The DoD Center of Excellence for TBI and Psychological 
Health will be supported by VA with the Deputy and two subject 
matter experts, one in TBI and one in PTSD.
    VA and DoD continue to collaborate on a number of projects 
related to mental health and TBI. Some examples include 
developing revisions to medical coding for TBI for submission 
to revision nine of the international classification of 
diseases (ICD), developing clinical practice guidelines for 
TBI, assigning VA polytrauma rehabilitation nurse liaisons at 
Water Reed and Bethesda, establishing a 5-year assisted living 
pilot project for veterans with TBI for implementation between 
now and June 2013.
    The Veterans Health Administration's Office of Research and 
Development has a strong portfolio of neurotrauma research, 
which included $43 million of support in fiscal year 2007.
    VA also maintains a continuing relationship with DoD's 
research programs and both Departments work closely on projects 
funded through DoD's Congressionally directed medical research 
program.
    VA and DoD are working together to address eye injuries. 
Beginning in November 2007, VA and DoD ophthalmologists and 
optometrists began meeting to discuss approaches for improving 
care and coordination. They initiated a consensus validation 
process, which will identify and disseminate the most effective 
strategies for treatment and services.
    In May, VA and DoD work group members began reviewing draft 
documents on system requirements and concepts of operations for 
military eye or vision injury registry.
    An OEF/OIF veteran seen at a VA medical facility is 
automatically screened for TBI. Veterans for whom the screen is 
positive are referred for a full in-depth evaluation, which 
includes checks for visual impairment.
    For veterans and active-duty personnel with visual 
impairment, VA provides comprehensive blind rehabilitation 
services that have demonstrated significantly greater success 
in increasing independent functioning than any other blind 
rehabilitation program anywhere.
    The law also requires development of a VA/DoD interagency 
program office to act as the single point of accountability for 
rapid development of fully interoperable personal healthcare 
information between VA and DoD.
    Last month, the Departments formed this office and 
appointed an acting Director from DoD and an acting Deputy 
Director from VA.
    On April 29th, VA and DoD delivered a joint implementation 
plan to Congress regarding interoperability of electronic 
health records. This plan also expands our vision for sharing 
essential viewable data by identifying improvements VA and DoD 
could make to meet the goal of interoperability by September of 
2009.
    Mr. Chairman, this concludes my statement, and I would be 
pleased to answer questions.
    [The prepared statement of Admiral Dunne appears on p. 68.]
    The Chairman. Thank you.
    Mr. Dominguez.

             STATEMENT OF HON. MICHAEL L. DOMINGUEZ

    Mr. Dominguez. Thank you very much.
    The first thing I want to do is apologize to the Committee 
for the lateness of my prepared testimony and to the staff. I 
recognize that poses a special burden on them.
    And I would like to make four major points. The first is I 
want to inform the Congress that we in the DoD have devoted a 
huge portion of energy and attention to fixing the continuum of 
care for our wounded, ill, and injured. And we, in DoD, are 
deeply grateful for our partnership with the Department of 
Veterans Affairs in this endeavor over the last 15 months.
    Second, I want to acknowledge that while we have 
accomplished much, much remains to be accomplished. We will 
continue to dedicate ourselves to the mission of creating a 
world-class continuum of care and that it is seamless between 
the Department of Defense and the Department of Veterans 
Affairs.
    Third, I would like to share my observation that over the 
last 15 months, our organizations have deeply internalized 
important lessons. We know, and this knowledge extends deeply 
into the career leadership of our organizations, both military 
and civilian, we know the importance of this mission and we 
know how important it is that what we do in DoD is to the VA's 
successful accomplishment of their mission. And further we have 
learned in DoD to rely on the VA's expertise to help us with 
the challenges we face.
    The fourth point I would like to make is that I am 
confident, therefore, that we will sustain our momentum, our 
energy, and our leadership focus through the end of this year 
and that momentum and that energy and that focus will also 
continue through the transition to the next Administration.
    Now, lastly, sir, I would like to correct what I think may 
be an important misunderstanding from the prior testimony, that 
the RAND study did not and cannot definitively say that there 
are 300,000 cases of clinically diagnosed PTSD. The fact that 
out of 1.6 million----
    The Chairman. They never said that.
    Mr. Dominguez. Sir, out of 1.6 million----
    The Chairman. They never said there were 300,000 clinically 
diagnosed. They said based on their data, it was an 
extrapolation to a possible----
    Mr. Dominguez. Yes. Well, they are certainly consistent 
with our data. Out of the 1.6 million members who have deployed 
into the combat theater, 300,000 people who experience some 
kind of mental health stress is very consistent with our data. 
And those people do need to be discovered. They need to get 
help.
    Many of them will with very little counseling and 
assistance resolve those combat stress issues themselves. A 
few, a few will, in fact, manifest the clinical diagnosis of 
PTSD and they will need much more sustained intervention by 
medical healthcare professionals.
    The Chairman. How many is a few?
    Mr. Dominguez. Sir?
    The Chairman. How many is a few?
    Mr. Dominguez. Well, this is part of the research efforts 
that we are now undergoing. But in the data that we have 
garnered so far, which I have to say are incomplete and not 
definitive, it is less than 1 percent will actually have 
clinical PTSD that will need treatment over the----
    The Chairman. You believe that? You believe what you just 
said, that there are fewer than 1 percent of these deployed 
soldiers who will have PTSD as a clinical diagnosis?
    Mr. Dominguez. I mean, so far, this is the numbers that we 
are seeing that----
    The Chairman. And that shows why you do not do anything, 
because you think there are only a few?
    Mr. Dominguez. No. Well, sir, no, not at all. I mean, I 
said the 300,000 need treatment and the 300,000 need care. The 
300,000 need to access mental health professionals to guide 
them through treatment.
    But if you look a year after their deployment in our 
system--now, there are a lot of leakers in our system. We do 
not capture all the data yet from the VA. We do not capture all 
the Guard and Reserve members who do not come to our system. In 
our system, it is less than 1 percent, but that is not 
definitive. It is not authoritative.
    That is why, with my gratitude to the Congress for the 
appropriations and the supplemental last year, we are doing 
this research to really understand this problem with much 
greater detail, sir.
    [The prepared statement of Hon. Dominguez appears on p. 
74.]
    The Chairman. I am going to call on Mr. Boozman for some 
questions. I know you are all trained in the process of 
Congressional testimony and you have to be objective and 
nonpolitical. But I think there has been a contest to see who 
can suck the humanity out of this issue better in one or the 
other bureaucracy.
    We are talking about our children. We are talking about 
life and death. We are talking about suicides. We are talking 
about homelessness. We are talking about a lifetime of dealing 
with brain injuries. And you all sit there without anything to 
say. It is absolutely unacceptable. We are going to do this and 
this and this, get angry, you know. You read a few sentences 
that do not say anything. You tell me there is 1 percent.
    I was going to give the award to the one who was most 
bureaucratic to the Admiral, but, Mr. Dominguez, with your 
notion that there are a few people who are deployed who will 
have a diagnosis of PTSD when your doctors in the Department of 
Defense have been told to purposely misdiagnose PTSD as 
personality disorder so we do not have to deal with them takes 
the prize.
    And the VA is sending e-mails to say do not diagnose PTSD. 
It is too expensive for us. Give them a diagnosis of adjustment 
disorder. And you are sitting here telling me that everything 
is fine. There are only a few.
    Mr. Boozman.
    Mr. Boozman. Thank you, Mr. Chairman.
    One of the things that I have been concerned about and 
working on is the eye registry and the Center of Excellence. 
And I guess I am a little concerned. I know we have made some 
headway, but I just want to make sure where we are at with that 
and kind of what is going on.
    I know that right now there is a working group with 
optometry and ophthalmology regarding the computer programming 
for the eye registry. I guess what I would like to know is when 
that is going to be online, when we are going to do some 
testing.
    Have we got some dates? Have we got something a little bit 
more concrete?
    Mr. Dominguez. Sir, I will start.
    Mr. Boozman. I guess what I would like to know is when are 
we going to test it and when are we going to implement it?
    Mr. Dominguez. I cannot specifically answer the question. I 
think maybe my colleagues could.
    I do want to report to you that the Assistant Secretary for 
Health Affairs, Dr. Caselles, met yesterday with the Surgeon 
Generals and with, I believe, the VA colleagues and they have 
agreed on the concept of operations for how the Center of 
Excellence will work. They have committed to the first steps of 
getting that registry in place.
    They have worked out how they are going to tap into and 
bond with the excellent technical capabilities in the VA and 
their centers. So the concept of ops of this thing has been 
worked out, has been approved, and we are on the way to moving 
it forward.
    I would like to yield if anyone has any dates.
    Admiral Dunne. Sir, we will get you a timeline for the IT 
portion of building the registry.
    [The DoD provided the following information:]

          In September 2007, the Vision Center of Excellence (VCoE) 
        concept was developed and two workgroups were formed--one 
        dealing with the stand up of the VCoE and the other dealing 
        with the Department of Defense (DoD)/Department of Veterans 
        Affairs (VA) Eye Injury Registry.
          In June 2008, the Assistant Secretary of Defense for Health 
        Affairs determined that the VCoE will be a distributed center 
        with the headquarters in the National Capital Region. The VCoE 
        Director will report to the Director, TRICARE Management 
        Activity.
          The DoD/VA Eye Injury Registry workgroup determined that the 
        registry should be housed on separate, stand-alone servers and 
        managed at VCoE headquarters and that the registry's primary 
        architecture should be the same as the existing Joint Theater 
        Trauma Registry and in compliance with the Bi-directional 
        Health Information Exchange, AHLTA, and Veterans Health 
        Information Systems and Technology Architecture.
          In November 2008, Colonel (Dr.) Donald Gagliano was named as 
        the Director and Dr. Claude Cowan (VA) was named as the Deputy 
        Director of the VCoE. Both are in the process of leaving their 
        current jobs. Once in place at the VCoE, they will work on 
        development of the concept of operations (CONOPS). The CONOPS 
        and related functional and technical requirements will be fully 
        coordinated with DoD and VA to ensure compliance. DoD and VA 
        will work collaboratively to obtain approval and funding, 
        develop project milestones, and support design, development, 
        and implementation efforts.

    Mr. Boozman. Good. Thank you very much.
    The Palo Alto, the VA Medical Center there, the vision 
screening program for TBI seems to be really, you know, doing a 
great job and things. It seems like it would be a key priority, 
you know, to replicate that in a sense.
    Is VHA going to ensure that occurs? Is that spreading 
throughout the system?
    Dr. Agarwal. Sir, thank you for that question.
    The VA is very interested in doing the comprehensive TBI 
specific evaluation for those who have had severe traumatic 
brain injury. And that is exactly what people at Palo Alto have 
done.
    We are in the midst of writing a directive because we would 
like to ensure that at all our Level 1 polytrauma center sites, 
this specific evaluation, which is TBI related, happens for all 
the servicemembers and the veterans who are currently in our 
system or who have been through our polytrauma centers in the 
past.
    Mr. Boozman. Okay. The continuing education of DoD and VA 
medical staff on screening for vision complications from TBI 
should be a priority, I think, for the TBI Centers of 
Excellence.
    Optometry and ophthalmology, you know, being involved seems 
to be key. And I guess I would like to know, you know, kind of 
what we are doing in that area. And, you know, again, are we 
getting it done?
    Dr. Agarwal. Sir, that is a work in progress at this moment 
in time. And within a short period, we will be giving you full 
updated report on that.
    Mr. Boozman. Good. Well, again, like I say, I am very 
concerned. We had testimony not too long ago and the Colonel 
said, you know, we need a little less talk and a lot more 
action regarding this. And we seem to be moving forward, so I 
would like a timeline again on what is going on in regard to 
these things.
    You know, we can disagree about the number of, you know, 
reported this and that, but I think we can all agree that we do 
have a significant number of eye injuries, some of which we do 
not really understand, you know, the mechanism yet. And, again, 
those things have to be addressed.
    So I would say, too, that, like I say, while we disagree 
with some of, you know, the numbers and the this and that, I 
know that you all are working hard. I know that you are doing 
the best. Certainly we are not doing near as good as we need to 
do in many of these issues, but I know that you have worked 
hard and that we are doing better than we ever have before.
    But, again, like I say, I hope you follow-up in a very 
timely way on the request so that we can move that issue 
forward. Thank you very much.
    The Chairman. Thank you, Mr. Boozman.
    Mr. Walz.
    Mr. Walz. Well, thank you, Mr. Chairman.
    I am going to follow up on Mr. Boozman's question because I 
think this is critical. I think it is critical for the reason 
we are here on the wounded warrior side of it and I think it is 
critical with the disconnect on the seamless transition between 
VA and DoD. Mr. Boozman was very kind on this, but he asked 
some very specific questions and I appreciate the offer to get 
the timeline on this.
    But make no mistake about it. All of us are here with the 
same commitment to our warriors and our veterans, which is 
uncompromised. That is an absolute given.
    This issue on TBI and the peripheral damage, vision damage 
that starts to happen because of this is absolutely critical. 
So this Center for Eye Care Excellence on these injuries is a 
big part of dealing with that. And this is mandated by what we 
came out with. And, granted, as was stated earlier, we are just 
a little bit ahead on this.
    But I would have to say I have been incredibly pleased with 
VA, detailed cost estimates all the way down the line, things 
that have been given to us. And, in fact, my office, myself 
have written Secretary Peake urging him to sign that in.
    DoD, on the other hand, it is vague. It is not here. I have 
not heard anything to tell me that it is coming other than some 
vague reassurances on this. And it gets back to the heart of 
the problem again, where is the seamless transition? Where is 
seeing the warrior and the veteran as one inseparable 
individual, that their quality of care from that originating 
station of when they raise their hand to when we honor them 
with a burial at one of our cemeteries, where is that there?
    And on this issue alone, it is mandated. It has been there. 
I have seen what I consider to be very positive movement on the 
VA side. And, quite honestly, and this is for you, Mr. 
Dominguez, I have not seen it on the DoD side to the same 
level.
    And I would like you to convince me or tell me why what I 
am seeing here is a picture of disconnect that does not reflect 
many of the problems we have had in the past on disconnect and 
why should I, as Mr. Boozman asked, how do I know this is 
actually going to come forward?
    Mr. Dominguez. Sir, it will come forward because it is 
mandated in the law and we are going to prepare a report, 
deliver that report. As I mentioned earlier, Dr. Caselles has 
met with the Surgeons General and they have agreed on the 
concept of operations, how this thing is going to work, where 
it ties into, you know, how information will move, who does 
what.
    Those concepts of operation are critical to costing the 
detailed specifics of, okay, how do we put it in place. Now 
that we understand what it is going to look like, how it is 
going to work, where it is going to be, how do we build all 
that stuff.
    So that work, you know, is now underway in partnership with 
the VA because, as I said, over the last 15 months, we have 
learned that we have to be together on these things absolutely.
    Mr. Walz. And this will look different than if I went back 
and found 18 years ago the seamless transition on electronic 
medical records where you were working together and 18 years 
later, we are asking the same questions.
    My concern is you are telling me that it takes more and you 
have to have the plan first before you can get the cost 
estimates. VA provided some pretty detailed cost estimates at 
this point, which is helpful in the implementation. So I guess 
we will wait and see.
    My optimism is, and I assure you, Mr. Dominguez, I know 
your commitment to these veterans and their eye care is 
unwavering, and so that is never the question. What we are 
questioning is how we actually deliver this on the large scale 
and I think it is our responsibility as the overseers of this 
to make sure that we are continuing to ask and push those 
questions. It is never a question of motive. It is always a 
question of how we get it in and especially this seamless 
transition.
    But I am pleased. There is movement forward. I am 
optimistic on this one and I think it is going to be a big 
first step in helping that seamless transition part get there.
    My last question to you on this, and this goes back, Mr. 
Dominguez, as the question in the interchange, I guess, with 
the Chairman on this, is I just want to be clear on this, do 
you have problems with the methodology in the RAND study?
    Mr. Dominguez. No. Well, they found the same thing that we 
are experiencing. It is just the conclusions.
    Mr. Walz. The extrapolation of the finding?
    Mr. Dominguez. No. Three hundred thousand people out there 
with combat stress symptoms that need attention is consistent 
with our findings internally. My objection was that you cannot 
conclude that those are clinical PTSD cases that a physician 
would say that is PTSD.
    Mr. Walz. All right. Very good. Thank you. I just wanted to 
be clear.
    I yield back.
    The Chairman. Thank you, Mr. Walz.
    Mr. Rodriguez.
    Mr. Rodriguez. Thank you very much.
    Let me first of all start by qualifying my statements and 
saying that I was extremely pleased to see Secretary Peake get 
appointed because he had been with the Department of Defense 
prior. And I was hoping and I am still hoping that will result 
in some efforts on both parts.
    I came to Congress in 1997. We talked about this issue then 
and, you know, we are talking about it 12 years later. They had 
talked about it prior to me arriving here. For the longest 
time, we have been talking. It is not a new issue. And I do not 
want to make it personal because the people that are here 
before me are not necessarily the ones responsible. It is a 
system the DoD and VA that need to get together.
    It is not only in terms of bringing down the cost when you 
work cooperatively, but also from a humane perspective in terms 
of what needs to happen for those soldiers. And the sooner we 
recognize that this is going to help our soldiers and that is 
the right thing to do, we are going to do it.
    And I hear the words we have to prepare the report, the 
importance of the mission. My God, we have been waiting for 
this for some time. It is not something that all of a sudden 
came about. And we have been talking about making every effort 
to start coming together and bring forth an effort to sincerely 
respond.
    When a soldier serves our country, that folder ought to 
follow him to the VA as quickly as possible so that we can be 
able to prepare the best type of services for him. And it is 
just as simple as that.
    And, again, I have been here. This is going to be my 12th 
year. And it has been like pulling teeth. And, once again, I do 
not want you to take this personally because you personally as 
individuals are not necessarily the ones responsible for this, 
but the system is, so that we have to show some sense of 
responsibility. As the Chairman talks about these are 
individuals that are hurting. And we have to start from scratch 
when they come to the VA and start the process all over again 
when in some of those cases, that is not needed. And we could 
be saving resources not to mention what it means in terms of 
the approach, the humane approach in terms of treating some of 
these individuals.
    Now, post traumatic stress disorder, in this area, we have 
to be able to pick it up as quickly as possible. I know we are 
doing some research now and we had not provided the resources 
there. And we also have a responsibility there that we had not 
been providing those resources in order to make that happen.
    And I agree and I hope that the result is that as soon as 
we engage them and provide that treatment that hopefully it 
will not be a long duration that they will be suffering from 
that. And hopefully within 6 months or a year, they will be 
okay. And I am hoping that will be the diagnosis that will come 
about.
    But the sooner we engage them, because right now my 
understanding was that it was taking almost over a year before 
we get to pick them up and so the sooner we pick them up, the 
better. And so it should not take a year in order for that to 
happen.
    So I do at least, Mr. Chairman, I want to thank you because 
I do not recall during the time that I have been in this 
Committee that we have been able to even get a DoD person to 
come before us, perhaps a very few times.
    So I do want to thank you for being here. That is a big 
plus, the fact that both of you are here. And we had not been 
able to even accomplish that with the previous Administration. 
And so, the fact that we got you both here is a big plus.
    The key now is to move forward and try to come up with some 
responses to how are we going to make it a seamless transition. 
How do we get that folder when that soldier leaves the DoD and 
allow that folder to follow him to the VA?
    You mentioned one other area that now concerns me, the 
National Guard and Reservists, 40 percent. How do we, and I 
will throw this out, how do we go after that 40 percent that 
are out there, State Guard and all the other National Guard, to 
be able to do the same thing?
    Admiral Dunne. Sir, Secretary Peake is equally concerned 
about the rural healthcare in all facets, not just PTSD. And, 
in fact, we do have an Advisory Committee, which is in place 
now to take a look and give him specific recommendations and 
advice in addition to his own staff working on it so that we 
can improve our capabilities.
    But things like the telemedicine, which we talked about 
earlier, those are key things that we are taking advantage of 
now and will continue to take advantage of any innovations that 
become available so that we can take care of veterans.
    Mr. Rodriguez. And I do want to thank you because I have a 
lot of rural areas in my district. But let me go to that 
question. How do we zero in on the Reservists that are--if 40 
percent of the Reservists are in Iraq and Afghanistan in harm's 
way, how do we reach out to them and who has their files?
    Admiral Dunne. Well, we also have worked together with the 
National Guard and Reserve to create advocates in each of the 
Guard units who in each State work together with VA very 
closely to make sure that we are aware of events where we could 
conduct outreach and get information out to the members of the 
Guard so that they know where we are and how to get in touch 
with us and come get care or compensation as appropriate.
    We are in the process of developing a similar memorandum of 
understanding with the Reserve throughout the country and we 
will continue to provide those same services to the members of 
the Reserve.
    Dr. Tibbits. Sir.
    Mr. Rodriguez. Yes, sir. Go ahead.
    Dr. Tibbits. Just to think out loud for a moment on that 
issue, the Guard and Reserve, as you heard, also could imply 
from the RAND comments is a broadly distributed problem. Part 
of the issue with respect to the folder that you brought up, I 
wanted to speak to a little bit.
    The electronic exchange of clinical information is 
problematic and a challenge and, of course, we have a lot of 
stuff we could say about that later if you wish to get into it. 
But when you add the distributed nature of the Guard and 
Reserve, it makes that further complex and it makes it complex 
for a variety of reasons.
    One, we are talking about a substantial amount of 
healthcare delivery that takes place in the private sector, 
where the penetration of information technology is very low. So 
in order for there to be an electronic exchange when that Guard 
and Reservist goes back home and may be seeking care from 
neither of our institutions is itself a whole other set of 
challenges.
    Mr. Rodriguez. Anybody looking at that right now?
    Dr. Tibbits. Well, our Secretary has asked us to begin to 
make some serious, let us say, end roads into that. There are 
several levels and I will yield back in a minute here. There 
are several levels.
    One is with the Guard and Reserve itself and the equipment 
they have.
    Number two, what it is both Departments do for purchased 
care when we purchase healthcare from the private sector not 
delivered inside of our institutions.
    And, thirdly, is the relationship that we need to develop 
or are developing with the National Health Information Network 
Initiative of the U.S. Department of Health and Human Services 
to facilitate the connection between us and all those private 
sector doctors who ultimately are going to be linking 
themselves electronically to that National Health Information 
Network.
    So it is a layered problem. There is a lot to think about 
there. And, yes, our Secretary is very interested in having us 
now weigh into that specifically.
    Mr. Rodriguez. Mr. Chairman, I know I went after my time, 
but can I get Mr. Dominguez to respond? I think he also wanted 
to respond. Is that okay, Mr. Chairman?
    Mr. Dominguez. Sir, if that is okay, the first is that the 
Authorization Act did require us to address in every report 
that we send to the Congress and every aspect of this continuum 
of care the unique challenges associated with providing that 
care and support to the members of the Guard and Reserve. So we 
intend to do that.
    There was a similar provision on gender issues, by the way, 
which we intend to do that.
    The next thing is that in the Authorization Act, NDAA 2008, 
it established the Yellow Ribbon Reintegration Program. We take 
a couple of experiments we were running with States in terms of 
trying to support Guard and Reserve members coming back and 
extended that to all 54 States and territories.
    Secretary Hall, the Assistant Secretary for Reserve 
Affairs, is now putting that program together to reach out to 
Guard and Reserve team people who are coming back with a full 
spectrum of care which will include some healthcare and mental 
health counselors and those kind of people that either we will 
provide or--and we have also actually seen our TRICARE network 
providers step up and in particular deal with the rural 
challenges by getting deployed teams of healthcare providers 
and particularly mental health people out to these events where 
we are either, you know, shipping people out or bringing them 
back.
    So there is a lot going on, a lot to be done, a lot going 
on.
    The Chairman. Mr. Dominguez, you said earlier that you do 
not have any problem with the 300,000 figure of people who 
showed some symptoms of mental illness.
    Would you consider those casualties of war?
    Mr. Dominguez. I do not know that I would call them 
casualties of war. I mean, they are people exhibiting----
    The Chairman. If someone has a broken arm, it is a 
casualty, right? If somebody gets a broken arm while in battle, 
is that a casualty?
    Mr. Dominguez. Uh-huh.
    The Chairman. So if somebody has depression or brain 
injury, is that a casualty?
    Mr. Dominguez. Well, brain injury is, I think, a 
different----
    The Chairman. Okay. Well, the RAND report gave a 320,000 
estimate. Do you accept that figure?
    Mr. Dominguez. What I----
    The Chairman. You made fun of the 300,000. How about 
320,000 who have brain injury?
    Mr. Dominguez. Well, again, I think you do not have 320,000 
brain injuries. You have 320,000 people who have been in or 
around a concussive event. Again, it is a spectrum of 
experience and then a spectrum of need that manifests itself 
there. So, no, there are not 320,000 people out there----
    The Chairman. Probably just a few, right?
    Mr. Dominguez [continuing]. Who have brain injuries.
    The Chairman. Probably just a few? I am just using your 
words.
    Mr. Dominguez. At the very severe end of the----
    The Chairman. You know, here is the problem that I have 
with your testimony and then I will shift over to the VA. You 
are a leader in the Department of Defense and people hear your 
words and you create a tone. You are the leader, or you are one 
of the leaders and the leadership creates a tone. Your tone is 
that it is only a few. We get them back into battle because 
they are not casualties. They have some symptoms.
    That leads to a lot of things. It leads to people not 
willing, first of all, to admit anything and commanders saying 
``Do not admit to anything because your promotion will be held 
up.'' It leads to, as I understand some of the reports, at 
least 20,000 people who had a PTSD diagnosis were rediagnosed, 
or deliberately diagnosed, with personality disorders.
    And now, not only does that beg the question of why we let 
these people in with personality disorders, but it means that 
the VA does not have to treat them because it was a pre-
existing condition. That is what your type of testimony leads 
to. It leads to people saying we are not going to even take 
this seriously.
    Mr. Dominguez. Sir, I apologize if I conveyed that tone. I 
want to emphasize that all of these people who experience 
combat stress need help. They need to get to people, 
therapists, counselors, and staff who can help them process 
that stress. What they have been through----
    The Chairman. Are they doing it?
    Mr. Dominguez [continuing]. Is not normal.
    The Chairman. Are they getting that help?
    Mr. Dominguez. We are trying our best, sir.
    Now, one of the things I do want to point out is the line 
leadership of the Department. Secretary Gates himself attacked 
this problem of question 21 on the security clearance form. And 
this year, we made some major revisions of that in terms of 
what people need to be able to answer again to deal with that 
stigma.
    The Chairman. It is an important step forward. I agree.
    Mr. Dominguez. Now, the line leadership, if you look at, 
for example, the Army, Secretary Garren and General Casey, the 
Chief of Staff, ensured that every soldier in the Army, 
including every leader in the Army, was trained about combat 
stress, the symptoms of combat stress, the importance of 
watching your peers, your buddies.
    The Chairman. There is no question you are doing all these 
good things.
    Mr. Dominguez. The leaders are----
    The Chairman. But there are thousands and thousands of 
young men and women who are not getting help. They are not 
allowed to admit they have a problem. When they get home, they 
do not get the help they need or they deny that they need the 
help.
    So, yes, you are doing all these things, but you have all 
this evidence that we are not doing enough or anywhere close to 
enough. The signals are being sent that we do not have to take 
it that seriously because----
    Mr. Dominguez. Sir, we are taking it very seriously and 
these things----
    The Chairman. When you say there are only a few who have 
PTSD, that is demonstrably false, demonstrably. You need to 
come to my district. Come home with me tomorrow. I have Camp 
Pendleton right near my district. We have the biggest Navy base 
in the world. I will show you more than a few with PTSD--both 
active duty and veterans. I see them every day and they do not 
know what to do.
    Some of them commit suicide. You have the highest rates of 
suicide since the Vietnam War in the Army, right, of our combat 
troops? Does that say it is just a problem, a few? A third of 
those who have been diagnosed with PTSD, that is who actually 
got the diagnosis, have committed felonies when they come home. 
Is that a big problem?
    Two hundred homicides among those felonies of family 
members. That is real, it is significant and it needs to be 
taken seriously by everybody from you on up to the President. 
And, I do not see anybody saying it. They just keep denying 
these figures. They say they are vastly overblown. It is only a 
few, so we do not have to take care of them.
    Mr. Dominguez. We are taking seriously the issue of combat 
stress, of finding people who need help and getting them help.
    The Chairman. How do you account for 200 homicides of guys 
coming right out of Iraq who have killed 200 people, most of 
them in their own family? How do you explain that? Because we 
are not doing our job. How do you explain the suicides? We are 
not doing the job. And if you do not----
    Mr. Dominguez. Suicide----
    The Chairman [continuing]. See that every suicide or every 
homicide is a criminal act that we committed, then you are not 
going to ever solve the problem. We have not taken care of our 
children. The evidence is there. You just do not want to admit 
it or look at it.
    Mr. Dominguez. What I am saying, sir, is that we are 
mounting an aggressive effort. It is continuing to deal with 
this combat stress.
    The Chairman. I notice you did not respond to my----
    Mr. Dominguez. We have every possible way we can do it.
    The Chairman. You did not respond to my statement about 
personality disorders. We have had, at this table, people who 
were diagnosed with personality disorders, who had demonstrated 
PTSD and they were not getting the help they needed.
    Mr. Dominguez. Sir, I have today, just today, sent to you 
the report that was required by the Congress on the personality 
disorder discharges and the percent of that 20,000 or so over 
the last several years and----
    The Chairman. So, you will say it is only a few. I have not 
read the report, but I am positive it is going to say there are 
only a few.
    Mr. Dominguez. For those who have been at discharge, the 
majority who have been in less than 2 years, the majority were 
not deployed into combat. However, this discussion of and your 
focus on that did cause us to tighten our policy.
    So the use of that discharge now requires certification by 
a psychiatrist that PTSD is not present. And if the person 
being discharged with this discharge has been to combat, that 
Surgeon General of the Service must sign off on it.
    [The report entitled, ``Administrative Separations Based on 
Personality Disorder,'' as required by section 597 of the 
National Defense Authorization Act for Fiscal Year 2008, 
appears on p. 83.]
    The Chairman. Okay. Well, I will read the report, but I can 
guess what is in it.
    I can tell you that doctors have come to me, I wish they 
would testify in public and I am trying to get them to do that, 
that they have been ordered to misdiagnose PTSD as personality 
disorder. I wish I could do this in public and I will try to do 
that. It is a real concern.
    As for the VA, you know about this e-mail that went out and 
became public. The head of the post-combat trauma unit at a VA 
hospital writes to all of her team. ``Given that we are having 
more and more compensation seeking veterans, I would like to 
suggest that you refrain from giving a diagnosis of PTSD 
straight out. Consider a diagnosis of adjustment disorder. 
Additionally, we really do not have time to do the extensive 
testing that should be done to determine PTSD.''
    Also, there have been some incidents where the veteran has 
his compensation and pension exam and is not given a diagnosis 
of PTSD. Then the veteran comes here and we give the diagnosis 
of PTSD and the veteran appeals his case based on our 
assessment. Now we have a problem. We are going to have to 
compensate them.
    How does that happen? I think it happens because of the 
kind of testimony you give today, that the leadership is giving 
the signals that we are spending too much money, we do not take 
it seriously. We only have a few, so some middle-level 
administrator has the nerve to send that kind of message out to 
her people. How does that happen?
    Admiral Dunne, they are your people.
    Admiral Dunne. Sir, that e-mail was poorly worded and Dr. 
Kussman----
    The Chairman. That is just like your head of mental health 
who poorly worded his ``shh, do not talk about suicide 
statistics'' email. Everybody seems to be poorly wording stuff. 
You should give them a course in not doing that. But, I mean, 
it is not poorly worded. It is very well worded. It says cut 
out the diagnosis of PTSD.
    Where is she getting that kind of instruction? Where is she 
getting that kind of sense? Where is she getting the right to 
say that? Is that coming from you at the top?
    Admiral Dunne. It did not come from me, sir.
    The Chairman. Well, did it come from anybody?
    Admiral Dunne. It did not come from anybody in the 
leadership of VA, sir.
    The Chairman. It came from somewhere. Nobody sends out a 
memo like that. It is based on the signals that you guys are 
giving at hearings like this. That is where it comes from.
    Now, can you explain to me? Everybody who comes to testify 
here says anybody who comes in the VA from OEF or OIF gets a 
mandatory screening for PTSD and TBI. First, you are saying 
only those who come in, right? You are not going out and 
finding people. Second, what happens in that screening, 
exactly?
    Dr. Agarwal. Sir, let me address two things. The first 
question is what are we doing about those who are not coming to 
us for care. Secretary Peake has an initiative of a call center 
which got started a few weeks ago where we are reaching out to 
all the servicemembers or veterans who have been discharged 
with----
    The Chairman. They have to call into the call center.
    Dr. Agarwal. No. They are making the outreach call.
    The Chairman. And what are they saying in that outreach? 
What is the script?
    Dr. Agarwal. And they are actually offering them services 
that VA offers including the sites. And if any of them need an 
appointment or assistance----
    The Chairman. Okay, that is great. I will tell you, by the 
way, because I have seen your suicide brochures that the very 
people you need to reach are those who do not want to talk to 
the government, they do not want to talk to bureaucrats. They 
want something else. But you are telling them to come see the 
government. We are here to help you.
    Dr. Agarwal. It is being done by a contracted service. But 
the second point more specifically----
    The Chairman. I would like to see the script for what they 
are saying.
    Dr. Agarwal. We can have it.
    The Chairman. Thank you.
    Dr. Agarwal. Sure.
    The Chairman. Okay. What happens when they come in and they 
get their screening?
    Dr. Agarwal. Actually, OEF/OIF veterans, there is a 
clinical reminder in the computerized record system which is 
based on Boolean logic. So anyone who has been discharged from 
the service since 2001, there are a series of reminders that 
they have to undergo and which the clinicians, especially the 
primary care physicians in our clinics, both in the community-
based outpatient clinics as well as the medical centers, have 
been trained to complete which includes a series of questions 
related to PTSD----
    The Chairman. The Secretary said when he was here and you 
said today that everybody who comes in gets a mandatory 
screening for PTSD.
    Dr. Agarwal. Yes, sir.
    The Chairman. Tell me what that screening is. What exactly 
is that? Is that an appointment for an hour with a 
psychiatrist? Is that a questionnaire given out by a clerk? 
What is it?
    Dr. Agarwal. Let me explain that, sir. It is actually a 
series of questions which are asked by the clinician. So a 
clinician who is seeing----
    The Chairman. How many questions are in that series?
    Dr. Agarwal. Sir, it has been a while since I have given it 
myself. I am a practicing clinician.
    The Chairman. It is two. I have seen the questionnaire. I 
have talked to the guys who have gone through the 
questionnaire. There are two questions that are asked, one that 
says have you ever been subject to a blast. I forget the other 
one but I believe it asks if you have nightmares. There are two 
questions. Am I wrong?
    Dr. Agarwal. Sir, I would need to get you the 
questionnaire.
    The Chairman. Well, you know, I want to know the exact 
screening. What happens? Who does it? What are the questions 
asked and for what time period?
    I am told by dozens and dozens of soldiers that there are 
only two questions. It is done by an intake clerk. And, if they 
do not want to admit that they have it, they know what to say--
no on both--and then there is no follow-up on it. They just say 
no and that is it.
    Dr. Agarwal. No, sir. It is actually a more detailed 
questionnaire than two questions. And the clinical questions 
are not asked by clerks. They are asked by a clinician.
    The Chairman. Well, you will have to show me because 
everybody I talk to tells me what they said to these questions.
    Dr. Agarwal. Sir, I will get you the screen.
    [The VA subsequently provided a Call Back Scripts, which 
appear on p. 120.]
    The Chairman. And, again, the Army and the Marines give 
mandatory evaluations for PTSD and brain injury when they leave 
combat areas or leave the service?
    Mr. Dominguez. Sir, we do these screening surveys, 
questionnaires to cue people to get them brought in for face-
to-face talks with a clinical provider.
    The Chairman. If they say yes to any of the questions?
    Mr. Dominguez. That is correct. And then----
    The Chairman. So, I mean, if a Marine knows that his 
promotion is threatened or he is not going to get a job in law 
enforcement when he leaves, most of your Marines are smart 
enough to answer ``no'' to those questions. If somebody checks 
yes, and I can give you the names and dates. Their commander 
says you better look at this again because if that stays yes, 
you are going to have to stay here a few more days for some 
further evaluation. That Marine wants to go home. He does not 
want to be saddled as weak. Everything is set up to make sure 
that they fear admitting----
    Mr. Dominguez. Well, which is why we are changing a lot of 
things in the Department. First, many places, not all yet, but 
many places the counselors and the psychologists, psychiatrists 
are actually in the health clinic, so you do not have to go 
some place else, you know, so you can mask that you are getting 
mental health treatment.
    Second is this training that is going on in the leadership 
about combat stress, taking care of your buddy, be observant, 
help your buddy. And then communicate that part of the warrior 
ethos is, you know, being strong, to get strong enough to get 
help, taking the stigma out of it by, you know, attacking that 
question 21 that Secretary Gates----
    The Chairman. Tell Secretary Gates, as I have told several 
of your Surgeon Generals, the best thing he can do is to take a 
Colonel who has had PTSD and publicly talk about his PTSD, 
treatment, and his healing and promote him to General. That 
would send a signal.
    I asked the Army Surgeon General how many Generals have had 
PTSD. He said many. I said name one and he said he cannot do 
that.
    Mr. Dominguez. Right.
    The Chairman. That is what you need to do.
    Mr. Dominguez. Sir, we are trying a lot of different 
things. I want to point out there is a brigade commander at 
Fort Lewis who has taken his entire brigade through mental 
health counseling as they redeploy starting with him. Okay? So 
there are things like that are going on----
    The Chairman. That is good.
    Mr. Dominguez [continuing]. Today in the Army to try, and 
the Department of Defense, try and understand how to do this 
better and how to make sure that people who do need care, 
because combat stress is real and combat is not a normal and 
natural thing, and people need help dealing with it, so we are 
trying to understand how to make that happen more effectively.
    Mr. Buyer. Will the gentleman yield?
    The Chairman. I will yield to you your time in a second. I 
just want one final thing.
    I think you need to do that a lot faster and a lot more 
comprehensively and get mad that it is not being done.
    Mr. Buyer, I would yield to you.
    Mr. Buyer. It was just to the point that you were making. 
If you remember when you held the hearing on personality 
disorders and your concern on PTSD and I had proposed that we 
had a brigade that was going. And it is the 76th brigade out of 
Indiana and this is their third deployment.
    And so what has happened, and just to tell you about this, 
is we have had extraordinary cooperation from VA and DoD with 
regard to this National Guard brigade. And we were going to try 
to do something outside the box that we had never done before. 
And it is about baselining.
    And so the VA normally is the receiver of the consequences 
of war and then manages that health aspect along with other 
things. This is where the VA, upon our request and your 
request, Mr. Chairman, they actually involved themselves in 
deployment. And DoD invited them in to do that.
    So the VA came. It was part of the counseling they gave not 
only to soldiers but also to family members and the spouses. It 
was done not only at Camp Atterbury but then you went down to 
Fort Stewart before they went over. The VA did that. That is 
operating outside the lines and the jurisdiction of the VA.
    Now, why was that pretty important? Because I think that 
was the VA being responsive to the concern that not only you 
have had over time but what you just brought up and that is 
when Secretary Dominguez talked about the job at DoD is to 
build warriors. And they build warriors. They build a warrior 
ethos. They instill them with values and the ideals to defend 
liberty and this country. And we want them strong, but we also 
recognize that there are times that it can be very challenging 
for them.
    And when they come back, you are absolutely right, Mr. 
Chairman, they are eager to get back to their families. They 
are eager to get back to their lives. And that is why the VA 
being responsive to DoD opening the door to be there, it is 
telling the first line of diagnosis. It is really the husband 
or wife that was left at home. They are watching the transition 
of their loved one in how they talk on the telephone, in their 
writings, what are they saying on e-mail.
    And then when they come home, are there sleepless nights? 
How are they reacting to the children? What do they see that is 
different? And they are the ones now that they are building a 
relationship with the VA that has been established during the 
family support centers. I think this is a good thing that is 
going on.
    It addresses the point that you were making. So I wanted to 
give you sort of an update on what is going on. I will yield 
back.
    The Chairman. Thank you.
    I would invite both Secretaries to meet with some of the 
people that are giving us this other kind of sense of what is 
going on and put a human face on all this stuff.
    I yield to Mr. Buyer for his questions.
    Mr. Buyer. Thank you, Mr. Chairman.
    I am going to get back to sort of the purpose of our 
hearing and that is the implementation of the Wounded Warrior 
provisions.
    Now, I have the Defense Authorization Act. And the reason 
all of this is in the Defense Authorization Act is that the 
Chairman waived jurisdiction of this Committee and we gave it 
then to the House Armed Services Committee in cooperation 
though. When the Chairman did that, he worked with Chairman Ike 
Skelton. So the House then adopted the recommendations of this 
Committee and so that is why I am referring now to this.
    Now, one of the things we did is that we put in specific 
benchmarks and reports. And we have done this because of 
oversight on implementation. So we are putting you under the 
gun.
    So in my opening critique here of the Chairman, my first 
reaction was, Mr. Chairman, a lot of these reports are not 
coming due until July and GAO in particular. But you know what? 
There are some reports and things that you were supposed to 
have done that I do not know if you have done or not.
    So let me ask you about these. Section 1616 was the 
establishment of a Wounded Warrior resource center and among 
other things, the center was to provide a multi-method of 
access including at a minimum one Internet Web site and a toll-
free phone number. I believe this was supposed to have been 
done within 90 days.
    Has this been done?
    Mr. Dominguez. No, sir. We are late on that.
    Mr. Buyer. Why?
    Mr. Dominguez. It is harder than it sounds. We have----
    Mr. Buyer. A toll-free number is harder than it sounds?
    Mr. Dominguez. Well, the important thing is ensuring that, 
and we have made the decision Military OneSource will be the 
number, but ensuring that the capacity to answer all the 
questions that are going to be there so that you can, when 
somebody calls, you can make sure that they get the assistance 
that they need. We are building that structure. And I want to 
say that we are doing that in partnership again with the 
military services who do also have their 800 numbers out there 
and working.
    Mr. Buyer. When can we anticipate that you are in 
compliance with section 1616 of the ``Wounded Warrior Act''?
    Mr. Dominguez. Sir, I will get you that for the record.
    Mr. Buyer. Oh, no. No. No. Sorry, Mr. Secretary. You are 
already behind.
    Mr. Dominguez. Yes, sir, we are behind.
    Mr. Buyer. So give us your expectation. You are the leader.
    Mr. Dominguez. Sir, I think it is best for me to provide 
that to you for the record so that we can be accurate in our 
communications to you about when that whole capability will be 
available.
    Mr. Buyer. No. No. You have the opportunity to provide the 
leadership. We have given you what we have wanted. You have had 
a lot of time. So please provide here to the Committee an 
expectation of when this will be implemented. You have already 
busted through our expectation as to when we thought it could 
be done.
    So what are we talking about? Within 15 days or within 30 
days, within 60 days, within 90 days? I mean, you are now not 
in compliance with the law. I would feel uncomfortable if I was 
a Secretary and I was not compliant with the law.
    Mr. Dominguez. Yes, sir. We are late in standing up that 
capability. It is of concern to me. And I have people working 
it assiduously.
    Mr. Buyer. So what is the expectation? What is your 
expectation?
    Mr. Dominguez. I cannot provide you that right now, sir.
    Mr. Buyer. Within a year? Within the year?
    Mr. Dominguez. Oh, yes, sir, absolutely.
    Mr. Buyer. Within 6 months?
    Mr. Dominguez. I would say so, yes, sir.
    Mr. Buyer. There we go, within 6 months.
    All right. Let us talk about the other provision. Section 
1664 was the report on traumatic brain injury classifications. 
Not later than 90 days after the date of the enactment of the 
``Wounded Warrior Act,'' the Secretary of Defense and the 
Secretary of Veterans Affairs shall jointly submit to the 
Committee on Armed Services and the House of Representatives a 
report describing the changes undertaken within the Department 
of Defense and the Department of Veterans Affairs to ensure 
that traumatic brain injury victims receive a medical 
designation that is concomitant with their injury rather than 
medical designation that assigns a generic classification.
    Now, to the DoD and the VA, do you have the report?
    Mr. Dominguez. No, sir. I think we are probably late on 
that one too. Now, I know that we are working this issue of 
the--do you have some better information?
    Dr. Agarwal. Provide some information, sir. Yes, there is a 
VA/DoD group that has been currently working on the coding 
proposal. This proposal is going to be submitted to the 
National Center of Health Statistics. And following that 
period, there is a comment period before it is accepted by the 
ICD-9 classification.
    Mr. Buyer. All right. One of the challenges that the 
Chairman and I and other Members of the Committee have had is 
working with the medical communities with regard to 
designations because we have been sort of uncomfortable with 
this mild traumatic brain injury and coming up with the right 
terminology because it is like what is the difference between a 
concussion and a mild TBI. And we are moving into this mental 
health and exploring this in greater detail.
    So we wanted to make sure when we put this together that 
with regard to the VA and DoD, if we are going to be seamless, 
that we wanted to make sure that everyone is using the right 
terminology and everything is coded in cooperation because if 
the VA, in fact, is the leader as RAND testified, that we 
wanted to make sure that as we then work in concert through 
TRICARE and with other providers that everybody begins to take 
off of our lead in designations and in coding.
    This is pretty important. Do you agree? All right. Admiral.
    Admiral Dunne. I agree.
    Mr. Buyer. Can you tell me where you are and why you have 
not met this deadline?
    Admiral Dunne. The revision will be submitted to the 
Committee by September of this year. The expectation is it 
takes about a year for that to go through the peer review and 
get actually assigned to that. VA does not, nor does DoD, 
control that international organization.
    Mr. Buyer. So the 90 day after enactment was really sort of 
an unrealistic deadline? I mean, we want it to be done 
accurately, the Chairman and I do, because we recognize this is 
pretty doggone important. You are leading a country with regard 
to best coding and designation and terminology, nomenclature. 
So 90 days was unrealistic?
    Dr. Agarwal. Sir, I could not answer you because I am not a 
subject matter expert. But what I do know that it does have to 
go, the proposal is pretty ready, but it has to go through 
external agencies like the National Center of Health Statistics 
before it can be submitted for the actual coding.
    The ICD-9 code currently, as you know, does not have a code 
for mild TBI, so there is a process that it has to go through 
and it is fairly in final processes of being submitted.
    Mr. Buyer. So you anticipate the compliance then with 
section 1664 by September?
    Dr. Agarwal. It will be submitted to the ICD-9 Committee by 
September.
    Mr. Buyer. All right. Let me ask this. We have other 
reports. You have all kinds of requirements here on reporting. 
Are you going to meet any of them? What I would like to know is 
why do you not just go ahead and tell us now. I mean, you have 
an incredible upcoming list of deadlines.
    Admiral Dunne. Yes, sir. We have----
    Mr. Buyer. And we are not beating the heck out of you here. 
Are these realistic deadlines that we set for you or which ones 
are you going to be able to accomplish and not accomplish?
    Admiral Dunne. Sir, Mike and I Chair a DoD/VA Committee 
which is tracking these. We have a spreadsheet that we have 
created that breaks those down based on the reports. We would 
be happy to provide you a copy of the spreadsheet. It gives you 
an indication of our progress on each of those requirements.
    [The DoD subsequently provided a table showing the Status 
of Congressionally Mandated Requirements, which appears on p. 
129.]
    Mr. Buyer. All right. To the two Secretaries, being 
transparent with us a good thing, right? Letting us know what 
you can achieve, what is realistic.
    And, you know, Secretary Dominguez, I did not mean to be 
too hard on you, but I am going to be hard on you because, you 
know, I think you need for us to do that. You are dealing with 
some pretty strong bureaucracies over there and we set these 
timelines for a reason, to set that backdrop so difficult 
decisions are not procrastinated.
    I do not question your heart. Neither of you. No one on 
this panel. That is why I am asking are the deadlines that we 
set, are they realistic to accomplish what the Committee has 
asked you to do?
    Mr. Dominguez. Sir, we have an already scheduled session. 
We are going to go through these reports when they are due. And 
so I think I will be able to have a better sense of that for 
you later this month.
    I do want to express some disappointment that I thought we 
were tracking every one of those and had sent you interim 
reports on the deadlines that were specified that told you what 
we were doing and that we were going to be late in those cases 
where we have.
    If we missed some of those and it appears we did, I will go 
back and make sure that we tighten up that effort. I apologize 
for that.
    Mr. Buyer. I am going to now switch gears about the 
disability evaluation systems, the pilot. I think the Chairman 
and I both were pleased that the VA and DoD got an early start. 
You began the joint pilot program on the disability evaluation 
system last November.
    Combining the examinations and evaluations into one process 
and having a single rating system for the use by both 
Departments is undoubtedly, it is a cumbersome task, but it is 
something that should have been accomplished long ago. It would 
have saved wounded warriors a lot of frustration and worry that 
they should not have to endure after sacrificing so much 
already.
    I see this pilot as a great opportunity for both 
Departments to start from scratch and to put in place a 
streamlined and efficient system that avoids many of the 
complications that mire the current system.
    As you know, I am a longstanding advocate for increased use 
of information technology and the electronic medical records.
    Here are my questions. Is the pilot program establishing 
electronic file systems for its claims?
    Admiral Dunne. Sir, it is through organization of the 
interoperable health records that we are getting. However, 
there is nothing unique to the pilot for IT support. It will 
benefit from the interagency program office, which we stood up 
for health records for everyone.
    Dr. Tibbits. Right. Yes, sir. And I will just add to that, 
of course, is an accurate statement of affairs today. As that 
pilot moves forward and we and DoD get smarter on how we want 
to conduct it, we well could come to realize that some 
additional requirements are necessary. Those will be formulated 
and more IT solutions will be brought to bear. But right now 
the answer is nothing unique to that. But we intend to learn 
from it.
    Mr. Buyer. It is an interest of the Chairman and myself. 
You know, we look out there in the private sector on how well 
they do the electronic claims processing and we do not do it as 
well. And so it is of interest to us, I want you to know.
    What successes and problems has the pilot revealed thus 
far?
    Mr. Dominguez. Sir, I will just start with a little. The 
success with right now a very limited sample size of one is, in 
fact, we did compress the time from entry into the disability 
system to the time when you have a notice in your hands of here 
are the benefits you will get from the Department of Veterans 
Affairs. We compressed that quite significantly. It was about 
160 days where normally it is in excess of 500.
    That 160 days actually involves about 70 or so days of 
convenience time to the member so that there is actually, you 
know, about 90 days of administrative processing time for us in 
our two Departments. So we have compressed the time.
    The second is there is a lot more customer care, a lot more 
customer care. So it is a higher touch, higher trained people 
around this system to make it work and to make sure that the 
people going through it understand what is going on. So we 
anticipate higher satisfaction which we are now surveying with 
that.
    Mr. Buyer. Those are positive. Any problems we see so far, 
challenges?
    Admiral Dunne. Sir, there are lots of challenges in 
conducting a process like that where we are working between not 
only just VA and DoD but between each of the services because 
they all do it slightly differently in accordance with their 
instructions.
    So we have had problems similar to getting the right type 
of computer on a coordinator's desk, getting the right amount 
of bandwidth to that person's computer so that they could 
provide the service that was needed.
    In some cases, we would have someone assigned an 
appointment and we might find that their commanding officer, 
for good reasons, had sent them on leave to be with their 
family and they were not available. We had to reschedule the 
appointment.
    So there are a lot of those sort of interaction type 
things.
    Mr. Buyer. Yeah. Those are anecdotal. You do not have show-
stopper challenges, right?
    Admiral Dunne. No, sir.
    Mr. Buyer. This can be done? It can be accomplished?
    Admiral Dunne. Yes, I am confident that it can be 
accomplished, sir. And as we look toward the expansion, we are 
going to look at more challenges of having capabilities close 
at hand.
    Mr. Buyer. So to date, Admiral, are you aware of how many 
claims have been processed through the pilot up to today?
    Admiral Dunne. There is one individual who has been 
completely through the process and been discharged through that 
process, sir. There are approximately 400 individual 
servicemembers who have been enrolled in this pilot program and 
they are in various stages.
    Mr. Buyer. When did you open the door for the pilot?
    Admiral Dunne. November 26th, sir.
    Mr. Buyer. And you have only processed one person through 
since November under the pilot?
    Admiral Dunne. One person has been discharged as a result 
of that, sir.
    Mr. Buyer. How many are in the pilot right now?
    Admiral Dunne. The last number I saw, which may be as much 
as a week old, was 387.
    Mr. Buyer. Okay. And so, Secretary Dominguez, when you said 
you compressed this, your expectation and anticipation is that 
this is going to be done and processed within 160 days----
    Mr. Dominguez. Well, the----
    Mr. Buyer [continuing]. When someone comes in?
    Mr. Dominguez. Yeah. The achievement that we had with this 
one individual, again, if you count the convenience time to 
them, allowing them to take leave and those kind of things, 
which runs on our clock. But, yeah. The goal we set was to cut 
this time in half from the time you enter the disability system 
to the time you have the VA benefits. So 180 was kind of where 
we were hoping----
    Mr. Buyer. Can you give the Committee some kind of a sense? 
Maybe this is too premature to ask these questions about an 
ongoing pilot, but the Chairman and I are both eager to learn. 
What is the rate of satisfaction among people who are involved 
in the program? That is my last question.
    Mr. Dominguez. Yeah. We are surveying now, so we do not 
have anything definitive other than, you know, the anecdotes 
and the fact that we are not getting complaints. And many 
people are not appealing, you know, their ratings. But, again, 
it is so early and such preliminary numbers, it is hard to 
tell. I mean, we were very concerned that this be a process 
that our people view as more user friendly and more open and 
concerned to them as opposed to for the convenience of the 
government.
    Mr. Buyer. All right. I do have the last, last thing. So 
when can you give the testimony to the Committee, not only 
ours, but the Armed Services Committee of the House and the 
Senate, definitive that this type of pilot, your findings? A 
year?
    Admiral Dunne. Sir, we instituted the pilot for a 1-year 
period of time and expected to gather data over that period of 
time. So I would say after November 26, 2008. We would need 
time to evaluate the numbers and we would be happy to provide a 
report.
    The Chairman. Thank you, Mr. Buyer.
    I do not think either Mr. Buyer or I disguised our 
frustration very well with what is going on. You talk about 
timelines and evaluations and a year to report the status to 
this Committee.
    If your child received a brain injury or concussion in 
Iraq, would you want to wait this amount of time before we make 
sure whether he has a brain injury or the treatment for it? 
Think of that because I have said it several times. These are 
our children. We are not taking care of them properly.
    And you sit here and talk about 1-year timelines. In that 
year, you are going to have thousands and thousands of our 
bravest young men and women who are injured, who do not get the 
proper help and may commit suicide. They may commit a felony. 
They may kill a family member. We know that is happening. Get 
mad and do something about it.
    This hearing is adjourned.
    [Whereupon, at 12:46 p.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Bob Filner,
             Chairman, Full Committee on Veterans' Affairs
    I would like to thank the Members of the Committee, our witnesses, 
and all those in the audience for being here today.
    Over 33,000 servicemembers have been wounded in Operations Enduring 
Freedom and Iraqi Freedom. Due to improved battlefield medicine, those 
who might have died in past conflicts are now surviving, many with 
multiple serious injuries such as amputations, traumatic brain injury 
(TBI), and post traumatic stress disorder (PTSD).
    In February 2007, a series of Washington Post articles about 
conditions at Walter Reed Army Medical Center highlighted the 
challenges our veterans face.
    The Wounded Warrior provisions of the 2008 National Defense 
Authorization Act were intended to address these issues. Many of them 
require the Department of Veterans Affairs (VA) and the Department of 
Defense (DoD) to collaborate to improve the care, management and 
transition of recovering servicemembers.
    The hearing today will explore the progress the two Departments 
have made in implementing the Wounded Warrior provisions.
    To improve care management in the Army, 32 Warrior Transition Units 
were established. Injured Soldiers are now assigned a primary care 
manager, nurse case manager and a squad leader to guide them through 
their recovery.
    The rapid creation of WTUs are a success, however according to GAO 
several challenges remain, including hiring medical staff in a 
competitive market, replacing temporarily borrowed personnel with 
permanent staff, and getting eligible servicemembers into the units.
    In December 2007, the VA, in coordination with DoD and the 
Department of Health and Human Services, established the joint Federal 
Recovery Coordinator Program to coordinate clinical and non-clinical 
care for severely injured and ill servicemembers. As of May 7, 2008, 
there were only six field staff members working with 85 patients at 
three sites. I look forward to hearing how effective this program has 
been and how it will be expanded to benefit more veterans.
    As our injured veterans transition from the military health system 
to the VA system, they face the difficulty of navigating through two 
different and cumbersome disability evaluation systems. The current 
system is a source of stress and frustration for many veterans.
    Last November, DoD and VA jointly initiated a 1-year pilot program 
to evaluate a streamlined evaluation system. I hope the departments 
will be able to expand this program in the coming months.
    Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury 
(TBI) are considered by many to be the signature injury of the war. 
According to a RAND Corporation report released on April 17, 2008, 
nearly 300,000 veterans of OEF and OIF are suffering from PTSD or major 
depression and nearly 20 percent of the 1.64 million veterans of Iraq 
and Afghanistan reported a probable traumatic brain injury (TBI) during 
deployment.
    Unfortunately, these veterans are not getting the care they 
deserve. Only 43 percent of those reporting a probable TBI have been 
evaluated by a physician for brain injury and only half of those who 
meet the criteria for PTSD or major depression sought help from a 
physician or mental health provider. This is not acceptable and we must 
do better.
    In November 2007, the DoD established the Center of Excellence for 
Psychological Health and Traumatic Brain Injury. I look forward to 
hearing how the VA and DoD are working together to conduct research and 
develop best practices.
    An essential component toward improving continuity of care for 
veterans is the development of an interoperable electronic health 
record. This will allow for the seamless transfer of medical 
information between departments.
    Over the past year and a half, both Departments have made 
significant progress toward improving care management and transition of 
recovering servicemembers. However, much work remains to be done. I 
look forward to hearing what progress has been made, what obstacles 
remain and how this Committee can help the two Departments move ahead.
    We look forward to an informative hearing, and a frank exchange. We 
wish to thank Terri Tanielian and Lisa Jaycox on our first panel for 
coming before us today to provide us with the background we need to 
begin this discussion, and we thank Mr. Dominguez and Admiral Dunne for 
joining us to give us updates from DoD and the VA.
    No matter where we stand on the war in Iraq, we all stand together 
in our desire to make sure that our returning servicemembers get the 
seamless healthcare they need, and the benefits they have earned.

                                 
          Prepared Statement of Hon. Stephanie Herseth Sandlin
    Thank you Chairman Filner and Ranking Member Buyer for holding 
today's hearing on implementing the wounded warrior provisions of the 
National Defense Authorization Act for Fiscal Year 2008.
    Like all Americans, I was outraged by the deplorable conditions 
reported at Walter Reed Army Medical Center's outpatient facilities. I 
am hopeful that the wounded warrior provisions implemented by last 
year's Defense Authorization Act and the public outcry generated from 
the shoddy treatment of our servicemen and women will focus enough 
attention on these problems to lead to the implementation of meaningful 
changes.
    For far too long, Congress did not live up to its constitutional 
duty of asking the tough questions to ensure that government programs 
and services are run efficiently, transparently, and free of corruption 
and incompetence.
    Today's hearing will provide us a valuable opportunity to examine 
what progress has been made in implementing the wounded warrior 
provisions and to explore barriers to implementation. I look forward to 
working with fellow Members of the Committee to ensure the VA and DoD 
are improving care for our wounded servicemembers.
    Again, I want to thank everyone for taking the time to be here and 
discuss these important matters.

                                 
              Prepared Statement of Hon. Harry E. Mitchell
    Thank you, Mr. Chairman.
    Thank you also for holding this hearing, today.
    Caring for the veterans of the wars in Iraq and Afghanistan has 
been a top priority for this Committee and this Congress.
    In the past 16 months, I have heard from veterans across the Nation 
that excessive bureaucracy and substandard living arrangements are 
complicating their war injuries.
    Last year, an outraged Nation learned about the terrible conditions 
many of our wounded warriors had to endure as they recovered from their 
battlefield injuries at the Walter Reed Army Medical Center. We have 
all heard the sad stories of moldy walls and rat droppings at Building 
18.
    Even worse, we learned that these dilapidated conditions extended 
beyond Walter Reed, to other military facilities . . . and even 
veterans' facilities, where troops turned veterans faced a long, 
complicated and confusing process to get the benefits and care they 
have earned.
    Conditions like these, and miles of bureaucratic red tape, rob our 
troops and veterans of what they deserve the most: dignity; respect; 
honor.
    Following The Washington Post report, I partnered with Rep. Rahm 
Emanuel and Sens. Barack Obama and Claire McCaskill to introduce H.R. 
1268, the Dignity for Wounded Warriors Act, to address the most serious 
problems facing our servicemembers and veterans.
    I was happy to see many pieces of that legislation included in the 
2008 National Defense Authorization Act, which was signed into law this 
January.
    This is a good start, but I believe we can, and will, do better.
    Our Nation's veterans served honorably to protect us and our 
country. The least we can do is fight for them when they come home.
    I yield back the balance of my time.

                                 
                Prepared Statement of Hon. Steve Scalise
    Mr. Chairman, I want to thank you and Ranking Member Buyer for 
holding this important hearing on implementing the wounded warrior 
provisions of the National Defense Authorization Act for Fiscal Year 
2008. It is important that we examine the progress of the Departments 
of Veterans Affairs and Defense in carrying out these provisions so we 
can improve the care, management, and transition of recovering 
servicemembers.
    Throughout American history, the men and women of our armed forces 
have answered their nation's call to battle. These men and women have 
bravely sacrificed for our country and defended our freedom while 
risking their lives and livelihoods. Unfortunately, for veterans 
wounded while fighting for our country, the conflict does not end when 
they leave the battlefield. Many of our servicemembers return home with 
life-changing injuries and disabilities.
    Currently, there are more than two million veterans with service 
connected injuries or illnesses. Thousands of these veterans have 
returned from Operation Enduring Freedom and Operation Iraqi Freedom, 
many with psychological distress from the horrors of war and severe 
injuries from IED attacks and other hazards.
    Modern medical science has allowed many of these veterans to 
survive injuries that would have proven fatal in previous wars. But 
there is still much work that needs to be done to adequately treat our 
wounded warriors. Military and VA hospitals are filling with veterans 
suffering from traumatic brain injuries and post-traumatic stress 
disorder.
    We must ensure that our wounded warriors receive the best care 
available to treat their injuries when they return home. We made a 
promise to these soldiers that they would be cared for when they return 
home, and that promise must be fulfilled.
    Our servicemembers deserve the best available medical, mental 
health, and dental care services when they return home. And we must 
ensure that our soldiers have a seamless transition from military 
service to veteran status, so they will continue to get the best 
treatment possible.
    In my own district, wounded warriors may have experienced 
additional problems receiving proper care because of the closure of the 
Southeast Louisiana VA Hospital due to damage caused by Hurricane 
Katrina. Because of this closure, approximately 221,000 veterans in a 
twenty-three parish area in southeast Louisiana are having to travel up 
to four hours to go to other VA hospitals just to receive basic care.
    With the help of this Committee, and the leadership of Chairman 
Filner and Ranking Member Buyer, the House passed the VA Medical 
Facility Authorization and Lease Act, which brought the full 
authorization for our replacement hospital to $625 million, which has 
already been appropriated. I'd like to take this opportunity to thank 
the Committee for their commitment to Louisiana veterans who are still 
recovering from the 2005 storms.
    Unfortunately, our hospital is not likely to be rebuilt before 
2013. It is my commitment to the veterans in Louisiana that I will work 
to change policy so they are able to receive quality healthcare in 
their own communities by the doctors of their choice until the new VA 
hospital opens.
    I look forward to working with the Committee to ensure that our 
wounded warriors throughout the country have access to the care that 
they deserve.

                                 
              Prepared Statement of Lisa H. Jaycox, Ph.D.,
    Senior Behavioral Scientist/Clinical Psychologist, and Study Co-
                               Director,
          Invisible Wounds of War Study Team, RAND Corporation

 Invisible Wounds of War: Summary of Key Findings on Psychological and 
                           Cognitive Injuries

    Chairman Filner, Representative Buyer, and distinguished Members of 
the Committee, thank you for inviting us to testify today to present 
the findings from our study of the Invisible Wounds of War. It is an 
honor and pleasure to be here.
    My testimony will briefly discuss the prevalence of post traumatic 
stress disorder and depression, as well as the incidence of traumatic 
brain injury among servicemembers returning from Operations Enduring 
Freedom and Iraqi Freedom; the costs to society associated with these 
conditions and of providing care to those afflicted with these 
conditions, and the gaps in the care systems designed to treat these 
conditions among our Nation's servicemembers and veterans. These 
findings form the basis of several recommendations which will be 
presented in the testimony of my colleague, Terri Tanielian. Together, 
Ms. Tanielian and I co-directed more than 30 researchers at RAND in the 
completion of this study and our testimony is drawn from the same body 
of work.
Background
    Since October 2001, approximately 1.64 million U.S. troops have 
deployed as part of Operation Enduring Freedom (OEF; Afghanistan) and 
Operation Iraqi Freedom (OIF; Iraq). The pace of the deployments in 
these current conflicts is unprecedented in the history of the all-
volunteer force (Belasco, 2007; Bruner, 2006). Not only is a higher 
proportion of the armed forces being deployed, but deployments have 
been longer, redeployment to combat has been common, and breaks between 
deployments have been infrequent (Hosek, Kavanagh, and Miller, 2006). 
At the same time, episodes of intense combat notwithstanding, these 
operations have employed smaller forces and have produced casualty 
rates of killed or wounded that are historically lower than in earlier 
prolonged wars, such as Vietnam and Korea. Advances in both medical 
technology and body armor mean that more servicemembers are surviving 
experiences that would have led to death in prior wars (Regan, 2004; 
Warden, 2006). However, casualties of a different kind are beginning to 
emerge--invisible wounds, such as mental health conditions and 
cognitive impairments resulting from deployment experiences.
    As with safeguarding physical health, safeguarding mental health is 
an integral component of the United States' national responsibilities 
to recruit, prepare, and sustain a military force and to address 
Service-connected injuries and disabilities. But safeguarding mental 
health is also critical for compensating and honoring those who have 
served our Nation.
    Public concern over the handling of such injuries is running high. 
The Department of Defense (DoD), the Department of Veterans Affairs 
(VA), Congress, and the President have moved to study the issues 
related to how such injuries are handled, quantify the problems, and 
formulate policy solutions. And they have acted swiftly to begin 
implementing the hundreds of recommendations that have emerged from 
various task forces and commissions. Policy changes and funding shifts 
are already occurring for military and veterans' healthcare in general 
and for mental healthcare in particular. However, despite widespread 
policy interest and a firm commitment from DoD and the VA to address 
these injuries, fundamental gaps remain in our knowledge about the 
mental health and cognitive needs of U.S. servicemembers returning from 
Afghanistan and Iraq, the adequacy of the care systems available to 
meet those needs, the experience of veterans and servicemembers who are 
in need of services, and factors related to whether and how injured 
servicemembers and veterans seek care.
    To begin closing these gaps, RAND undertook this unprecedented, 
comprehensive study. We focused on three major conditions--post-
traumatic stress disorder (PTSD), major depressive disorder and 
depressive symptoms, and traumatic brain injury (TBI)--because these 
are the conditions being assessed most extensively in servicemembers 
returning from combat. In addition, there are obvious mechanisms that 
might link each of these conditions to specific experiences in war--
i.e., depression can be a reaction to loss; PTSD, a reaction to trauma; 
and TBI, a consequence of blast exposure or other head injury. 
Unfortunately, these conditions are often invisible to the eye. Unlike 
the physical wounds of war that maim or disfigure, these conditions 
remain invisible to other servicemembers, to family members, and to 
society in general. All three conditions affect mood, thoughts, and 
behavior; yet these wounds often go unrecognized and unacknowledged. 
The effects of traumatic brain injury are still poorly understood, 
leaving a large gap in knowledge related to how extensive the problem 
is or how to handle it.
    The study was guided by a series of overarching questions:

    Prevalence: What is the scope of mental health and cognitive 
conditions that troops face when returning from deployment to 
Afghanistan and Iraq?

    Costs: What are the costs of these conditions, including treatment 
costs and costs stemming from lost productivity and other consequences? 
What are the costs and potential savings associated with different 
levels of medical care--including proven, evidence-based care; usual 
care; and no care?

    The care system: What are the existing programs and services to 
meet the health related needs of servicemembers and veterans with post 
traumatic stress disorder, major depression, or traumatic brain injury? 
What are the gaps in the programs and services? What steps can be taken 
to close the gaps?
Key Findings
    Our study was the first of its kind to independently assess and 
address these issues from a societal perspective. Below we summarize 
the key findings of our research. We consider each of the questions in 
turn. Please note that in the findings discussed below, we use the term 
servicemembers returning from OIF or OEF, this includes servicemembers 
in the Active and Reserve component, as well as those that may have 
since separated from the military. We use the term veteran to refer to 
any servicemember who served in major combat operations.
What is the scope of mental health and cognitive issues faced by OEF/
        OIF troops returning from deployment?
    Most of the 1.64 million military servicemembers who have deployed 
in support of OIF or OEF will return home from war without problems and 
readjust successfully, but many have already returned or will return 
with significant mental health conditions. Among OEF/OIF veterans, 
rates of PTSD, major depression, and probable TBI are relatively high, 
particularly when compared with the general U.S. civilian population. A 
telephone study of 1,965 previously deployed individuals sampled from 
24 geographic areas found substantial rates of mental health problems 
in the past 30 days, with 14 percent screening positive for PTSD and 14 
percent for major depression. Major depression is often not considered 
a combat-related injury; however, our analyses suggest that it should 
be considered one of the post-deployment mental health consequences. In 
addition, 19 percent, reported a probable TBI during deployment. 
Although a substantial proportion of respondents had reported 
experiencing a TBI while they were deployed, it is not possible to know 
from the survey the severity of the injury or whether the injury caused 
functional impairment.
    Assuming that the prevalence found in this study is representative 
of the 1.64 million servicemembers who had been deployed for OEF/OIF as 
of October 2007, we estimate that approximately 300,000 individuals 
currently suffer from PTSD or major depression and that 320,000 
individuals experienced a probable TBI during deployment.
    About one-third of those previously deployed have at least one of 
these three conditions, and about 5 percent report symptoms of all 
three. Some specific groups, previously understudied--including the 
Reserve Components and those who have left military service--may be at 
higher risk of suffering from these conditions.

    Seeking and Receiving Treatment. Of those reporting a probable TBI 
while deployed, 57 percent had not been evaluated by a physician for 
brain injury. Without such clinical evaluation, it is unclear the 
extent of treatment need among those that reported a probable TBI. If 
TBI is diagnosed, treatment would depend in large part on the 
associated impairments. Military servicemembers with probable PTSD or 
major depression seek care at about the same rate as the civilian 
population, and, just as in the civilian population, many of the 
afflicted individuals were not receiving treatment. About half (53 
percent) of those who met the criteria for current PTSD or major 
depression had sought help from a physician or mental health provider 
for a mental health problem in the past year.

    Getting Quality Care. Even when individuals receive care for their 
mental health condition, too few receive acceptable quality of care. Of 
those who have a mental disorder and also sought medical care for that 
problem, just over half received a minimally adequate treatment. The 
number who received quality care (i.e., a treatment that has been 
demonstrated to be effective) would be expected to be even smaller. 
Focused efforts are needed to significantly improve both accessibility 
to care and quality of care for these groups. The prevalence of PTSD 
and major depression will likely remain high unless greater efforts are 
made to enhance systems of care for these individuals.
    Survey respondents identified many barriers that inhibit getting 
treatment for their mental health problems. In general, respondents 
were concerned that treatment would not be kept confidential and would 
constrain future job assignments and military-career advancement. About 
45 percent were concerned that drug therapies for mental health 
problems may have unpleasant side effects, and about one-quarter 
thought that even good mental healthcare was not very effective. These 
barriers suggest the need for increased access to confidential, 
evidence-based psychotherapy, to maintain high levels of readiness and 
functioning among previously deployed servicemembers and veterans.
What are the costs of these mental health and cognitive conditions to 
        the individual and to society?
    Unless treated, each of these conditions (PTSD, depression, and 
diagnosed TBI) has wide-ranging and negative implications for those 
afflicted. We considered a wide array of consequences that affect work, 
family, and social functioning, and we considered co-occurring 
problems, such as substance abuse, homelessness, and suicide. The 
presence of any one of these conditions can impair future health, work 
productivity, and family and social relationships. Individuals 
afflicted with any of these conditions are more likely to have other 
psychiatric diagnoses (e.g., substance use) and are at increased risk 
for attempting suicide. They have higher rates of unhealthy behaviors 
(e.g., smoking, overeating, unsafe sex) and higher rates of physical 
health problems and mortality. Individuals with any of these conditions 
also tend to miss more days of work or report being less productive. 
There is also a possible connection between having one of these 
conditions and being homeless. Suffering from these conditions can also 
impair relationships, disrupt marriages, aggravate the difficulties of 
parenting, and cause problems in children that may extend the 
consequences of combat experiences across generations.

    Associated Costs. In dollar terms, the costs associated with PTSD, 
depression, and diagnosed TBI stemming from the conflicts in 
Afghanistan and Iraq are substantial. We estimated costs using two 
separate methodologies. For PTSD and major depression, we used a 
microsimulation model to project two-year costs--costs incurred within 
the first two years after servicemembers return home. Because there 
were insufficient data to simulate two-year-cost projections for TBI, 
we estimated one-year costs for TBI using a standard, cost-of-illness 
approach. On a per-case basis, two-year costs associated with PTSD are 
approximately $5,904 to $10,298, depending on whether we include the 
cost of lives lost to suicide. Two-year costs associated with major 
depression are approximately $15,461 to $25,757, and costs associated 
with co-morbid PTSD and major depression are approximately $12,427 to 
$16,884. One-year costs for servicemembers who have accessed the 
healthcare system and received a diagnosis of traumatic brain injury 
are even higher, ranging from $25,572 to $30,730 in 2005 for mild cases 
($27,259 to $32,759 in 2007 dollars), and from $252,251 to $383,221 for 
moderate or severe cases ($268,902 to $408,519 in 2007 dollars). 
However, our cost figures omit current as well as potential later costs 
stemming from substance abuse, domestic violence, homelessness, family 
strain, and several other factors, thus understating the true costs 
associated with deployment-related cognitive and mental health 
conditions. Translating these cost estimates into a total-dollar figure 
is confounded by uncertainty about the total number of cases in a given 
year, by the little information that is available about the severity of 
these cases, and by the extent to which the three conditions co-occur. 
Given these caveats, we used our microsimulation model to predict two-
year costs for the approximately 1.6 million troops who have deployed 
since 2001.
    We estimate that PTSD-related and major depression-related costs 
could range from $4.0 to $6.2 billion over two years (in 2007 dollars). 
Applying the costs per case for TBI to the total number of diagnosed 
TBI cases identified as of June 2007 (2,726), our analyses estimates 
that total costs incurred within the first year after diagnosis could 
range from $591 million to $910 million (in 2007 dollars). These 
figures are for diagnosed TBI cases that led to contact with the 
healthcare system; they do not include costs for individuals with 
probable TBI who have not sought treatment or who have not been 
formally diagnosed. To the extent that additional troops deploy and 
more TBI cases occur in the coming months and years, total costs will 
rise. Because these calculations include costs for servicemembers who 
returned from deployment starting as early as 2001, many of these costs 
(for PTSD, depression, and TBI) have already been incurred. However, if 
servicemembers continue to be deployed in the future, rates of 
detection of TBI among servicemembers increase, or there are costs 
associated with chronic or recurring cases that linger beyond two 
years, the total expected costs associated with these conditions will 
increase beyond the range.

    Lost Productivity. Our findings also indicate that lost 
productivity is a key cost driver for major depression and PTSD. 
Approximately 55 to 95 percent of total costs can be attributed to 
reduced productivity; for mild TBI, productivity losses may account for 
47 to 57 percent of total costs. Because severe TBI can lead to death, 
mortality is the largest component of costs for moderate to severe TBI, 
accounting for 70 to 80 percent of total costs.

    Providing Evidence-Based Treatment for PTSD and Depression. Certain 
treatments have been shown to be effective for both PTSD and major 
depression, but these evidence-based treatments are not yet available 
in all treatment settings. We estimate that evidence-based treatment 
for PTSD and major depression would pay for itself within two years, 
even without considering costs related to substance abuse, 
homelessness, family strain, and other indirect consequences of mental 
health conditions. Evidence-based care for PTSD and major depression 
could save as much as $1.7 billion, or $1,063 per returning veteran; 
the savings come from increases in productivity, as well as from 
reductions in the expected number of suicides. Given these numbers, 
investments in evidence-based treatment would make sense from DoD's 
perspective, not only because of higher remission and recovery rates 
but also because such treatment would increase the productivity of 
servicemembers. The benefits to DoD in retention and increased 
productivity would outweigh the higher costs of providing evidence-
based care. These benefits would likely be even stronger (higher) had 
we been able to capture the full spectrum of costs associated with 
mental health conditions. However, a caveat is that we did not consider 
additional implementation and outreach costs (over and above the day-
to-day costs of care) that might be incurred if DoD and the VA 
attempted to expand evidence-based treatment beyond current capacity.
    Cost studies that do not account for reduced productivity may 
significantly understate the true costs of the conflicts in Afghanistan 
and Iraq. Currently, information is limited on how mental health 
conditions affect career outcomes within DoD. Given the strong 
association between mental health status and productivity found in 
civilian studies, research that explores how the mental health status 
of active duty personnel affects career outcomes would be valuable. 
Ideally, studies would consider how mental health conditions influence 
job performance, promotion within DoD, and transitions from DoD into 
the civilian labor force (as well as productivity after transition).

What are the existing programs and services to meet the health-related 
  needs of servicemembers with PTSD or major depression? What are the 
gaps in the programs and services? What steps can be taken to close the 
                                 gaps?

    To achieve the cost savings outlined above, servicemembers 
suffering from PTSD and major depression must be identified as early as 
possible and be provided with evidence-based treatment. The capacity of 
DoD and the VA to provide mental health services has been increased 
substantially, but significant gaps in access and quality remain.

    A Gap Between Need and Use. For the active duty population in 
particular, there is a large gap between the need for mental health 
services and the use of such services--a pattern that appears to stem 
from institutional and cultural factors barriers as well as from 
structural aspects of services (wait times, availability of providers). 
Institutional and cultural barriers to mental healthcare are 
substantial--and not easily surmounted. Military servicemembers 
expressed concerns that use of mental health services will negatively 
affect employment and constrain military career prospects, thus 
deterring many of those who need or want help from seeking it. 
Institutional barriers must be addressed to increase help-seeking and 
utilization of mental health services. In particular, the requirement 
that service usage be reported may be impeding such utilization. In 
itself, addressing the personal attitudes of servicemembers about the 
use of mental health services, although important, is not likely to be 
sufficient if the institutional barriers remain in place.

    Quality-of-Care Gaps. We also identified gaps in organizational 
tools and incentives that would support the delivery of high-quality 
mental healthcare to the active duty population, and to retired 
military who use TRICARE, DoD's health insurance plan. In the absence 
of such organizational supports, it is not possible to provide 
oversight to ensure high quality of care, which includes ensuring both 
that the treatment provided is evidence-based and that it is patient-
centered, efficient, equitable, and timely. DoD has initiated training 
in evidence-based practices for providers, but these efforts have not 
yet been integrated into a larger system redesign that values and 
provides incentives for quality of care. The newly created Defense 
Center of Excellence for Psychological Health and Traumatic Brain 
Injury, housed within DoD, represents a historic opportunity to 
prioritize a system-level focus on monitoring and improving quality of 
care; however, continued funding and appropriate regulatory authority 
will be important to sustain this focus over time. The VA provides a 
promising model of quality improvement in mental healthcare for DoD. 
Significant improvements in the quality of care the VA provides for 
depression have been documented, and efforts to evaluate the quality of 
care provided within the VA for PTSD remain under way. However, it too 
faces challenges in providing access to OEF/OIF veterans, many of whom 
have difficulty securing appointments, particularly in facilities that 
have been resourced primarily to meet the demands of older veterans. 
Better projections of the amount and type of demand among the newer 
veterans are needed to ensure that the VA has the appropriate resources 
to meet the potential demand. At the same time, OEF/OIF veterans report 
feeling uncomfortable or out of place in VA facilities (some of which 
are dated and most of which treat patients who are older and 
chronically ill), indicating a need for some facility upgrades and 
newer approaches to outreach.

    Going Beyond DoD and the VA. Improving access to mental health 
services for OEF/OIF veterans will require reaching beyond DoD and VA 
healthcare systems. Given the diversity and the geographic dispersal of 
the OEF/OIF veteran population, other options for providing health 
services, including Vet Centers, nonmedical centers that offer 
supportive counseling and other services to veterans, and other 
community-based providers, must be considered. Vet Centers already play 
a critical role and are uniquely designed to meet the needs of 
veterans. Further expansion of Vet Centers could broaden access, 
particularly for veterans in underserved areas. Networks of community-
based mental health specialists (available through private, employer-
based insurance, including TRICARE) may also provide an important 
opportunity to build capacity. However, taking advantage of this 
opportunity will require critical examination of the TRICARE 
reimbursement rates, which may limit network participation.
    Although Vet Centers and other community-based providers offer the 
potential for expanded access to mental health services, ways to 
monitor performance and quality among these providers will be essential 
to ensuring quality care. Although ongoing training for providers is 
being made broadly available, it is not supported with a level of 
supervision that will result in high-quality care. Systems for 
supporting delivery of high-quality care (information systems, 
performance feedback) are currently lacking in these sectors. 
Commercial managed healthcare organizations have some existing 
approaches and tools to monitor quality that may be of value and 
utility, but many of the grassroots efforts currently emerging to serve 
OEF/OIF veterans do not.

What are the existing programs and services to meet the health-related 
  needs of those with Traumatic Brain Injuries? What are the gaps in 
           care? What steps can be taken to close those gaps?

    The medical science for treating combat-related traumatic brain 
injury is in its infancy. Research is urgently needed to develop 
effective screening tools that are both valid and sensitive, as well as 
to document what treatment and rehabilitation will be most effective. 
For mild TBI (or concussion), a head injury that may or may not result 
in symptoms and long term neurocognitive deficits, we found gaps in 
access to services stemming from poor documentation of blast exposures 
and failure to identify individuals with probable TBI. These gaps not 
only hamper provision of acute care but may also place individuals at 
risk of additional blast exposures. Servicemembers with more severe 
injuries face a different kind of access gap: lack of coordination 
across a continuum of care. Because of the complex nature of healthcare 
associated with severe combat injuries, including moderate and severe 
TBI, an individual's need for treatment, as well as for supportive and 
rehabilitative services, will change over time and involve multiple 
transitions across systems. Task forces, commissions, and review groups 
have already identified multiple challenges arising from these 
complexities; these challenges remain the focus of improvement 
activities in both DoD and the VA.
Summary
    Our study revealed a high prevalence (18\1/2\ percent) of current 
PTSD and depression among servicemembers who had returned from OEF or 
OIF, as well as significant gaps in access to and the quality of care 
provided to this population. Too few of those with PTSD and depression 
were getting help, and among those that were getting help too few were 
getting even minimally adequate care. If left untreated or under-
treated, these conditions can have negative, cascading consequences and 
result in a high economic toll. Investing in evidence-based care for 
all of those in need can reduce the costs to society in just two years.
    With respect to TBI, we found that approximately 19 percent report 
having experienced a probable TBI during deployment but that 57 percent 
of them had not been evaluated by a physician for a head injury. While 
the majority of these cases were likely to be mild, similar to a 
concussion, the extent of impairment in this group remains unknown. At 
the same time, the science of treating combat-related traumatic brain 
injury remains in its infancy leaving many unknowns for planning and 
delivering high quality care to those suffering from long-term 
impairments associated with TBI.
    Thank you again for the opportunity to testify today and to share 
the results of our research. Additional information about our study 
findings and recommendations can be found at http://veterans.rand.org.
References Cited
    Belasco, A. The Cost of Iraq, Afghanistan, and Other Global War on 
Terror Operations Since 9/11. Washington, D.C.: Congressional Research 
Service, 2007.
    Bruner, E. F. Military Forces: What Is the Appropriate Size for the 
United States? Washington, D.C.: Congressional Research Service, 2006.
    Hosek, J., J. Kavanagh, and L. Miller. How Deployments Affect 
Servicemembers. Santa Monica, Calif.: RAND Corporation, MG-432-RC, 
2006. As of March 13, 2008: http://www.rand.org/pubs/monographs/MG432/.
    Institute of Medicine, Committee on Treatment of Posttraumatic 
Stress Disorder, Board on Population Health and Public Health Practice. 
Treatment of Posttraumatic Stress Disorder: An Assessment of the 
Evidence. Washington, D.C.: National Academies Press, 2007.
    Regan, T. Report: High survival rate for U.S. troops wounded in 
Iraq. Christian Science Monitor, November 29, 2004.
    Warden, D. Military TBI during the Iraq and Afghanistan wars. 
Journal of Head Trauma Rehabilitation, Vol. 21, No. 5, 2006, pp. 398-
402.

                               __________
    The summary of ``Invisible Wounds of War--Psychological and 
Cognitive Injuries, Their Consequences, and Services to Assist 
Recovery'' can be found at http://www.rand.org/pubs/monographs/2008/
RAND_MG720.sum.pdf
    The full report of ``Invisible Wounds of War--Psychological and 
Cognitive Injuries, Their Consequences, and Services to Assist 
Recovery'' can be found at http://www.rand.org/pubs/monographs/2008/
RAND_MG720.pdf

                               __________
    ** The opinions and conclusions expressed in this testimony are the 
author's alone and should not be interpreted as representing those of 
RAND or any of the sponsors of its research. This product is part of 
the RAND Corporation testimony series. RAND testimonies record 
testimony presented by RAND associates to Federal, state, or local 
legislative Committees; government-appointed commissions and panels; 
and private review and oversight bodies. The RAND Corporation is a 
nonprofit research organization providing objective analysis and 
effective solutions that address the challenges facing the public and 
private sectors around the world. RAND's publications do not 
necessarily reflect the opinions of its research clients and sponsors.
    This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT307/

                                 
       Prepared Statement of Terri L. Tanielian, MA, Co-Director,
   Center for Military Health Policy Research, and Study Co-Director,
          Invisible Wounds of War Study Team, RAND Corporation

 Invisible Wounds of War: Recommendations for Addressing Psychological 
                         and Cognitive Injuries

    Chairman Filner, Representative Buyer, and distinguished Members of 
the Committee, thank you for inviting me to testify today to discuss 
the findings and recommendations from our study of the Invisible Wounds 
of War. It is an honor and pleasure to be here.
    My testimony will briefly discuss several recommendations for 
addressing the psychological and cognitive injuries among 
servicemembers returning from deployments to Operations Enduring 
Freedom and Iraqi Freedom. Dr. Jaycox shared with you our findings 
about the prevalence of post traumatic stress disorder and depression, 
as well as the incidence of traumatic brain injury among servicemembers 
returning from Operations Enduring Freedom and Iraqi Freedom; the costs 
to society associated with these conditions and of providing care to 
those afflicted with these conditions, and the gaps in the care systems 
designed to treat these conditions among our Nation's servicemembers 
and veterans. Together, Dr. Jaycox and I co-directed more than 30 
researchers at RAND in the completion of this study and our testimony 
is drawn from the same body of work. The purpose of these 
recommendations is to close the gaps in access and quality for our 
Nation's veterans that Dr. Jaycox briefly described in her testimony.
Background
    Throughout its history, the United States has striven to recruit, 
prepare, and sustain an armed force with the capacity and capability to 
defend the Nation. The Department of Defense (DoD), through the 
Secretary of Defense and the Services, bears the responsibility for 
ensuring that the force is ready and deployable to conduct and support 
military operations. The Nation has committed not only to compensating 
military servicemembers for their duty but also to addressing and 
providing compensation, benefits, and medical care for any Service-
connected injuries and disabilities. For those who suffer injuries but 
remain on active duty, benefits and medical care are typically provided 
through DoD, which remains their employer. Veterans who have left the 
military may be eligible for healthcare and other benefits (disability, 
vocational training), as well as memorial and burial services, through 
the Department of Veterans Affairs (VA).
    Safeguarding mental health is an integral part of the national 
responsibility to recruit, prepare, and sustain a military force and to 
address Service-connected injuries and disabilities. Safeguarding 
mental health is also critical for compensating and honoring those who 
have served the nation. The Departments of Defense and Veterans Affairs 
are primarily responsible for these critical tasks; however, other 
Federal agencies (e.g., the Department of Labor) and states also play 
important roles in ensuring that the military population is not only 
ready as a national asset but also valued as a national priority. Our 
research focused mainly on services available through DoD and the VA; 
however, where applicable, we also examined state programs and other 
resources.
Addressing the Invisible Wounds of War
    With the United States still involved in military operations in 
Afghanistan and Iraq, psychological and cognitive injuries among those 
deployed in support of Operations Enduring Freedom (OEF) and Iraqi 
Freedom (OIF) are of growing concern. Most servicemembers return home 
from deployment without problems and successfully readjust to ongoing 
military employment or work in civilian settings. But others return 
with mental health conditions, such as post traumatic stress disorder 
(PTSD) or major depression, and some have suffered a traumatic brain 
injury (TBI), such as a concussion, leaving a portion of sufferers with 
cognitive impairments. Our analyses found that approximately 18\1/2\ 
percent of U.S. servicemembers who have returned from Afghanistan and 
Iraq currently have post traumatic stress disorder or depression; and 
19 percent report experiencing a probable traumatic brain injury while 
they were deployed. Based on the existing literature, our study found 
that these conditions can have negative, cascading consequences if left 
untreated. In addition, the economic costs to society associated with 
PTSD and depression among veterans are high, totaling an estimated $6.2 
billion over two years following deployment. Our research demonstrated 
that delivering evidence based treatment to all of combat veterans 
afflicted with PTSD and depression would significantly reduce these 
costs to society.
    Despite widespread policy interest and a firm commitment from the 
Departments of Defense and Veterans Affairs to address these injuries, 
fundamental gaps remain in the understanding of these conditions and 
the adequacy of the care systems to meet the mental health and 
cognitive needs of U.S. servicemembers returning from Afghanistan and 
Iraq. RAND undertook this comprehensive study to examine these 
conditions and make their consequences visible. Our study focused on 
three major conditions--post traumatic stress disorder, major 
depression, and traumatic brain injury--because there are obvious 
mechanisms that link each of these conditions to specific experiences 
in war. All three conditions affect mood, thoughts, and behavior, yet 
these conditions often go unrecognized or unacknowledged. In addition, 
the effects of traumatic brain injury are still poorly understood, 
leaving a substantial gap in knowledge about the extent of the problem 
and its effective treatment.
Closing the Gaps
    Concern about the invisible wounds of war is increasing, and many 
efforts to identify and treat those wounds are already under way. Our 
data show that these mental health and cognitive conditions are 
widespread; in a cohort of otherwise-healthy, young individuals they 
represent the primary type of morbidity or illness for this population 
in the coming years. Unfortunately, only about half of those who need 
treatment for a mental health condition sought it in the past year. 
Servicemembers and veterans report several barriers to seeking care, 
including concerns about negative career repercussions if they seek 
help for a mental health problem.
    What is most worrisome is that these problems are not yet fully 
understood, particularly TBI, and systems of care are not yet fully 
available to assist recovery for any of the three conditions. OEF and 
OIF veterans, depending on their current status, may be eligible to 
seek care through the Department of Defense or the Department of 
Veterans Affairs. Many may also seek care in the private sector. Our 
analyses found that while effective treatments for these conditions 
exist, they were not being implemented in all sectors that provide 
healthcare to OEF and OIF veterans. In addition, our survey found that 
only slightly more than half of those with PTSD and depression who 
receive treatment get what is defined as minimally adequate care. Our 
review of the systems of care also found that the use of performance 
and quality monitoring techniques was lacking in several of the sectors 
that serve OEF and OIF veterans. Our analyses also concluded that 
improving access to high quality care can be cost-effective and improve 
recovery rates. Improving access to high quality care for these 
veterans, however, will require closing the gaps in access and quality 
that our study identified.
    Looking across the dimensions of our analysis and findings, our 
report offers four specific recommendations that would improve the 
understanding and treatment of PTSD, major depression, and TBI among 
military servicemembers and veterans. Below, I briefly describe each 
recommendation and then discuss some of the issues that would need to 
be addressed for its successful implementation. To the greatest extent 
possible efforts to address these recommendations should be 
standardized to the greatest extent possible within DoD (across Service 
branches, with appropriate guidance from the Assistant Secretary of 
Defense for Health Affairs), within the VA (across healthcare 
facilities and Vet Centers), and across these systems and extended into 
the community-based civilian sector. These policies and programs must 
be consistent within and across these sectors in order to have the 
intended effect on care seeking and improvements in quality of care for 
our Nation's veterans.
 1. Increase the cadre of providers who are trained and certified to 
        deliver proven (evidence-based) care, so that capacity is 
        adequate for current and future needs.
    There is substantial unmet need for treatment of PTSD and major 
depression among military servicemembers following deployment. Both DoD 
and the VA have had difficulty in recruiting and retaining 
appropriately trained mental health professionals to fill existing or 
new slots. With the possibility of more than 300,000 new cases of 
mental health conditions among OEF/OIF veterans, a commensurate 
increase in treatment capacity is needed. Increased numbers of trained 
and certified professionals are needed to provide high-quality care 
(evidence-based, safe, patient-centered, efficient, equitable, and 
timely care) in all sectors, both military and civilian, serving 
previously deployed personnel. Although the precise increase of newly 
trained providers is not yet known, it is likely to number in the 
thousands. These would include providers not just in specialty mental 
health settings but also embedded in settings such as primary care, 
where servicemembers are already served. Stakeholders consistently 
referred to challenges in hiring and retaining trained mental health 
providers. Determining the exact number of providers will require 
further analyses of demand projections over time, taking into account 
the expected length of evidence-based treatment and desired utilization 
rates. Additional training in evidence-based approaches for trauma will 
also be required for tens of thousands of existing providers. Moreover, 
since there is already an increased need for services, the required 
expansion in trained providers is already several years overdue.
    This large-scale training effort necessitates substantial 
investment immediately. Such investment could be facilitated by several 
strategies, including the following:

      Adjustment of financial reimbursement for providers to 
offer appropriate compensation and incentives to attract and retain 
highly qualified professionals and ensure motivation for delivering 
quality care.
      Development of a certification process to document the 
qualifications of providers. To ensure that providers have the skills 
to implement high-quality therapies, substantial change from the status 
quo is required. Rather than relying on a system in which any licensed 
counselor is assumed to have all necessary skills regardless of 
training, certification should confirm that a provider is trained to 
use specific evidence-based treatments for specific conditions. 
Providers would also be required to demonstrate requisite knowledge of 
unique military culture, military employment, and issues relevant to 
veterans (gained through their prior training and through the new 
training/certification our report recommends).
      Expansion of existing training programs for 
psychiatrists, psychologists, social workers, marriage and family 
therapists, and other counselors. Programs should include training in 
specific therapies related to trauma and to military culture.
      Establishment of regional training centers for joint 
training of DoD, VA, and civilian providers in evidence-based care for 
PTSD and major depression. The centers should be federally funded. This 
training could occur in coordination with or through the Department of 
Health and Human Services. Training should be standardized across 
training centers to ensure both consistency and increase fidelity in 
treatment delivery.
      Linkage of certification to training to ensure that 
providers not only receive required training but also are supervised 
and monitored to verify that quality standards are met and maintained 
over time.
      Retraining or expansion of existing providers within DoD 
and the VA (e.g., military community-service program counselors) to 
include delivery or support of evidence-based care.
      Evaluation of training efforts as they are rolled out, so 
that there is an understanding about how much training is needed and of 
what type, thereby ensuring delivery of effective care.

 2. Change policies to encourage active duty personnel and veterans to 
        seek needed care.
    Creating an adequate supply of well-trained professionals to 
provide care is but one facet of ensuring access to care. Strategies 
must also increase demand for necessary services. Many servicemembers 
are reluctant to seek services for fear of negative career 
repercussions. Policies must be changed so that there are no perceived 
or real adverse career consequences for individuals who seek treatment, 
except when functional impairment (e.g., poor job performance or being 
a hazard to oneself or others) compromises fitness for duty. Primarily, 
such policies will require creating new ways for servicemembers and 
veterans to obtain treatments that are confidential, to operate in 
parallel with existing mechanisms for receiving treatment (e.g., 
command referral, unit-embedded support, or self-referral). We are not 
suggesting that the confidentiality of treatment should be absolute; 
both military and civilian treatment providers already have a legal 
obligation to report to authorities/commanders any patients that 
represent a threat to themselves or others. However, information about 
being in treatment is currently available to command staff, even though 
treatment itself is not a sign of dysfunction or poor job performance 
and may not have any relationship to deployment eligibility. Providing 
an option for confidential treatment has the potential to increase 
total-force readiness by encouraging individuals to seek needed 
healthcare before problems accrue to a critical level. In this way, 
mental health treatment would be appropriately used by the military as 
a tool to avoid or mitigate functional impairment, rather than as 
evidence of functional impairment. Our analyses suggest that this 
option would ultimately lead to better force readiness and retention, 
and thus be a beneficial change for both the organization and the 
individual. This recommendation would require resolving many practical 
challenges, but it is vital for addressing the mental health problems 
of servicemembers who, out of concern for their military careers, are 
not seeking care. Specific strategies for facilitating care seeking 
include the following:

      Developing strategies for early identification of 
problems that can be confidential, so that problems are recognized and 
care sought early before the problems lead to impairments in daily 
life, including job function or eligibility for deployment.
      Developing ways for servicemembers to seek mental 
healthcare voluntarily and off-the-record, including ways to allow 
servicemembers to seek this care off-base if they prefer and ways to 
pay for confidential mental healthcare (that is not necessarily tied to 
an insurance claim from the individual servicemember). Thus, the care 
would be offered to military personnel without mandating disclosure, 
unless the servicemember chooses to disclose use of mental healthcare 
or there is a command-initiated referral to mental healthcare.
      Separating the system for determining deployment 
eligibility from the mental healthcare system. This may require the 
development of new ways to determine fitness for duty and eligibility 
for deployment that do not include information about mental health 
service use.
      Making the system transparent to servicemembers so that 
they understand how information about mental health services is and is 
not used. This may help mitigate servicemembers' concerns about 
detriments to their careers.

 3. Deliver proven, evidence-based care to servicemembers and veterans 
        whenever and wherever services are provided.
    Our extensive review of the scientific literature documented that 
treatments for PTSD and major depression vary substantially in their 
effectiveness. In addition, the recent report from the Institute of 
Medicine shows reasonable evidence for treatments for PTSD among 
military servicemembers and veterans (Institute of Medicine, 2007). Our 
evaluation shows that the most effective treatments are being delivered 
in some sectors of the care system for military personnel and veterans, 
but that gaps remain in system-wide implementation. Delivery of 
evidence-based care to all veterans with PTSD or major depression would 
pay for itself, or even save money, by improving productivity and 
reducing medical and mortality costs within only two years. Providing 
evidence-based care is not only the humane course of action but also a 
cost-effective way to retain a ready and healthy military force for the 
future. Providing one model, the VA is at the forefront of trying to 
ensure that evidence-based care is delivered to its patient population, 
but the VA has not yet fully evaluated the success of its efforts 
across the entire system. Our analysis suggests requiring all providers 
who treat military personnel to use treatment approaches empirically 
demonstrated to be effective. This requirement would include uniformed 
providers in theater and embedded in active duty units; primary and 
specialty care providers within military and VA healthcare facilities 
and Vet Centers; and civilian providers. Evidence-based approaches to 
resilience-building and other programs need to be enforced among 
informal providers, including promising prevention efforts pre-
deployment, noncommissioned officer support models in theater, and the 
work of chaplains and family support providers. Such programs could 
bolster resilience before mental health conditions develop, or help to 
mitigate the long-term consequences of mental health conditions. The 
goal of this requirement is not to stifle innovation or prevent 
tailoring of treatments to meet individual needs, but to ensure that 
individuals who have been diagnosed with PTSD or major depression are 
provided the most effective evidence based treatment available. Some 
key transformations may be required to achieve this needed improvement 
in the quality of care:

      The ``black box'' of psychotherapy delivered to veterans 
must be made more transparent, making providers accountable for the 
services they are providing. Doing so might require that TRICARE and 
the VA implement billing codes to indicate the specific type of therapy 
delivered, documentation requirements (i.e., structured medical note-
taking that needs to accompany billing), and the like.
      TRICARE and the VA should require that all patients be 
treated by therapists who are certified to handle the diagnosed 
disorders of that patient.
      Veterans should be empowered to seek appropriate care by 
being informed about what types of therapies to expect, the benefits of 
such therapies, and how to evaluate for themselves whether they are 
receiving quality care.
      A monitoring system could be used to ensure sustained 
quality and coordination of care and quality improvement. Transparency, 
accountability, and training/certification, as described above, would 
facilitate ongoing monitoring of effectiveness that could inform 
policymaking and form the basis for focused quality improvement 
initiatives (e.g., through performance measurement and evaluation). 
Additionally, linking performance measurements to reimbursement and 
incentives for providers may also promote delivery of quality care.

 4. Invest in research to close information gaps and plan effectively.
    In many respects, this study raised more research questions than it 
provided answers. Better understanding is needed of the full range of 
problems (emotional, economic, social, health, and other quality-of-
life deficits) that confront individuals with post-combat PTSD, major 
depression, and TBI. This knowledge is required both to enable the 
healthcare system to respond effectively and to calibrate how 
disability benefits are ultimately determined. Greater knowledge is 
needed to understand who is at risk for developing mental health 
problems and who is most vulnerable to relapse, and how to target 
treatments for these individuals. Policymakers need to be able to 
accurately measure the costs and benefits of different treatment 
options so that fiscally responsible investments in care can be made. 
Better documentation how these mental health and cognitive conditions 
affect families of servicemembers and veterans is needed so that 
appropriate support services can be provided. Sustained research is 
also needed into the effectiveness of treatments, particularly 
treatments that can improve the functioning of individuals who do not 
improve from the current evidence-based therapies. Finally, more 
research is needed that evaluates the effects of policy changes 
implemented to address the injuries of OEF/OIF veterans, including how 
such changes affect the health and well-being of the veterans, the 
costs to society, and the state of military readiness and 
effectiveness. Addressing these vital questions will require a 
substantial, coordinated, and strategic research effort. Several types 
of studies are needed to address these information gaps. A coordinated 
Federal research agenda on these issues within the veterans' population 
is needed. Further, to adequately address knowledge gaps will require 
funding mechanisms that encourage longer term research that examines a 
broader set of issues than can be financed within the mandated 
priorities of an existing funder or agency. Such a research program 
would likely require funding in excess of that currently devoted to 
PTSD and TBI research through DoD and the VA, and would extend to the 
National Institutes of Health, the Substance Abuse and Mental Health 
Services Administration, the Centers for Disease Control and 
Prevention, and the Agency for Healthcare Research and Quality. These 
agencies have limited research activities relevant to military and 
veteran populations, but these populations have not always been 
prioritized within their programs.
    Initial strategies for implementing this national research agenda 
include the following:

      Launch a large, longitudinal study on the natural course 
of these mental health and cognitive conditions among OEF/OIF veterans, 
including predictors of relapse and recovery. Ideally, such a study 
would gather data pre-deployment, during deployment, and at multiple 
time points post-deployment. The study should be designed so that its 
findings can be generalized to all deployed servicemembers while still 
facilitating identification of those at highest risk, and it should 
focus on the causal associations between deployment and mental health 
conditions. A longitudinal approach would also make it possible to 
evaluate how use of healthcare services affects symptoms, functioning, 
and outcomes over time; how TBI and mental health conditions affect 
physical health, economic productivity, and social functioning; and how 
these problems affect the spouses and children of servicemembers and 
veterans. These data would greatly inform how services are arrayed to 
meet evolving needs within this population of veterans. They would also 
afford a better understanding of the costs of these conditions and the 
benefits of treatment so that the Nation can make fiscally responsible 
investments in treatment and prevention programs. Some ongoing studies 
are examining these issues (Smith et al., 2008; Vasterling et al., 
2006); however, they are primarily designed for different purposes and 
thus can provide only partial answers.
      Continue to aggressively support research to identify the 
most effective treatments and approaches, especially for TBI care and 
rehabilitation. Although many studies are already under way or under 
review (as a result of the recent congressional mandate for more 
research on PTSD and TBI), an analysis that identifies priority-
research needs within each area could add value to the current programs 
by informing the overall research agenda and creating new program 
opportunities in areas in which research may be lacking or needed. More 
research is also needed to evaluate innovative treatment methods, since 
not all individuals benefit from the currently available treatments.
      Evaluate new initiatives, policies, and programs. Many 
new initiatives and programs designed to address psychological and 
cognitive injuries have been put into place, ranging from screening 
programs and resiliency training, to use of care managers and recovery 
coordinators, to implementation of new therapies. Each of these 
initiatives and programs should be carefully evaluated to ensure that 
it is effective and is improving over time. Only programs that 
demonstrate effectiveness should be maintained and disseminated.

Treating the Invisible Wounds of War
    Addressing PTSD, depression, and TBI among those who deployed to 
Afghanistan and Iraq should be a national priority. But it is not an 
easy undertaking. The prevalence of these injuries is relatively high 
and may grow as the conflicts continue. And long-term negative 
consequences are associated with these injuries if they are not treated 
with evidence-based, patient-centered, efficient, equitable, and timely 
care. The systems of care available to address these injuries have been 
improved significantly, but critical gaps remain.
    The Nation must ensure that quality care is available and provided 
to its military veterans now and in the future. As a group, the 
veterans returning from Afghanistan and Iraq are predominantly young, 
healthy, and productive members of society. However, about a third are 
currently affected by PTSD or depression, or report exposure to a 
possible TBI while deployed. Whether the TBIs will translate into any 
lasting impairments is unknown. In the absence of knowing, these 
injuries cause great concern for servicemembers and their families. 
These veterans need our attention now, to ensure a successful 
adjustment post-deployment and a full recovery.
    Meeting the goal of providing quality care for these servicemembers 
will require system-level changes, which means expanding our focus to 
consider issues not just within DoD and the VA, from which the majority 
of veterans will receive benefits, but across the overall U.S. 
healthcare system, where veterans may seek care through other, 
employer-sponsored health plans and in the public sector (e.g., 
Medicaid). System-level changes are essential if the Nation is to meet 
not only its responsibility to recruit, prepare, and sustain a military 
force but also its responsibility to address Service-connected injuries 
and disabilities.
    Thank you again for the opportunity to testify today and to share 
the results of our research. Additional information about our study 
findings and recommendations can be found at http://veterans.rand.org.
References Cited
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Preparedness. Evaluation of Services for Seriously Mentally Ill 
Patients in the Veterans Health Administration of the Department of 
Veterans Affairs, Revised Statement of Work. Washington, D.C., March 
2006.
    ``Executive Order Establishing Task Force; Executive Order 13426--
Establishing a Commission on Care for America's Returning Wounded 
Warriors and a Task Force on Returning Global War on Terror Heroes.'' 
Federal Register, March 8, 2007, Appendix A. As of December 31, 2007: 
http://www1.va.gov/taskforce/.
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stress disorder, Board on Population Health and Public Health Practice. 
Treatment of post traumatic stress disorder: An Assessment of the 
Evidence. Washington, D.C.: National Academies Press, 2007.
    President's Commission on Care for America's Returning Wounded 
Warriors. Serve, Support, Simplify: Report of the President's 
Commission on Care for America's Returning Wounded Warriors. July 2007.
    Smith, T. C., M. A. K. Ryan, D. L. Wingard, D. J. Slymen, J. F. 
Sallis, and D. Kritz-Silverstein. New onset and persistent symptoms of 
post traumatic stress disorder self reported after deployment and 
combat exposures: Prospective population based U.S. military cohort 
study. British Medical Journal, January 15, 2008.
    Vasterling, J. J., S. P. Proctor, P. Amoroso, R. Kane, T. Heeren, 
and R. F. White. Neuropsychological outcomes of Army personnel 
following deployment to the Iraq war. Journal of the American Medical 
Association, Vol. 296, No. 5, August 2, 2006, pp. 519-529.

                               __________
    The summary of ``Invisible Wounds of War--Psychological and 
Cognitive Injuries, Their Consequences, and Services to Assist 
Recovery'' can be found at http://www.rand.org/pubs/monographs/2008/
RAND_MG720.sum.pdf
    The full report of ``Invisible Wounds of War--Psychological and 
Cognitive Injuries, Their Consequences, and Services to Assist 
Recovery'' can be found at http://www.rand.org/pubs/monographs/2008/
RAND_MG720.pdf

                               __________
    ** The opinions and conclusions expressed in this testimony are the 
author's alone and should not be interpreted as representing those of 
RAND or any of the sponsors of its research. This product is part of 
the RAND Corporation testimony series. RAND testimonies record 
testimony presented by RAND associates to Federal, state, or local 
legislative Committees; government-appointed commissions and panels; 
and private review and oversight bodies. The RAND Corporation is a 
nonprofit research organization providing objective analysis and 
effective solutions that address the challenges facing the public and 
private sectors around the world. RAND's publications do not 
necessarily reflect the opinions of its research clients and sponsors.
    This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT308/.

                                 
     Prepared Statement of Hon. Patrick W. Dunne, RADM, USN (Ret.),
    Acting Under Secretary for Benefits, and Assistant Secretary for
         Policy and Planning, Veterans Benefits Administration,
                  U.S. Department of Veterans Affairs
    Good morning Chairman Filner, Ranking Member Buyer, and Members of 
the Committee. Thank you for inviting me here to update the Committee 
on the Department of Veterans Affairs' (VA) progress in implementing 
the wounded warrior provisions in the National Defense Authorization 
Act of Fiscal Year 2008. I also would like to thank the Committee for 
its work in passing this important legislation, and I am pleased to 
report VA and the Department of Defense (DoD) are making demonstrable 
progress in implementing the provisions of the Wounded Warrior Act, 
title XVI of Public Law 110-181, which addresses those matters that 
require VA and DoD cooperation to improve the care, management and 
transition of recovering servicemembers. I will describe VA and joint 
VA/DoD efforts with respect to eight specific sections of the law in 
which this Committee has particular interest. I am accompanied today by 
Dr. Madhulika Agarwal, Chief Patient Care Services Officer for the 
Veterans Health Administration (VHA), and Dr. Paul Tibbits, Deputy 
Chief Information Officer, Office of Enterprise Development.
Section 1611. Comprehensive policy on improvement to care, management, 
        and transition of recovering servicemembers
    Section 1611 requires VA and DoD to:

      Jointly develop and implement a comprehensive policy on 
improvements to the care, management, and transition of recovering 
servicemembers.
      Jointly and separately conduct a review of all policies 
and procedures of VA and DoD that apply to, or shall be covered by, the 
comprehensive policy described above.

    In January 2008, VA awarded a contract for two studies on 
disability benefits. The first study will examine the nature and 
feasibility of making ``long-term transition payments'' to veterans 
undergoing rehabilitation. The second study concerns appropriate 
compensation for loss in earnings capacity and information on potential 
quality of life payments. The report on both study findings is due to 
VA by August 2008 and will inform VA efforts regarding disability 
benefits' policies and procedures.
    As part of our comprehensive policy, VA is working on two 
handbooks: one for our Federal Recovery Coordinators, and another for 
Transition Assistance and Case Management of Operation Enduring Freedom 
(OEF) and Operation Iraqi Freedom (OIF) Veterans.
    VA, in collaboration with DoD, is developing a Federal Recovery 
Coordinator (FRC) handbook, which will significantly improve care for 
veterans and servicemembers. The FRC Handbook describes primary 
approaches and available resources to Federal Recovery Coordinators 
(FRCs) and other care managers. This handbook will guide the FRCs in 
the delivery of all needed programs and services to recovering 
servicemembers and veterans. In an effort to comply with section 1611 
and to maintain the handbook's value, VHA's Care Management and Social 
Work Service will be responsible for the final review of the FRC 
Handbook. The target date for completion of this handbook is summer 
2008.
    VA completed a separate handbook on the Transition Assistance and 
Case Management of OEF/OIF Veterans on May 31, 2007. VA will continue 
to review and update the Handbook as necessary.
    Another effort currently underway is a charter group comprised of 
specialty care managers across VA including OEF/OIF teams, spinal cord, 
blind rehabilitation, mental health, polytrauma and others. This group 
will be making recommendations for a systemwide approach to care 
management with emphasis on the coordination between programs. This 
charter group is expected to submit its report to VA leadership in July 
2008. In addition, this charter group will assist in the development of 
VHA policy for care management.
Section 1612. Medical evaluations and physical disability evaluations 
        of recovering servicemembers
    Section 1612 requires:

      The Secretary of Defense shall, no later than July 1, 
2008, develop a policy on improvements to the processes, procedures, 
and standards for the conduct by the military departments of medical 
evaluations of recovering servicemembers.
      The Secretary of Defense and the Secretary of Veterans 
Affairs shall, no later than July 1, 2008, develop a policy on 
improvements to the processes, procedures, and standards for the 
conduct of physical disability evaluations of recovering servicemembers 
by the military departments and by the Department of Veterans Affairs.
      The Secretary of Defense and the Secretary of Veterans 
Affairs shall jointly submit to the appropriate Committees of Congress 
a report on the feasibility and advisability of consolidating the 
disability evaluation systems of the military departments and the 
disability evaluation system of the Department of Veterans Affairs into 
a single disability evaluation system.

    VA and DoD are improving the medical and disability evaluation 
processes. This was a key recommendation by the President's Commission 
on Care for America's Returning Wounded Warriors, chaired by former 
Senator Dole and former Secretary Shalala. We are currently piloting a 
joint VA/DoD medical examination process for servicemembers from Walter 
Reed Army Medical Center, National Naval Medical Center at Bethesda, 
and Malcolm Grow Medical Center. This pilot combines the examination 
processes into one examination and the evaluation processes into one 
rating decision for use by both VA and DoD and is currently in 
operation at the Washington, D.C. VA Medical Center. Military 
Departments make the Fitness for Duty determination using the above 
information.
Section 1614. Transition of recovering servicemembers from care and 
        treatment through the Department of Defense for the care, 
        treatment, and rehabilitation through VA
    Section 1614 requires VA and DoD to jointly develop and implement 
processes, procedures, and standards for the transition of recovering 
servicemembers from DoD to VA.
    On August 31, 2007, the Deputy Secretaries of Defense and Veterans 
Affairs signed a Memorandum of Understanding establishing the Federal 
Recovery Coordination Program (FRCP) as a joint VA/DoD Program. This 
program was implemented in January 2008. VA and DoD continue to jointly 
review and develop this program through recurring meetings and 
initiatives.
    On January 7, 2008, the newly identified FRCs completed a 
comprehensive VA and DoD training program, which included specialized 
training on the newly developed Federal Individualized Recovery Plan 
(FIRP). FRCs are already developing FIRPs for severely injured 
servicemembers and veterans. As of June 1, 2008, this program has 
enrolled and is currently serving 80 servicemembers and veterans. 
Presently, an ongoing, iterative approach to enhance the FIRP is 
underway to ensure those needs identified by recovering servicemembers 
and veterans are included as the program matures. Over time, the FRCP 
will take increasing advantage of onsite mentoring and online delivery 
of training resources to ensure our Coordinators are employing best 
practices and are responsive to the needs of America's brave wounded 
warriors.
    Sections 1618, 1621, and 1622 of the 2008 National Defense 
Authorization Act (NDAA) assign DoD primary responsibility for 
establishing traumatic brain injury (TBI) and post traumatic stress 
disorder (PTSD) Centers of Excellence and for establishing a 
comprehensive plan to deal with TBI and mental health conditions. VA is 
collaborating with DoD to support these efforts.
Section 1618. Comprehensive plan on prevention, diagnosis, mitigation, 
        treatment, and rehabilitation of, and research on, traumatic 
        brain injury, post traumatic stress disorder, and other mental 
        health conditions in members of the Armed Forces
    Section 1618 requires joint planning between VA, DoD, and the 
military departments regarding the prevention, diagnosis, mitigation, 
treatment, research, and rehabilitation of TBI, PTSD, and other mental 
health conditions in members of the Armed Forces. This planning will 
cover the continuum of care from DoD to VA for those in need of this 
care.
    Section 1618 also specifically requires the Secretary of Defense, 
with VA consultation, to provide to the Congressional defense 
Committees a comprehensive plan for DoD programs and activities to 
prevent, diagnose, mitigate, treat, research, and otherwise respond to 
TBI, PTSD, and other mental health conditions in members of the Armed 
Forces. This plan should assess current DoD capabilities, identify gaps 
in current capabilities, and identify the resources required to address 
those gaps.
Section 1621. Center of excellence in the prevention, diagnosis, 
        mitigation, treatment, and rehabilitation of traumatic brain 
        injury
    Section 1621 requires the Secretary of Defense to establish, within 
the Department of Defense, a center of excellence in the prevention, 
diagnosis, mitigation, treatment, and rehabilitation of traumatic brain 
injury, including mild, moderate and severe TBI. The Secretary of 
Defense is to maximize collaborative efforts with various private and 
public entities, including VA, to carry out the responsibilities 
enumerated in section 1621.
Section 1622. Center of excellence in prevention, diagnosis, 
        mitigation, treatment, and rehabilitation of post traumatic 
        stress disorder and other mental health conditions
    Section 1622 requires the Secretary of Defense to establish, within 
the Department of Defense, a center of excellence in the prevention, 
diagnosis, mitigation, treatment, and rehabilitation of post traumatic 
stress disorder, including mild, moderate and severe PTSD. The 
Secretary of Defense is to maximize collaborative efforts with various 
private and public entities, including VA, to carry out the 
responsibilities enumerated in section 1622.
VA and DoD Collaborations on TBI and PTSD
    In response to sections, 1618, 1621 and 1622, VA provides expertise 
and experience to the DoD Center of Excellence for TBI and 
Psychological Health. VA's contribution will include providing a Deputy 
and two subject matter experts, one in TBI and one in PTSD. VA's Acting 
Deputy Director for the Center of Excellence (COE) is already in place.
    VA and DoD continue to collaborate on a number of projects related 
to mental health and TBI. Some examples include:

      VA and DoD are developing revisions to medical coding for 
TBI for submission to the International Classification of Diseases 
(ICD) revision 9. These will be submitted in September 2008 and should 
become effective October 1, 2009.
      VA and DoD are developing clinical practice guidelines 
for TBI for use by both Departments, to be completed by September 2008.
      VA assigned Polytrauma Rehabilitation Nurse Liaisons at 
Walter Reed Army Medical Center and the National Naval Medical Center 
at Bethesda.
      VA establishing a 5-year Assisted Living Pilot project 
for veterans with TBI for implementation between April 2008 and June 
2013.
      Since 2004, VA and DoD have operated a Mental Health Work 
Group to improve collaboration and clinical coordination between the 
two Departments. This Group identifies issues and develops policies for 
improving care for veterans with mental disorders, including support 
for disseminating evidence-based Cognitive Processing Therapy and 
Prolonged Exposure Therapy for PTSD and collaborating on PTSD research.
      VA, DoD, and the National Institute of Mental Health 
began meeting in January 2008 to improve research methodology regarding 
effective treatments for PTSD. On January 22 and 23, 2008, VA, DoD, and 
the Department of Health and Human Services convened a group of 
scientific experts and research administrators to develop 
methodological guidance for conducting treatment studies for patients 
with PTSD. This is particularly significant because this will allow our 
researchers to have identified objectives and measures for any study on 
PTSD, which will enable them to make comparisons between studies, 
meaningfully analyze results, and advance our understanding of the 
field. This group will publish and distribute a report this summer. VA 
is aggressively pursuing numerous activities to improve treatment for 
PTSD, including:
        Interagency coordination with the National Institute of 
Mental Health, National Institute of Drug Abuse, National Institute on 
Alcohol Abuse and Alcoholism, and DoD, including the Congressionally 
Directed Medical Research Program, Defense Centers of Excellence, and 
the Office of the Assistant Secretary of Defense for Health.
        Ensuring research priorities are identified and 
addressed by working with the Federal research funding agencies.
      Recently, a joint VA/National Institutes of Health 
solicitation for proposals was issued entitled, ``Network(s) for 
Developing PTSD Risk Assessment Tools.'' Discussions continue about 
other ways to collaborate to answer important treatment questions. 
Proposals are due August 2008, and the review will be complete in 
Fiscal Year 2009. VA and the National Institutes of Health may each 
fund up to three projects.
      VA is disseminating evidence-based psychotherapies for 
PTSD, including Cognitive Processing Therapy and Prolonged Exposure 
Therapy, throughout the VA system and to DoD clinicians. As of May 28, 
2008, 1,168 VA Mental Health providers have been trained in Cognitive 
Processing Therapy: 839 of these were trained as part of the national 
rollout, while the others were trained through locally arranged and 
funded training. In addition, 607 DoD clinicians separately 
participated in a 2-day training seminar on Cognitive Processing 
Therapy similar in format to VA's training.
      VA continues to work with identified DoD PTSD experts in 
an effort to continually improve clinical care and enhance research 
programs on PTSD. VA will fully collaborate with DoD's Center of 
Excellence for TBI and Psychological Health on research and educational 
programs including, but not limited to, projects involving VA's 
National Center for PTSD.

    The Veterans Health Administration's Office of Research and 
Development has a strong portfolio of neurotrauma research, which 
included $43 million of support in Fiscal Year 2007. This Office 
sponsored a State of the Art Conference from April 30 to May 2, 2008, 
titled, ``Research to Improve the Lives of Veterans: Approaches to 
traumatic brain injury: Screening, Treatment, Management, and 
Rehabilitation.'' Representatives from DoD, the National Institutes of 
Health, the Defense and Veterans Brain Injury Center, and VA attended. 
VA also maintains a continuing relationship with DoD's research 
programs, and both Departments work closely on projects funded through 
DoD's Congressionally Directed Medical Research Program.
Section 1623. Center of Excellence in Prevention, Diagnosis, 
        Mitigation, Treatment, and Rehabilitation of Military Eye 
        Injuries
    Section 1623 directs DoD to establish a Center of Excellence in the 
prevention, diagnosis, treatment, and rehabilitation of eye injuries, 
and requires VA to collaborate to the maximum extent practicable with 
the activities of the Center. It further requires a comprehensive plan 
and strategy for a registry and establishes several conditions the 
registry must achieve. Finally, section 1623 requires VA and DoD to 
jointly provide for a cooperative program on traumatic brain injury 
post traumatic visual syndrome, including vision screening, diagnosis, 
rehabilitative management, and vision research, including research on 
prevention and visual dysfunction related to traumatic brain injury.
    VA and DoD began working together to address eye injuries before 
the passage of the NDAA. In November 2007, VA's Director of 
Ophthalmology began meeting with DoD ophthalmologists and optometrists 
to discuss approaches for improving care and coordination. In December 
2007, VA and DoD participated in a conference on the visual 
consequences of TBI, which was well attended by representatives from VA 
Polytrauma Rehabilitation Centers and blind rehabilitation specialists, 
as well as optometrists and ophthalmologists from both Departments. 
This conference provided an opportunity to initiate a consensus 
validation process, which will identify and disseminate the most 
effective strategies for treatment and services when they are known and 
to determine where additional research is needed. VA has also assembled 
teams of specialists, to develop questions for determining evidence-
based treatments; we anticipate this process will be complete in the 
summer.
    In February 2008, VA's Directors of Ophthalmology and Optometry met 
with their DoD counterparts to begin preparing a presentation on the 
concept of the Center of Excellence; VA and DoD appreciate the 
importance of the Center and have even agreed to call it a joint Center 
of Excellence. The following month, VA and DoD began developing an 
interoperative plan that will help establish the registry and allow a 
bidrectional flow of information. Throughout the month of April, VA and 
DoD continued discussing both the Center of Excellence and the 
registry. In May, VA and DoD workgroup members began reviewing draft 
documents on Systems Requirements and Concept of Operations for a 
Military Eye/Vision Injury Registry.
    From April 30 to May 2, 2008, VA's Office of Research and 
Development held a State of the Art meeting in Arlington, Virginia 
examining the latest advances and research on diagnosis and management 
of traumatic brain injury and put forth an agenda for research to 
explore currently unanswered questions. One session of this meeting was 
devoted to sensory changes (i.e., hearing and vision) and the results 
of this meeting will soon be published to guide future research.
    Any OEF/OIF veteran seen at a VA medical facility is automatically 
screened for TBI. Veterans for whom the screen is positive are referred 
for a full, in-depth evaluation. The evaluation process includes a 
standardized evaluation template of common problems following brain 
injury. This template includes checks for visual impairment. Our visual 
treatment specialists conduct full visual examinations including, but 
not limited to, acuity, full visual field testing, pressures within the 
eye, and imaging of both the retina and the cornea to assess damage to 
these structures. In all, this screening process includes a 22-item 
checklist, including an evaluation for visual impairment and presence 
of visual symptoms. VHA is currently drafting policy to initiate eye 
examinations for active duty servicemembers and veterans who are 
currently receiving care or who previously received care at a VA 
Polytrauma Rehabilitation Center.
    For veterans and active duty personnel with visual impairment, VA 
provides comprehensive Vision Rehabilitation services. Currently, 164 
Visual Impairment Service Team (VIST) Coordinators provide lifetime 
case management for all legally blind veterans, and all OEF/OIF 
patients with visual impairments. Additionally, 38 Blind Rehabilitation 
Outpatient Specialists (BROS) provide blind rehabilitation training to 
patients who are unable to travel to a blind center. These Polytrauma 
Blind Rehabilitation Specialists have certification in two areas, low 
vision rehabilitation and orientation and mobility training. They work 
in close collaboration with our neuro-ophthalmologists and low vision 
optometrists who evaluate, diagnose, and recommend treatment for our 
patients with visual impairments. Each Polytrauma Rehabilitation Center 
and Polytrauma Network Site has dedicated funding for a BROS on the 
Polytrauma team.
    Blind Rehabilitation Service involvement often begins while the 
injured servicemember is still a patient at a military treatment 
facility. The patient is transferred to a VA Blind Rehabilitation 
Center as soon as it is medically needed and at the patient's request. 
There is no waiting time for OEF/OIF veterans for this service.
Section 1635. Fully interoperable electronic personal health 
        information for the Department of Defense and Department of 
        Veterans Affairs
    Section 1635 requires VA and DoD to jointly develop and implement 
electronic health record capabilities that allow for full 
interoperability of personal healthcare information by September 2009. 
Section 1635 also requires development of a VA/DoD Inter-Agency Program 
Office to act as a single point of accountability. This office will 
oversee the rapid development of capabilities that will allow for full 
interoperability of personal healthcare information between VA and DoD. 
The office will then implement those developed capabilities while 
continuing to accelerate information exchanges.
Fully Interoperable Electronic Personal Health Information
    VA and DoD have been, and will continue to be, extremely committed 
to achieving the goal of health information interoperability. To that 
end, on April 17, the Departments formed the Interagency Program Office 
(IPO) and appointed an Acting Director from DoD and an Acting Deputy 
Director from VA. Shortly thereafter, on April 29, VA and DoD delivered 
a joint National Defense Authorization Act (NDAA) Implementation Plan 
to Congress regarding interoperability of electronic health records. 
The Implementation Plan includes a detailed schedule for developing 
electronic health record (EHR) requirements, acquisition and testing 
activities, and implementation milestones for the interoperable EHR. 
The Implementation Plan also documents the intended course of action 
for the IPO, and builds upon the already significant success achieved 
by the Departments toward sharing health information used in the care 
and treatment of all VA and DoD shared patients. The Implementation 
Plan also expands our vision for sharing essential viewable data--as 
depicted in Exhibit 1 and Exhibit 2--by identifying improvements VA and 
DoD could make to meet the goal of interoperability by September 2009, 
as well as further improvements to our EHR capabilities in years 
beyond.
Status of the Interagency Program Office
    VA understands the imperative to form a joint IPO and is working 
closely with our DoD partners to ensure our commitments are fulfilled. 
Based on our Implementation Plan, the IPO is now implementing other 
activities and milestones identified in the Implementation Plan, 
including efforts to secure permanent shared facilities and 
infrastructure for the IPO. We believe our Implementation Plan is both 
aggressive and achievable. By October 2008, we anticipate we will 
complete much of the initial staffing and facilities activities, 
including appointing a permanent Director and Deputy. While we do not 
have a permanent IPO facility and staff yet, we continue to make 
progress toward our goals. As of last week, the IPO facilities and 
space requirements are being finalized in the format required by the 
DoD Facilities personnel. In addition, the IPO budget submission is 
being finalized for inclusion in the Wounded Warrior Program Object 
Memorandum, which covers FY 2010 to FY 2015.
IPO and Joint Activities Governance
    The mission of the IPO will evolve over time. Initially, the IPO 
will provide a forum for high level coordination and guidance to ensure 
the Departments achieve full interoperability of the electronic health 
record data. Moving forward, the IPO will work in parallel with and 
build upon the successes already achieved by the VA/DoD Joint Executive 
Council (JEC) and the Senior Oversight Committee (SOC). This will 
ensure necessary IPO activities are captured and incorporated into the 
JEC's Joint Strategic Plan as measurable objectives. Operationally, the 
IPO will report to, and receive guidance from, the JEC and its 
cochairs.
Strategy to Achieve an Interoperable Electronic Health Record
    VA and DoD are already sharing some viewable health information 
one-way and some bidirectionally. Some selected data elements can be 
used as computable data. For example, the Departments now share 
computable allergy and pharmacy information that checks for drug or 
allergy interactions using data from each other's systems.
    We continue to take steps to expand our bidirectional sharing of 
viewable data. For example, VA and DoD are already sharing pharmacy, 
radiology, laboratory, progress notes, problems and procedures, theater 
data and limited inpatient data in bidirectional viewable format. This 
month, we will begin to share vital sign information, such as heart 
rate, temperature and blood pressure readings, to our existing 
capabilities. We will add history data and questionnaires by September 
2008. Additionally, throughout 2008, we are expanding a successful 
bidirectional image sharing pilot beyond the William Beaumont Army 
Medical Center and El Paso VA Healthcare System, our initial test 
sites, and we will continue to expand our image sharing program in 
2009. These steps will address the Dole-Shalala Commission's 
Recommendation to ensure that all essential health information is 
viewable and sharable by October 2008.
    VA and DoD have formed a VA/DoD Joint Clinical Information Board. 
This Board is essential to our overall acquisition strategy for a fully 
interoperable EHR and is composed of clinical experts and physicians 
tasked with prioritizing the data needs of an interoperable EHR. The 
Board's work includes defining what information must be shared and 
determining how that information will be shared. The Board will serve 
as a bridge between our current capabilities in viewable format and our 
future needs for full interoperability.
    The Joint Clinical Information Board has already defined and 
validated EHR requirements, which should be approved by the end of the 
month. Following this, and contingent upon funding, the Departments 
will proceed with acquisition, development, testing, and implementation 
of interoperable EHR capabilities. VA is confident we will achieve full 
interoperable electronic health record capability with DoD by September 
2009.
Beyond the 2009 Target for Interoperability
    VA recognizes ``interoperability'' does not have a discrete end 
point, since technologies and standards continue to evolve. VA and DoD 
remain leading stakeholders in the effort led by Office of the National 
Coordinator for Health Information Technology and the Department of 
Health and Human Services. VA and DoD will advance the identification 
and implementation of standards and will achieve a national framework 
for sharing health information with other key health providers.
    This concludes my prepared statement. I would be pleased to answer 
any questions you or any of the Members of the Committee may have.
                     Exhibit 1--Health Data Sharing
[GRAPHIC] [TIFF OMITTED] 43057A.001

            Exhibit 2--Personnel/Administrative Data Sharing
[GRAPHIC] [TIFF OMITTED] 43057A.002


                                 
            Prepared Statement of Hon. Michael L. Dominguez,
     Principal Deputy Under Secretary of Defense for Personnel and 
                               Readiness,
                       U.S. Department of Defense
    Chairman Filner, Congressman Buyer, Members of the House Committee 
on Veterans' Affairs, we appreciate your support of our military and 
welcome the opportunity to appear here today to discuss improvements 
implemented and planned for the care, management, and transition of 
wounded, ill, and injured Servicemembers. We are pleased to report that 
while much work remains to be completed, meaningful progress has been 
made.
    The Administration has worked diligently--commissioning independent 
review groups, task forces, and a Presidential Commission to assess the 
situation and make recommendations. We established a close partnership 
between the Department of Defense (DoD) and the Department of Veterans 
Affairs (VA), punctuated by formation of the Senior Oversight Committee 
(SOC) on May 8, 2007, to identify immediate corrective actions and to 
review and implement recommendations of the external reviews. The SOC 
continues work to streamline, deconflict, and expedite the two 
Departments' efforts to improve support of wounded, ill, and injured 
Servicemembers' recovery, rehabilitation, and reintegration.
    Many of the specific initiatives we have implemented are described 
in the remainder of this testimony. These initiatives fit within a 
context of four fundamental changes we have made over the last year. 
First, DoD and VA are collaborating on more issues to deliver a world 
class continuum of care for our wounded, ill and injured. Second, we've 
completely overhauled our approach to command and control of recovering 
Servicemembers and now provide for people in long-term outpatient 
status, the same military leadership structure found in our maneuver 
units. Third, we have revamped our approach to care and case management 
and we have fully embraced ``customer''-centered processes. Finally, we 
recognize psychological fitness is as important to the warrior's 
mission as is physical fitness, and we can both prepare warriors for 
the stress of combat and help them regain their psychological fitness 
after enduring the combat experience. The initiatives I will describe 
to you will help us make permanent these big changes in direction.
    The critical clarification and simplification in the fundamental 
responsibilities of the DoD and VA, however, remain one of the most 
significant recommendations from the many task forces and commissions 
yet to be implemented. This shift in the fundamental responsibilities 
would take the DoD out of the disability rating business. Creating this 
clear line between the responsibilities of the two Departments, as 
specifically recommended by the Dole/Shalala Commission, would allow 
DoD to focus on the fit or unfit determination and streamline the 
transition from Servicemember to veteran.
Senior Oversight Committee
    The driving principle guiding SOC efforts is the establishment of a 
world-class continuum of care that is efficient and effective in 
meeting the needs of our wounded, ill, and injured Servicemembers, 
veterans, and their families. The body is composed of senior DoD and VA 
representatives and cochaired by the Deputy Secretary of Defense and 
Deputy Secretary of Veterans Affairs. The SOC brings together, on a 
regular basis, the most senior decisionmakers to ensure wholly 
informed, timely action.
    Supporting the SOC decisionmaking process is an Overarching 
Integrated Product Team (OIPT), cochaired by the Principal Deputy Under 
Secretary of Defense for Personnel and Readiness and the Department of 
Veterans Affairs' Under Secretary for Benefits, and composed of senior 
officials from both DoD and VA. The OIPT reports to the SOC and 
coordinates, integrates, and synchronizes work and recommends resource 
decisions.
Major Initiatives and Improvements
    The two Departments are in the process of implementing 
recommendations of five major studies, as well as implementing the 
Wounded Warrior and Veterans titles of the National Defense 
Authorization Act (NDAA) for Fiscal Year 2008. We continue to implement 
recommended changes through the use of policy and existing authorities. 
Described below are some of the major SOC initiatives now underway.
Disability Evaluation System
    The fundamental goal is to improve the continuum of care from the 
point-of-injury to reintegration. To that end, in November of last 
year, a Disability Evaluation System (DES) Pilot test was implemented 
for disability cases originating at the three major military medical 
treatment facilities (MTFs) in the National Capital Region (Walter Reed 
Army Medical Center, National Naval Medical Center Bethesda, and 
Malcolm Grow Medical Center). The pilot is a Servicemember-centric 
initiative designed to eliminate the often-confusing elements of the 
two current disability processes of our Departments. Key features 
include both a single medical examination and single disability rating 
for use by both Departments. A primary goal is to reduce by half the 
time required to transition a member to veteran status and receipt of 
VA benefits and compensation. Its specific objectives are to improve 
timeliness, effectiveness, transparency, and resource utilization by 
integrating DoD and VA processes, eliminating duplication, and 
improving case management practices. To ensure a continuum of care for 
our wounded, ill, or injured from the care, benefits, and services of 
DoD to VA's system, the pilot is testing enhanced case management 
methods and identifying opportunities to improve the flow of 
information and identification of additional resources to the 
Servicemember and family.
Psychological Health and TBI
    Improvements have been made in addressing issues concerning 
Psychological Health (PH) and traumatic brain injury (TBI). The focus 
of these efforts has been to create and ensure a comprehensive, 
effective, and individually focused program dedicated to prevention, 
protection, identification, diagnosis, treatment, recovery, and 
rehabilitation for our Servicemembers and to support their families who 
deal with these challenging health conditions.
    To facilitate the evaluation and management of TBI cases, DoD is 
about to expand a program to collect baseline neurocognitive 
information on all Active and Reserve personnel before their deployment 
to combat theaters. The Army has incorporated neurocognitive 
assessments as part of its Soldier Readiness Processing in select 
locations. Select Air Force units are assessed in Kuwait before going 
into Iraq.
    To ensure all Servicemembers are appropriately screened for PTSD, 
questions have been added to the Post-Deployment Health Assessment and 
the Post-Deployment Health Reassessments. That same information is 
shared with VA clinicians for patients who seek care with the VA as 
part of an effort to facilitate the continuity of care for the veteran 
or Servicemember.
    To ensure appropriate staffing levels for PH, a comprehensive 
staffing plan for PH services has been developed based on a risk-
adjusted, population-based model and the Services have received 
resources to staff that model. In addition, DoD has partnered with the 
Department of Health and Human Services (HHS) to provide uniformed 
Public Health Service (PHS) officers in medical treatment facilities 
(MTFs) to increase available mental health providers for DoD. The two 
Departments recently signed a Memorandum of Agreement and have begun 
hiring PHS officers. DoD program expansions, documented in an updated 
report to Congress submitted in February 2007, include:

      Addition of telephone-based screening for those who do 
not have access to the Internet including a direct referral to Military 
OneSource for individuals identified at significant risk;
      Availability of locally tailored, installation-level 
referral sources via the online screening;
      Introduction of the evidence-based Suicide Prevention 
Program for Department of Defense Education Activity schools to ensure 
education of children and parents of children who are affected by their 
sponsor's deployment;
      Addition of a Spanish language version for all screening 
tools, expanded educational materials, and integration with the newly 
developed pilot program on web-based self-paced care for post traumatic 
stress disorder and depression; and
      Enhancement of the web based Mental Health Self 
Assessment Program.

    In November 2007, the Department of Defense Center of Excellence 
(DCoE) for Psychological Health and traumatic brain injury was 
established as a national Center of Excellence for PH and TBI. It 
includes VA and HHS liaisons, as well as an external advisory panel 
organized under the Defense Health Board, to provide the best advisors 
across the country to the military health system. The center 
facilitates coordination and collaboration for PH and TBI related 
services among the Military Services and VA, promoting and informing 
best practice development, research, education, and training. The DCoE 
is designed to lead clinical efforts toward developing excellence in 
practice standards, training, outreach, and direct care for our 
military community with PH and TBI concerns. It also serves as a nexus 
for research planning and monitoring the research in this important 
area of knowledge. Functionally, the DCoE is engaged in several focus 
areas, including:

      Mounting a pro-resiliency campaign (Army's Mental Health 
Advisory Team V survey shows that stigma and fears of seeking help are 
being reduced, but more to do);
      Establishing effective outreach and educational 
initiatives;
      Promulgating a Telehealth network for care, monitoring, 
support, and follow-up;
      Coordinating an overarching program of research including 
all DoD assets, academia and industry, focusing on near-term advances 
in protection, prevention, diagnosis, and treatment;
      Providing training programs aimed at providers, line 
leaders, families, and community leaders; and
      Designing and planning for the National Intrepid Center 
of Excellence (anticipated completion in fall 2009), a building that 
will be located on the Bethesda campus adjacent to the new Walter Reed 
National Military Medical Center.

    The FY 2007 Supplemental Appropriation provided DoD $900 million in 
additional funds to make improvements to our PH and TBI systems of care 
and research. These funds are important to support, expand, improve, 
and transform our system and are being used to leverage change through 
optimal planning and execution. The funds have been allocated and 
distributed in three phases to the Services for execution based on an 
overall strategic plan created by representatives from DoD and the 
Services with VA input.
    The Department is in close collaboration with VA to plan for and 
establish a center of excellence that would build and operate the 
Military Eye Injury Registry. Planning for the registry is underway by 
working groups comprised of military and VA subject matter experts. 
These specialty leaders recognize the value and contribution such a 
registry will make toward improved care and rehabilitation of their 
patients. Our initial plan will co-locate the Eye Center of Excellence 
with the Defense Center of Excellence for TBI/PTSD at Bethesda with 
treatment facilities at Brooke Army Medical Center, Madigan, Balboa and 
Bethesda.
Care Management
    To improve the continuity of care management and transitions across 
our two Departments, new programs and processes are being put into 
place like the Federal Recovery Coordination Program, which will 
identify and integrate care and services for the severely wounded, ill, 
and injured Servicemembers, veterans, and their families through the 
phases of recovery, rehabilitation, and reintegration.
    This Dole/Shalala recommended program will be linked to additional 
efforts in response to the National Defense Authorization Act 2008 
regarding recovering Servicemembers. Progress is being made toward an 
integrated continuity of quality care and service delivery through 
inter-Service, interagency, intergovernmental, public, and private 
collaboration. Our joint DoD and VA efforts include important reforms 
such as uniform training for medical and non-medical care/case managers 
and recovery coordinators, and a single tracking system and a 
comprehensive recovery plan for the seriously and severely injured or 
ill.
    The joint Program, coordinated by VA, trains and assigns Federal 
Recovery Coordinators (FRCs) to work closely with medical and non-
medical care/case managers in the care, management, and transition of 
severely ill, and injured Servicemembers, veterans, and their families. 
The Program will develop and implement two significant web-based tools: 
including a Servicemember/veteran/family focused Federal Individualized 
Recovery Plan (FIRP) to identify goals and needs across time and a 
national Resource Directory for use by all care providers and the 
general public to identify and deliver the full range of medical and 
non-medical services and resources identified in the plan.
    The Departments have:

      Hired, trained, and placed eight FRCs at three of our 
busiest medical treatment facilities as recommended by the Dole/Shalala 
Commission. Currently, there are four FRCs located at Walter Reed Army 
Medical Center, National Naval Medical Center in Bethesda, and Brooke 
Army Medical Center. As of July 1, there will be an additional FRC at 
Brooke Army Medical Center and National Naval Medical Center, and one 
FRC at Naval Medical Center Balboa.
      Developed a prototype of the Federal Individual Recovery 
Plan (FIRP) as recommended by the Dole/Shalala Commission; and
      Produced educational/informational materials for FRCs, 
Multi-Disciplinary Teams, and Servicemembers, veterans, families, and 
caregivers.

    We have also:

      Developed a prototype of the National Resource Directory 
in partnership with Federal, State, and local governments and the 
private/voluntary sector, with public launch this summer;
      Produced a Family Handbook in partnership with relevant 
DoD/VA offices; and
      Identified a process to review workloads for Medical 
Case/Care Managers, Non-medical Care Managers, and Recovery 
Coordinators.

Data Sharing Between Defense and Veterans Affairs
    Steps have been taken to improve the sharing of medical information 
between our Departments to develop a seamless health information 
system. Our long-term goal is to ensure appropriate beneficiary and 
medical information is visible, accessible, and understandable through 
secure and interoperable information technology. The SOC has approved 
initiatives to ensure health and administrative data are made available 
and are viewable by both agencies. DoD and VA are securely sharing more 
electronic health information than at any time in the past. In addition 
to the outpatient prescription data, outpatient and inpatient 
laboratory and radiology reports, allergy information, access to 
provider/clinical notes, problem lists, and theater health data have 
recently been added. In December 2007, DoD began making inpatient 
discharge summary data from Landstuhl Regional Medical Center 
immediately available to VA facilities. The plan for information 
technology support of a FIRP for use by Federal Recovery Coordinators 
was approved in November 2007. A single Web portal to support the needs 
of wounded, ill, or injured Servicemembers, commonly referred to as the 
eBenefits Web Portal, is planned based on VA's successful My HealtheVet 
website. The Veterans Tracking Application (VTA) is a data management 
tool utilized by both Veterans Benefits Administration and Veterans 
Health Administration staff to track very severely injured veterans, 
and assist in case management and prioritizing care for all Operation 
Enduring Freedom and Operation Iraqi Freedom veterans.
Medical Facilities Inspection Standards
    Progress has been made to ensure our wounded warriors are properly 
housed in appropriate facilities. Using the comprehensive Inspection 
Standards, all 475 military MTFs were inspected and found to be in 
compliance although deferred maintenance and upgrades were cited. The 
Services are inspecting MTFs on a semi-annual basis to ensure continued 
compliance, identify maintenance requirements, and sustain a world-
class environment for medical care. In the event a deficiency is 
identified, the commander of the facility will take immediate action to 
mitigate the condition. The commander will submit to the Secretary of 
the Military Department a detailed plan to correct the deficiency, and 
the commander will periodically re-inspect the facility until the 
deficiency is corrected. All housing units for our wounded warriors 
have also been inspected and determined to meet applicable quality 
standards. The Services recognize that existing temporary medical hold 
housing is an interim solution and have submitted FY 2008 military 
construction budgets to start building appropriate housing complexes 
adjacent to MTFs. They will also implement periodic and comprehensive 
follow-up programs using surveys, interviews, focus groups, and town-
hall meetings to learn how to improve housing and related amenities and 
services.
Transition Issues/Pay and Benefits
    Servicemembers transitioning from military to civilian life can 
benefit from collaborative efforts between DoD and the Department of 
Labor (DoL). The DoD Pre-Separation Guide, which informs Servicemembers 
and their families of available transition assistance services and 
benefits, is now available at http://www.TurboTAP.org and was developed 
in collaboration with DoL. Additionally, DoD and DoL are working to 
assure needed employment services are provided to Servicemembers. DoL 
has been an active participant in many of the SOC activities.
    DoD and VA have shared information concerning the traumatic injury 
protection benefit under Servicemembers' Group Life Insurance (TSGLI) 
and implemented plans replicating best practices. The Army is now 
placing subject-matter experts at MTFs to provide direct support of the 
TSGLI application process and improve processing time and TSGLI payment 
rates. Upon receipt of a completed claim form, the claim is adjudicated 
by the Services and paid within 3 weeks. VA's insurance provider's 
payment time, upon receipt of a certified claim from the branch of 
Service, averages between 2 and 4 days.
    DoD has been successful using Congressional authority from the NDAA 
allowing continuation of deployment related pays for those recovering 
in the hospital after injury or illness in the combat zone. This 
ensures no reduction in deployment pays while the Servicemember is 
recovering.
Wounded Warrior Resource Center
    In accordance with the FY 2008 NDAA, we are establishing a Wounded 
Warrior Resource Center to provide wounded warriors, their families, 
and their primary caregivers with a single point of contact for 
assistance through a 24-hour/7 day a week, 1-800 number.
    The Wounded Warrior Resource Center will operate under the 
universally known Military OneSource call center and take hotline 
calls, track all calls and responses, refer the issue for remediation 
and follow up with the caller. To ensure the calls are handled 
appropriately, we are developing a comprehensive contact list for 
health issues, facility concerns and benefit information. We have 
established a working group with the Services to integrate the 
comprehensive programs and services provided by the individual Services 
and FRCs.
Conclusion
    The SOC and its OIPT continue to work diligently to resolve the 
many outstanding issues while aggressively implementing Dole/Shalala, 
the NDAA, and the various aforementioned task forces and commissions. 
These efforts will expand in the future to include the recommendations 
of the DoD Inspector General's Report on DoD/VA Interagency Care 
Transition, which is due shortly.
    As previously stated, one of the most significant recommendations 
from the task forces and commissions is the shift in the fundamental 
responsibilities of the Departments of Defense and Veterans Affairs. 
The core recommendation of the Dole/Shalala Commission centers on the 
concept of taking the Department of Defense out of the disability 
rating business so that DoD can focus on the fit or unfit 
determination, streamlining the transition from Servicemember to 
veteran.
    We have made four fundamental changes in our support and care for 
wounded warriors:

      Increased VA and DoD collaboration on more projects 
related to improved care coordination for returning veterans and 
Servicemembers.
      Identified new approaches to support outpatients (e.g., 
Warrior Transition Units and Americans with Disabilities Act compliant 
barracks).
      Developed new approaches to address PH and 
TBI.Revolutionized customer care.

    We envision five major changes that need to be addressed:

      Create and deploy an effective performance management 
structure that will be functional when handed off to the Joint 
Executive Council. The structure will be a sensor suite or pulse point 
to ensure the system is operating as intended.
      Rationalize DoD/VA roles and responsibilities in 
accordance with Dole/Shalala.
      Define a solution for the Reserve Component.
      Define the path toward an interoperable information 
environment.
      Drive home the changed approach to psychological and 
customer care.

    While we are pleased with the quality of effort and progress made, 
we fully understand that there is much more to do. We also believe that 
the greatest improvement to the long-term care and support of America's 
wounded warriors and veterans will come from enactment of the 
Administration's proposed bill to implement the recommendations of the 
Dole/Shalala Commission. We have, thus, positioned ourselves to 
implement these provisions and continue our progress in providing 
world-class support to our warriors and veterans while allowing our two 
Departments to focus on our respective core missions. Our dedicated, 
selfless Servicemembers, veterans, and their families deserve the very 
best, and we pledge to give our very best during their recovery, 
rehabilitation, and return to the society they defend.
    Chairman Filner, Congressman Buyer, and Members of the Committee, 
thank you again for your generous support of our wounded, ill, and 
injured Servicemembers, veterans, and their families. I look forward to 
your questions.

                                 
                       Statement of Kerry Baker,
  Associate National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Committee:

    On behalf of the 1.3 million members of the Disabled American 
Veterans (DAV), I am honored to present this testimony to the Committee 
to address the implementation of the wounded warrior provisions of the 
National Defense Authorization Act of 2008 (NDAA). In accordance with 
our congressional charter, the DAV's mission is to ``advance the 
interests, and work for the betterment, of all wounded, injured, and 
disabled American veterans.''
The Department of Defense (DoD) Knowingly Violated the Law and Ignored 
        the Intent of Congress When it Implemented section 1646 of the 
        NDAA.
    The NDAA made several positive changes as part of an enhanced 
wounded warrior benefits plan--changes that in many respects, were 
nothing short of groundbreaking. The DAV applauds Congress for 
achieving these milestones on behalf of all service men and women 
injured in the line of duty.
    One of those changes was improvements in disability severance pay 
from the military, which previously was based on a maximum of 12 years 
of military service, and is now based on a maximum 19 years of military 
service. This change alone will make a remarkable difference in the 
lives of career service men and women who received disability 
separations from service prior to reaching full retirement tenure.
    The above change would be pointless if an applicable servicemember 
was forced to pay back that severance pay from any future VA 
compensation, which has always been required until passage of the NDAA. 
Disability severance pay is based on past achievements in a 
servicemember's career, i.e., rank and number of service years 
completed. Alternatively, VA disability compensation is paid based on 
future loss of earnings potential. It is obvious the two are designated 
for different purposes. As a consequence, a servicemember should not be 
forced to return his or her severance pay to the DoD via his or her VA 
disability compensation.
    Congress understood this, and in addition to increasing the amount 
of severance pay, section 1646 of the NDAA (``enhancement of disability 
severance pay for members of the armed forces'') (emphasis omitted) 
eliminated the offset of VA disability compensation by the amount of 
any severance pay received by certain servicemembers, but not all. The 
pertinent language in sec. 1646 reads:

          No deduction may be made . . . in the case of disability 
        severance pay received by a member for a disability incurred in 
        line of duty in a combat zone or incurred during performance of 
        duty in combat-related operations as designated by the 
        Secretary of Defense.

    National Defense Authorization Act of 2008, Pub. L. No. 110-181, 
Sec. 1646(b), 122 Stat 3 (codified at 10 U.S.C. Sec. 1212).
    A veteran must satisfy one of two criteria in order to be exempt 
from the offset of disability compensation. The first criterion--``in 
line of duty in a combat zone''--is self-explanatory and not in 
dispute. The latter criterion requires a deeper understanding of the 
term ``combat-related.''
    The logical explanation is that ``combat-related'' disabilities are 
incurred as a result of ``combat-related'' operations. The term 
``combat-related disability'' is defined by the NDAA in, inter alia, 
section 1632 as ``having the meaning given that term in 10 U.S.C.A. 
Sec. 1413a'' (``Combat-related special compensation''). Id. at sec. 
1632. Section 1413a defines the phrase as follows:

          Combat-related disability.--In this section, the term 
        ``combat-related disability'' means a disability that is 
        compensable under the laws administered by the Secretary of 
        Veterans Affairs and that--
          (1) is attributable to an injury for which the member was 
        awarded the Purple Heart; or
          (2) was incurred (as determined under criteria prescribed by 
        the Secretary of Defense)--
            (A) as a direct result of armed conflict;
            (B) while engaged in hazardous service;
            (C) in the performance of duty under conditions simulating 
        war; or
            (D) through an instrumentality of war.
          10 U.S.C.A. 1413a(e) (West 2002 & Supp 2007).

    The Department of Defense (DoD) has defined the foregoing terms in 
DoD Instruction (DoDI) 1332.38, as follows:

          E3.P5.2.2. Combat-related. This standard covers those 
        injuries and diseases attributable to the special dangers 
        associated with armed conflict or the preparation or training 
        for armed conflict. A physical disability shall be considered 
        combat-related if it makes the member unfit or contributes to 
        unfitness and was incurred under any of the circumstances 
        listed in paragraphs E3.P5.2.2.1. through E3.P5.2.2.4., below.
          E3.P5.2.2.1. As a direct result of armed conflict. The 
        criteria are the same as in paragraph E3.P5.1.2. [Paragraph 
        E3.P5.1.2 defines armed conflict as follows:]
             E3.P5.1.2. Armed conflict. [] The physical disability is a 
        disease or injury incurred in the line of duty as a direct 
        result of armed conflict. The fact that a member may have 
        incurred a disability during a period of war or in an area of 
        armed conflict, or while participating in combat operations is 
        not sufficient to support this finding. There must be a 
        definite causal relationship between the armed conflict and the 
        resulting unfitting disability.
             E3.P5.1.2.1. Armed conflict includes a war, expedition, 
        occupation of an area or territory, battle, skirmish, raid, 
        invasion, rebellion, insurrection, guerrilla action, riot, or 
        any other action in which Servicemembers are engaged with a 
        hostile or belligerent nation, faction, force, or terrorists.
             E3.P5.1.2.2. Armed conflict may also include such 
        situations as incidents involving a member while interned as a 
        prisoner of war or while detained against his or her will in 
        custody of a hostile or belligerent force or while escaping or 
        attempting to escape from such confinement, prisoner of war, or 
        detained status.
          E3.P5.2.2.2. While engaged in hazardous service. Such service 
        includes, but is not limited to, aerial flight duty, parachute 
        duty, demolition duty, experimental stress duty, and diving 
        duty.
          E3.P5.2.2.3. Under conditions simulating war. In general, 
        this covers disabilities resulting from military training, such 
        as war games, practice alerts, tactical exercises, airborne 
        operations, leadership reaction courses; grenade and live fire 
        weapons practice; bayonet training; hand-to-hand combat 
        training; rappelling, and negotiation of combat confidence and 
        obstacle courses. It does not include physical training 
        activities, such as calisthenics and jogging or formation 
        running and supervised sports.
          E3.P5.2.2.4. Caused by an instrumentality of war. Incurrence 
        during a period of war is not required. A favorable 
        determination is made if the disability was incurred during any 
        period of service as a result of such diverse causes as wounds 
        caused by a military weapon, accidents involving a military 
        combat vehicle, injury, or sickness caused by fumes, gases, or 
        explosion of military ordnance, vehicles, or material. However, 
        there must be a direct causal relationship between the 
        instrumentality of war and the disability. For example, an 
        injury resulting from a Servicemember falling on the deck of a 
        ship while participating in a sports activity would not 
        normally be considered an injury caused by an instrumentality 
        of war (the ship) since the sports activity and not the ship 
        caused the fall. The exception occurs if the operation of the 
        ship caused the fall.

    Based on all of the above, it is clear that when a veteran receives 
a medical discharge based on a disability resulting from any of the 
above circumstances then such disability constitutes a ``combat-related 
disability'' in accordance with section 1413a of title 10, United 
States Code, and DoD instructions. (See also 26 U.S.C. Sec. 104). 
Therefore, under the plain language of section 1646 of the NDAA and 
title 10, United States Code, such a veteran is not subject to an 
offset of VA disability compensation by the amount of any military 
severance pay.
    However, the Under Secretary of Defense for Personnel and 
Readiness, (``Secretary''), has issued a ``directive-type memorandum'' 
dated March 13, 2008, implementing, inter alia, the foregoing 
provisions of the NDAA. In that memorandum, the Secretary directed that 
determinations of whether a servicemember's disability was ``incurred 
during performance of duty in combat-related operations'' is to be made 
consistent only with the criteria set forth in DoDI 1332.38 paragraph 
E3.P5.1.2., which defines ``armed conflict.''
    The effect of the Memorandum is to impose an express limitation on 
NDAA Sec. 1646. Under the Memorandum, the definition of ``combat-
related operations'' excludes hazardous service, duty under conditions 
simulating war, or disabilities incurred through an instrumentality of 
war unless the servicemember was engaged in armed conflict. The 
Memorandum defines ``combat-related operations'' even more narrowly 
than ``in a combat zone.'' The interpretation renders the alternative 
basis upon which Congress intended that a disabled former member should 
be exempt from the offset of VA disability compensation under the NDAA, 
``or incurred during performance of duty in combat-related operations 
as designated by the Secretary of Defense,'' superfluous. This action 
has intentionally read ``hazardous service,'' ``conditions simulating 
war,'' and ``instrumentality of war'' completely out of the law.
    In doing so, the Secretary has narrowed the scope of the statute 
contrary to the intent of Congress, ignored the plain language of the 
NDAA and associated statutes, and otherwise violated the law. The 
Secretary's action has rendered it far more difficult for veterans to 
benefit from this provision of the NDAA than as otherwise intended. It 
is unlawful to read such a limitation into a statute, thereby narrowing 
its scope and construing it against veterans. See Brown v. Gardner, 513 
U.S. 115, 117-18 (1994); Miller v. United States, 294 U.S. 435, 439-40 
(1935) (regulation or procedural rule that is inconsistent with the 
authorizing statute constitutes impermissible legislation). Congress 
must not let the Secretary's action stand.
    Essentially, the Secretary has drawn a distinction between 
``combat-related operations'' and ``combat-related disability.'' Such 
distinction lies not with the words ``operation'' and ``disability,'' 
but rather with the established and well-defined meaning of ``combat-
related.'' We do not view this as an oversight--we view this as an 
intentional effort to conserve monetary resources at the expense of 
disabled veterans.
    Countless thousands of veterans will be detrimentally affected by 
this unforgivable situation. Congress must also understand that once 
this injustice is perpetrated, reconciliation will be nearly 
impossible. There is currently no procedure in place for unsuspecting 
servicemembers that have been and will be harmed by this unlawful and 
uncaring act that could rectify the injustice and correct their 
records.
    The ultimate result of this interpretation of NDAA Sec. 1646 is 
that thousands of servicemembers who Congress intended to exempt from 
offset of their VA disability compensation will be denied that 
protection. Those who become disabled while performing hazardous 
service or training for combat will have their VA disability 
compensation reduced contrary to the intent of Congress.
    The foregoing action by the Secretary forces one to question his 
true resolve to care for those he sends into battle, or orders to train 
for battle. This same Secretary has stood before this Committee and 
declared that no unlawful decision that may have deprived 
servicemembers injured in the line of duty was ever made based on an 
intention to save monetary resources. If that is the case in this 
circumstance, then the DAV must ask one simple question. Why? We can 
think of no other conceivable reason for the Secretary to circumvent 
the law as he has done here. The offset discussed herein is governed by 
title 10, United States Code, not title 38, meaning it is a DoD offset, 
not a VA offset. To answer the question of ``why,'' Congress need only 
determine in whose budget the disability compensation is deposited once 
offset by VA. We believe the answer to that question is the DoD budget.
    In light of the above, Congress must act to prevent the Secretary 
from continuing such blatant disregard for the law and for the 
livelihood and welfare of those that stand up to defend this Country.
    Mr. Chairman, this concludes my testimony on behalf of DAV. We hope 
you will consider our recommendations.

                                 

                                         U.S. Department of Defense
                                         Under Secretary of Defense
                                            Personnel and Readiness
                                                     Washington, DC
                                                       June 9, 2008

The Honorable Ike Skelton
Chairman
Committee on Armed Services
U.S. House of Representatives
Washington, DC 20515
Dear Mr. Chairman:
    Section 597 of the National Defense Authorization Act for Fiscal 
Year 2008 requested that the Secretary of Defense provide a report on 
administrative separations based on personality disorder.
    The Department appreciates the opportunity to provide Congress with 
information regarding the administrative separation of Servicemembers 
based on personality disorder who had deployed in support of the Global 
War on Terror (GWOT) since October 2001. The data requested are 
enclosed. Analysis of separation data showed that only 3.4K (15 
percent) of the 22.6K servicemembers with personality disorder coded 
separations had deployed in support of GWOT. Additionally, data 
indicate that the majority, 19.2K (85 percent), of the 22.6K 
Servicemembers with personality disorder coded separations had two or 
fewer years in the service. Nevertheless, the Department shares 
Congress' concern regarding the use of personality disorder as the 
basis for administratively separating Servicemembers who deployed in 
support of GWOT and who may have been more appropriately processed for 
disability.
    To address this concern, the Department has been working over the 
past few months to implement changes that add additional rigor to the 
personality disorder separation policy. The new policy guidance, 
expected to be released later this month, will include allowing 
personality disorder separations only if diagnosed by a psychiatrist or 
PhD-level psychologist. The proposed change would require members who 
are being considered for administrative discharge based on personality 
disorder who had deployed or are currently deployed to designated 
imminent danger pay areas to have their personality disorder diagnosis 
corroborated by a peer, psychiatrist or PhD-level psychologist who must 
address post traumatic stress disorder or other mental illness 
comorbidity in their diagnosis. An additional change under 
consideration would require The Surgeon General of the Military 
Department concerned to review and endorse the personality disorder 
case for this class of Servicemember.
    Finally, each Military Department has well established processes 
and procedures for former Servicemembers who believe that their 
discharges were incorrectly characterized or processed to request 
adjudication through their respective Military Department's Discharge 
Review Board. The Department encourages former Servicemembers to 
utilize these processes and procedures to request review of their 
specific cases.
    A similar letter is being sent to the Chairman and Ranking Member 
of the House Armed Services Committee.

            Sincerely,
                                                     David S.C. Chu
                                         Under Secretary of Defense
                                            Personnel and Readiness
Enclosure:
As stated
cc: The Honorable Duncan Hunter Ranking Member

                               __________

                         REPORT TO CONGRESS ON
        ADMINISTRATIVE SEPARATIONS BASED ON PERSONALITY DISORDER
                      Fiscal Years 2002 thru 2007
                              Prepared By:
                Office of the Under Secretary of Defense
                        Personnel and Readiness
    The Department appreciates the opportunity to provide Congress with 
information regarding the administrative separation of Servicemembers 
on the basis of personality disorder for those members who had deployed 
in support of the Global War on Terror from October 2001 through 2007. 
To meet the specific requirements of Section 597 of the National 
Defense Authorization Act (NDAA) for Fiscal Year 2008 (FY08), the 
Secretary of Defense provides the following review and advice on 
administrative separations based on personality disorder.

              FY08 NDAA, Section 597, Report Requirements

Section 597 of the FY08 NDAA requires:
     (a) SECRETARY OF DEFENSE REPORT ON ADMINISTRATIVE SEPARATIONS 
BASED ON PERSONALITY DISORDER.--
       (1) REPORT REQUIRED.--Not later than April 1, 2008, the 
Secretary of Defense shall submit to the Committees on Armed Services 
of the Senate and the House of Representatives a report on all cases of 
administrative separation from the Armed Forces of covered members of 
the Armed Forces on the basis of a personality disorder.
       (2) ELEMENTS.--The report required by paragraph(1) shall include 
the following:
         (A) A statement of the total number of cases, by Armed Force, 
in which covered members of the Armed Forces have been separated from 
the Armed Forces on the basis of a personality disorder, and an 
identification of the various forms of personality disorder forming the 
basis for such separations.
         (B) A statement of the total number of cases, by Armed Force, 
in which covered members of the Armed Forces who have served in Iraq 
and Afghanistan since October 2001 have been separated from the Armed 
Forces on the basis of a personality disorder, and the identification 
of the various forms of personality disorder forming the basis for such 
separations.
         (C) A summary of the policies, by Armed Force, controlling 
administrative separations of members of the Armed Forces based on 
personality disorder, and an evaluation of the adequacy of such 
policies for ensuring that covered members of the Armed Forces who may 
be eligible for disability evaluation due to mental health conditions 
are not separated from the Armed Forces on the basis of a personality 
disorder.
         (D) A discussion of measures being implemented to ensure that 
members of the Armed Forces who should be evaluated for disability 
separation or retirement due to mental health conditions are not 
processed for separation from the Armed Forces on the basis of a 
personality disorder, and recommendations regarding how members of the 
Armed Forces who may have been so separated from the Armed Forces 
should be provided with expedited review by the applicable board for 
the correction of military records.

     (b) COMPTROLLER GENERAL REPORT ON POLICIES ON ADMINISTRATIVE 
SEPARATION BASED ON PERSONALITY DISORDER.--
       (1) REPORT REQUIRED.--Not later than June 1, 2008; the 
Comptroller General shall submit to Congress a report evaluating the 
policies and procedures of the Department of Defense and of the 
military departments relating to the separation of members of the Armed 
Forces based on a personality disorder.
       (2) ELEMENTS.--The report required by paragraph (1) shall--
         (A) include an audit of a sampling of cases to determine the 
validity and clinical efficacy of the policies and procedures referred 
to in paragraph (1) and the extent, if any, of the divergence between 
the terms of such policies and procedures and the implementation of 
such policies and procedures; and
         (B) include a determination by the Comptroller General of 
whether, and to what extent, the policies and procedures referred to in 
paragraph (1)--
           (i) deviate from standard clinical diagnostic practices and 
current clinical standards; and
           (ii) provide adequate safeguards aimed at ensuring that 
members of the Armed Forces who suffer from mental health conditions 
(including depression, post traumatic stress disorder, or traumatic 
brain injury) resulting from service in a combat zone are not separated 
from the Armed Forces on the basis of a personality disorder.
       (3) ALTERNATIVE SUBMISSION METHOD.--In lieu of submitting a 
separate report under this subsection, the Comptroller may include the 
evaluation, audit and determination required by this subsection as part 
of the study of mental health services required by section 723 of the 
Ronald W. Reagan National H.R. 4986--139 Defense Authorization Act of 
2005 (Public Law 108-375; 118 Stat. 1989).

     (c) COVERED MEMBER OF THE ARMED FORCES DEFINED.--In this section, 
the term ``covered member of the Armed Forces'' includes the following:
       (1) Any member of a regular component of the Armed Forces who 
has served in Iraq or Afghanistan since October 2001.
       (2) Any member of the Selected Reserve of the Ready Reserve of 
the Armed Forces who served on active duty in Iraq or Afghanistan since 
October 2001.

        Data on Personality Disorder Administrative Separations

         (A) A statement of the total number of cases, by Armed Force, 
in which covered members of the Armed Forces have been separated from 
the Armed Forces on the basis of a personality disorder, and an 
identification of the various forms of personality disorder forming the 
basis for such separations.

    Paragraph (a)(2)(A), above, of section 597 of the FY08 NDAA 
specifically asks for, ``A statement of the total number of cases, by 
Armed Force, in which covered members of the Armed Forces have been 
separated from the Armed Forces on the basis of a personality disorder, 
and an identification of the various forms of personality disorder 
forming the basis for such separations.'' Paragraph (c) of section 597 
defines ``covered members'' as Servicemembers who served on active duty 
in Iraq or Afghanistan since October 2001. Based on the definition of 
``covered members'' the information requested by paragraph (a)(2)(A) is 
the same as what is requested by paragraph (a)(2)(B), which 
specifically asks for:

         (B) A statement of the total number of cases, by Armed Force, 
in which covered members of the Armed Forces who have served in Iraq 
and Afghanistan since October 2001 have been separated from the Armed 
Forces on the basis of a personality disorder, and the identification 
of the various forms of personality disorder forming the basis for such 
separations.

    The Department assumes that Paragraph (a)(2)(A) was intended to 
request the total number of ALL cases, by Armed Force, in which members 
of the Armed Forces have been separated on the basis of a personality 
disorder since October 2001 (beginning of Fiscal Year 2002), and an 
identification of the various forms of personality disorder forming the 
basis for such separations. Given this assumption the Departments 
submits the information in Table 1 to meet the requirements of 
paragraph (a)(2)(A) of section 597 of the FYO8 NDAA. The data include 
the total number of separations coded for personality disorder, by 
Armed Force, from fiscal year 2002, which began October 2001, through 
fiscal year 2007.

     Table 1--Number of Administrative Separations Coded as Based on
            Personality Disorder from Fiscal Year 2002-2007.
------------------------------------------------------------------------
                               Number of Personality Disorder Separation
         Armed Forces                            Cases
------------------------------------------------------------------------
Army                                                              5,652
------------------------------------------------------------------------
Navy                                                              7,554
------------------------------------------------------------------------
Marine Corps                                                      3,527
------------------------------------------------------------------------
Air Force                                                         5,923
------------------------------------------------------------------------
Total                                                            22,656
------------------------------------------------------------------------


    Table 2 lists the various forms of personality disorder forming the 
basis for the personality disorder coded separations of Servicemembers 
from fiscal years 2002 through 2007.

     Table 2--The Various Forms of Personality Disorder Forming the Basis for the Personality Disorder Coded
                            Separation of Servicemembers from Fiscal Year 2002-2007.
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Paranoid Personality Disorder                                                    Explosive Personality Disorder
----------------------------------------------------------------------------------------------------------------
Affective Personality Disorder, Unspecified                           Obsessive-Compulsive Personality Disorder
----------------------------------------------------------------------------------------------------------------
Chronic, Hypomanic Personality Disorder                            Histrionic Personality Disorder, Unspecified
----------------------------------------------------------------------------------------------------------------
Chronic Depressive Personality Disorder                                        Unspecified Personality Disorder
----------------------------------------------------------------------------------------------------------------
Cyclothymic Disorder                                                      Other Histrionic Personality Disorder
----------------------------------------------------------------------------------------------------------------
Schizoid Personality Disorder, Unspecified                                       Dependent Personality Disorder
----------------------------------------------------------------------------------------------------------------
Introverted Personality                                                         Antisocial Personality Disorder
----------------------------------------------------------------------------------------------------------------
Schizotypal Personality Disorder                                              Narcissistic Personality Disorder
----------------------------------------------------------------------------------------------------------------
Avoidant Personality Disorder                                                   Borderline Personality Disorder
----------------------------------------------------------------------------------------------------------------
Passive-Aggressive Personality                                                      Other Personality Disorders
----------------------------------------------------------------------------------------------------------------
Chronic Factitious Illness with Physical Symptoms
----------------------------------------------------------------------------------------------------------------


    Paragraph (a)(2)(B) of section 597 of the FYO8 NDAA specifically 
asks for:

         (B) A statement of the total number of cases, by Armed Force, 
in which covered members of the Armed Forces who have served in Iraq 
and Afghanistan since October 2001 have been sepatated from the Armed 
Forces on the basis of a personality disorder, and the identification 
of the various forms of personality disorder forming the basis for such 
separations.

    The Department submits the information in Table 3 to meet the 
requirements of Paragraph (a)(2)(B). The data include the total number 
of separations coded for personality disorder, by Armed Force, of 
Servicemembers who deployed in support of the Global War on Terror 
during fiscal years 2002 through 2007. The Department included all 
Servicemembers who had deployed in support of the Global War on Terror 
as opposed to only those who had deployed to Afghanistan and Iraq in an 
attempt to identify a more comprehensive class of Servicemembers for 
Congressional consideration.

     Table 3--Number of Administrative Separations Coded as Based on
  Personality Disorder of Servicemembers Who Deployed in Support of the
     Global War on Terror for Some Period of Time Between 2002-2007.
------------------------------------------------------------------------
                               Number of Personality Disorder Separation
         Armed Forces                            Cases
------------------------------------------------------------------------
Army                                                              1,480
------------------------------------------------------------------------
Navy                                                              1,155
------------------------------------------------------------------------
Marine Corps                                                        455
------------------------------------------------------------------------
Air Force                                                           282
------------------------------------------------------------------------
Total                                                             3,372
------------------------------------------------------------------------


    The various forms of personality disorder forming the basis of 
personality disorder coded separations of Servicemembers who deploy in 
support of the Global War on Terror are the same as those previously 
listed in Table 2.

   Summary of Policy Controlling Personality Disorder Administrative 
                              Separations

         (C) A summary of the policies by Armed Force, controlling 
administrative separations of members of the Armed Forces based on 
personality disorder, and an evaluation of the adequacy of such 
policies for ensuring that coveted members of the Armed Forces who may 
be eligible for disability evaluation due to mental health conditions 
are not separated from the Armed Forces on the basis of a personality 
disorder.

    Department Policy governing the administrative separation of 
Servicemembers for personality disorder is contained in DoD Directive, 
1332.14, Enlisted Administrative Separations. The policy states that 
the Secretary concerned may authorize separation on the basis of other 
designated physical or mental conditions (may include, but not limited 
to, personality disorder, air sickness, and seasickness) not amounting 
to disability, that potentially interfere with assignment to or 
performance of duty under the separation guidance set forth in the 
directive.
    Specific guidance on personality disorder separations is contained 
in DoD Directive 1332.14, Section E3.A1.1.304.8, Other designated 
physical or mental conditions. Separation processing may not be 
initiated on the basis of personality disorder ``until the 
Servicemember concerned has been counseled formally concerning 
deficiencies and has been afforded an opportunity to overcome those 
deficiencies as reflected in appropriate counseling or personnel 
records.'' Additionally, ``separation on the basis of personality 
disorder is authorized only if a diagnosis by a psychiatrist or 
psychologist, completed in accordance with procedures established by 
the Military Department concerned, concludes that the disorder is so 
severe that the member's ability to function effectively in the 
military environment is significantly impaired. Furthermore, Department 
policy states that separation for personality disorder is not 
appropriate when separation is warranted for any of the following: 
expiration of Service obligation; selected changes in Service 
obligations; disability; defective enlistments and inductions; entry-
level performance and conduct; unsatisfactory performance; homosexual 
conduct; drug abuse rehabilitation failure; alcohol abuse 
rehabilitation failure misconduct; separation in lieu of trial by court 
martial; security; unsatisfactory participation in the ready reserve or 
reasons estab1ished by the Military Departments. Finally, Department 
policy requites the written notification to Servicemembers prior to 
being involuntarily separated on the basis of personality disorder.
    The written notification to Servicemembers dictated by Department 
policy in DoD Directive, 1332.14, Section E3.A3.1.2, Notification 
Procedure, requires the Servicemember to be notified, in writing, of:

      The basis of the proposed separation, including the 
circumstances upon which the action is based and a reference to the 
applicable provision of the Military Department's regulation.
      Whether the proposed separation could result in 
discharge, release from active duty to a Reserve component, transfer 
from the Selected Reserve to the Individual Ready Reserve, release from 
custody or control of the Military Services, or other form of 
separation.
      The least favorable characterization of service or 
description of separation authorized for the proposed separation.
      The right to obtain copies of documents that will be 
forwarded to the Separation Authority supporting the basis of the 
proposed separation.
      The respondent's right to submit statements.
      The respondent's right to consult with counsel qualified 
under Article 27(b)(1) of the Uniform Code of Military Justice. Non-
lawyer counsel may be appointed when the member is deployed and aboard 
a vessel or in similar circumstances of separation from sufficient 
judge advocate resources as determined under standards and procedures 
specified by the Secretary of the Military Department concerned. The 
respondent also may consult with civilian counsel at the member's own 
expense.
      If the respondent has 6 or more years of total active and 
Reserve military service, the right to request an Administrative Board.
      The right to waive the preceding four rights (right to 
obtain copies of documents; right to submit statements; right to 
consult with qualified counsel; and, right to request an Administrative 
Board) after being afforded a reasonable opportunity to consult with 
counsel, and that failure to respond shall constitute a waiver of the 
right.

    In addition to Department policy each Military Department has 
supplemental guidance controlling the administrative separation of 
Servicemembers on the basis of personality disorder. They are listed 
below:

    Army Policy: Army policy for administrative separation of enlisted 
Soldiers on grounds of personality disorder is contained in Army 
Regulation 635-200, Active Duty Enlisted Administrative Separations, 
paragraph 5-13 titled, ``Separation because of personality disorder.'' 
The policy is not unilateral, but rather derives from governing 
Department of Defense policy (DoD Directive 1332.14, Enlisted 
Administrative Separations). The basis is a deeply ingrained 
maladaptive pattern of behavior of long duration, not amounting to a 
disability, which it interferes with the Soldier's ability to perform 
duty. A key provision is that the diagnosis of personality disorder 
must be established by a psychiatrist or a doctoral-level municipal 
psychologist. In addition, the local Military Treatment Facility Chief 
Behavioral Health must review the finding of personality disorder to 
ensure accurate diagnosis. Separation is authorized only if the 
diagnosis concludes that the personality disorder is so severe that the 
Soldier's ability to function effectively in the military environment 
is significantly impaired. Based on the medical diagnosis and 
conclusion, the Soldier's unit commander initiates involuntary 
separation proceedings and refers them to the separation authority, who 
is the special court martial convening authority (a colonel).

    Navy Policy (includes Marine Corps): Navy policy for administrative 
separation on the basis of personality disorder is contained in 
Department of the Navy Military Personnel Manual (MILPERSMAN) 1910-122, 
Separation by Reason of Convenience of the Government--Personality 
Disorder(s). Marine Corps policy is contained in Marine Corps Order 
(MCO) P1900.16F, Marine Corps Separation and Retirement Manual, Section 
3, titled Personality Disorder. Both references state that 
administrative separation on the basis of personality disorder is 
allowed only if the disorder is so severe that the member's ability to 
function effectively in a military environment is significantly 
impaired.
    Servicemembers recommended for administrative separation on the 
basis of personality disorder must receive a Mental Health Evaluation 
(MHE) conducted by a Mental Health Professional. A Mental Healthcare 
Provider is defined in Secretary of the Navy (SECNAV) Instruction 
6320.24A, Mental Health Evaluation of Members of the Armed Forces, 
Enclosure 1, as a psychiatrist, doctoral-level clinical psychologist, 
or doctoral-level social worker with necessary and appropriate 
professional credentials who is privileged to conduct mental health 
evaluations for DoD components. According to the same reference, the 
mental health evaluation ``shall consist of, at a minimum, a clinical 
interview and mental status examination and may include, additionally: 
a review of medical records; a review of other record, such as the 
Service personnel record; information forwarded by the Servicemember's 
commanding officer; psychological testing; physical examination; and 
laboratory and/or other specialized testing.''
    Navy MILPERSMAN 1910-120, Separation by Reason of Convenience of 
the Government--Physical and Mental Conditions, is currently being 
revised to ensure alignment with guidance contained in MILPERSMAN 1910-
122. The Department of the Navy Manual of the Medical Department, 
Chapter 18-5 lists personality disorders as ``conditions not meriting a 
Medical Evaluation Board.''

    Air Force Policy: For enlisted Airmen, Personality Disorder 
discharges are processed under Air Force Instruction 36-3208, 
Administrative Separation of Airmen, Chapter 5, Involuntary Convenience 
of the Government (COG) Discharge. Specifically, paragraph 5.11., 
``Conditions That Interfere With Military Service,'' states that Airmen 
may be discharged when the commander determines that the condition 
interferes with assignment or duty performance. A recommendation for 
discharge under this provision must be supported by a report of 
evaluation by a psychiatrist or clinical psychologist (doctoral level) 
that confirms the diagnosis of a disorder as contained in the 
Diagnostic and Statistical Manual of Medical Disorders (DSM-IV). This 
report must state the disorder is so severe that the Airman's ability 
to function effectively in the military environment is significantly 
impaired. This report may not be used as, or substituted for, the 
explanation of the adverse effect of the condition on assignment or 
duty performance. When a psychiatrist or psychologist confirms 
diagnosis of a mental disorder that is so severe that the Airman's 
ability to function effectively in the military environment is 
significantly impaired, and the commander chooses not to initiate 
separation action, the commander must have that decision reviewed by 
the discharge authority. Conditions that warrant disability processing 
will not be used to justify a separation under this instruction. A 
recommendation for discharge must be supported by documents confirming 
the existence of the condition and showing the member is medically 
qualified for worldwide duty. Except when enuresis or sleepwalking is 
involved, the commander must explain the adverse effect on assignment 
or duty performance. Similarly, administrative discharges of officers 
with Personality Disorder are processed under the guidance of API 36-
3206, Administrative Discharge Procedures for Commissioned Officers.
    Current DoD and Military Department policies, regarding the use of 
personality disorder as the basis for administrative separations of 
Servicemembers, allow for the controlled separations of Servicemembers 
by the Military Departments, enabling the Military Department 
Secretaries to manage separations to ensure their forces are fit to 
fight. The requirement for the Military Departments to notify 
Servicemembers, in writing, and to allow them to consult with legal 
counsel helps ensure Servicemembers are not wantonly discharged at the 
convenience of the Military Department Secretaries on the basis of 
personality disorder and that the separation proceedings receive due 
diligence. The Department believes that existing policy could be 
strengthened and has been working over the past few months to implement 
more rigorous policy regarding the use of personality disorders the 
basis for separation of Servicemembers who have deployed to designated 
imminent danger pay areas (e.g., Iraq, Afghanistan, Kuwait, Saudi 
Arabia, Pakistan, Serbia, and Djibouti).

    Measures Being Taken Regarding Personality Disorder Separations

         (D) A discussion of measures being implemented to ensure that 
members of the Armed Forces who should be evaluated for disability 
separation or retirement due to mental health conditions are not 
processed for separation from the Armed Forces on the basis of a 
personality disorder, and recommendations regarding how members of the 
Armed Forces who may have been so separated from the Armed Forces 
should be provided with expedited review by the applicable board for 
the correction of military records.

    The Department is in the final phase of adding additional rigor to 
the personality disorder administration separation policy. The revised 
policy would authorize personality disorder separations only if 
diagnosed by a psychiatrist or PhD-level psychologist. Moreover, 
members who are being considered for administrative discharge based on 
personality disorder who have served or are currently serving in 
designated imminent danger pay areas (e.g., Iraq, Afghanistan, Kuwait, 
Saudi Arabia, Pakistan, Serbia, and Djibouti) would have their 
personality disorder diagnosis corroborated by a peer, psychiatrist or 
PhD-level psychologist, or another higher level mental health 
professional. The diagnosis would address post traumatic stress 
disorder or other mental illness comorbidity. Finally, before a member 
who has served or is currently serving in an imminent danger pay area 
can be separated on the basis of personality disorder their case would 
be reviewed and endorsed by The Surgeon General of the Military 
Department concerned. The Department anticipates implementing the 
revised policy by July 2008.
    Separation data show that only 3.4K of the 23K Servicemembers 
administratively discharged with personality disorder coded separations 
between fiscal years 2002 and 2007 had deployed in support of the 
Global War on Terror. There is no indication that personality disorder 
diagnoses for members who were deployed in support of the Global War on 
Terror were prone to systematic or widespread error. Moreover, 
Department mental health providers are competent professionals who 
regularly screen and diagnosis post traumatic stress disorder and 
related mental health disorders. Furthermore, the Department is aware 
of no studies that show a strong correlation between personality 
disorder separations and post traumatic stress disorder, Traumatic 
Brain Injuries, or other Global War on Terror related mental health 
disorders. Still, the Department shares Congress' concern regarding the 
possible use of personality disorder as the basis for administratively 
separating this class of Servicemember. This concern led to the 
aforementioned pending policy change which specifically provides 
additional protections to ensure Servicemembers who suffer from post 
traumatic stress disorder are not separated on the basis of personality 
disorder.
    The Department encourages all former Servicemembers who believe 
that their discharges were incorrectly characterized or processed to 
request adjudication through their respective Military Department's 
Discharge Review Board. Given that there are no indications that 
Servicemembers suffering from post traumatic stress disorder were 
systematically processed for administrative separation based on 
personality disorder, the Department believes that members from this 
class of veterans should utilize the existing Discharge Review Board 
processes. These boards have well established processes and procedures 
in place to fairly evaluate each veteran's request in an expeditious 
fashion.
Conclusion
    In conclusion, the Department appreciates the opportunity to 
provide Congress with information regarding the administrative 
separating of Servicemembers based on personality disorder for those 
members who deployed in support of the Global War on Terror. There is 
no indication that personality disorder diagnoses for members who were 
deployed in support of the Global War on Terror were prone to 
systematic or widespread error. Moreover, Department mental health 
providers are competent professionals who regularly screen and diagnose 
post traumatic stress disorder and related mental health disorders.
    The Department, however, has been working over the past few months 
to implement policy that adds additional rigor to the personality 
disorder administrative separation policy. The revised policy would 
specifically require personnel being considered for personality 
disorder separations who have served or are currently serving in 
designated imminent danger pay areas to be evaluated for post traumatic 
stress disorder or other mental illness co-morbidity prior to being 
separated on the basis of personality disorder.

                                 

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                      June 19, 2008

The Honorable James B. Peake, M.D.
The Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
    In reference to our Full Committee hearing on ``Implementing the 
Wounded Warrior Provisions of the National Defense Authorization Act 
for Fiscal Year 2008'' on June 11, 2008, I would appreciate it if you 
could answer the enclosed hearing questions by the close of business on 
August 4, 2008.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax your responses at 202-225-2034. If you have any 
questions, please call 202-225-9756.

            Sincerely,
                                                         BOB FILNER
                                                           Chairman

                               __________

                        Questions for the Record
                   The Honorable Bob Filner, Chairman
                  House Committee on Veterans' Affairs
                             June 11, 2008
  Implementing the Wounded Warrior Provisions of the National Defense 
                 Authorization Act for Fiscal Year 2008
    Question 1(a): Section 1615 of the NDAA, requires the two agencies 
to submit a final report on the comprehensive policy that is required 
to be developed in section 1611 of the NDAA on improvements to care, 
management, and transition of recovering servicemembers. Could you tell 
the Committee what the status of the final report is?

    Response: Section 1615 of the National Defense Authorization Act 
(NDAA) requires a comprehensive final report regarding care management 
and transition of recovering servicemembers. The Department of Veterans 
Affairs (VA) has provided input to the Department of Defense (DoD) 
section. Letters dated June 26, 2008, were sent to the Committees on 
Armed Services and the Committees on Veterans' Affairs, signed by 
Admiral Patrick Dunne, Co-Chair VA, Wounded, Ill and Injured 
Overarching Integrated Product Team and Mr. Michael L. Dominquez, Co-
Chair DoD, Wounded, Ill and Injured Overarching Integrated Product Team 
indicating that the report would be submitted by August 2008.

    Question 1(b): If you do not believe that it will be finished on 
time; do you have an expected completion time?

    Response: The report will be delivered by August 2008.

    Question 1(c): What, in your experience, has been the biggest 
barrier in carrying out section 1611?

    Response: VA has not experienced any significant barriers.

    Question 2(a): Oftentimes we find that implementing policy can be 
very difficult. section 1611 of the NDAA required a program for the 
assignment to recovering servicemembers of recovery care coordinators. 
Could you discuss with the Committee the implementation of the Federal 
Recovery Coordinator Program in terms of patient ratios and where the 
Agencies believe the program will be in the future?

    Response: The Federal Recovery Coordination Program (FRPC) was 
recently moved from it's location within the Veterans' Health 
Administration and will now report directly to the Secretary. Karen 
Guice, MD, MPP, was hired as the Executive Director to run the program. 
Dr. Guice served as the Deputy Director of the President's Commission 
on Care for America's Wounded Warriors.''
    The ratio of Federal Recovery Coordinators (FRC) to patients is 
being determined based on the complexity and intensity of needed 
services and the acuity level of the patient. An electronic workload 
reporting system is in place and data are being collected. Analysis of 
these data will allow appropriate allocation of resources. The program 
will also examine best practices in administrative and clinical care 
staffing models to better inform staffing decisions.
    For now, the FRCP will continue to identify individuals classified 
as catastrophically wounded, ill or injured Operation Enduring Freedom 
and Operation Iraqi Freedom (OEF/OIF) servicemembers. These individuals 
clearly need the support offered by the FRC program. The FRCP office is 
hiring a full time registered nurse to review records of patients who 
have already been through the acute phase of care and may now living in 
the community. Targeted patient populations, such as those who have 
been through the VA polytrauma, spinal cord injury treatment or blind 
rehabilitation will be evaluated and offered enrollment or referral to 
other existing programs as appropriate. Similarly, the FRC program will 
work with TRICARE and DoD partners to identify those catastrophically 
wounded, ill or injured servicemembers and veterans who have not 
enrolled in VA care, but may still benefit from the FRCP.

    Question 2(b): Do you have any preliminary feedback as to the 
effectiveness of the program?

    Response: FRCs report that the feedback from servicemembers, 
veterans, and families participating in the FRC program has been 
uniformly positive.

    Question 3: Have either of the agencies worked on satisfaction 
surveys with veterans and caregivers who participate in the program? If 
not, are there any plans to conduct a survey in the future?

    Response: VA has not administered an official satisfaction survey 
of participants in the FRC program yet. However, VA expects to initiate 
a satisfaction survey in fiscal 2009.

    Question 4: Federal Recovery Coordinators have to be proficient in 
not only DoD and VA benefits, but also those benefits that wounded 
servicemembers and their families will need to access under the 
Department of Labor and Social Security. How have the agencies dealt 
with training the coordinators so they are able to address all of the 
aspects required of them in assisting recovering servicemembers?

    Response: FRCs received training in both DoD and VA benefits, as 
well as Department of Labor and Social Security Administration 
benefits. More importantly, FRCs have access to experts from each of 
these Departments to assist with questions and concerns.

    Question 5: In your testimony you state that VA is putting a 
charter group together comprised of specialty care managers across VA 
including OEF/OIF teams, spinal cord, blind rehabilitation, mental 
health, polytrauma and others. This group is to make recommendations on 
a systemwide approach to care management with emphasis on the 
coordination between programs. Are DoD personnel involved in this group 
or is this just VHA?

    Response: The charter group is composed of VA members only. It is 
responsible for developing Veterans Health Administration (VHA) policy 
for care management, with an emphasis on coordinating care throughout 
the VA system.

    Question 6(a): In reference to section 1612 of the NDAA for fiscal 
year 2008, could you discuss the progress made in VA and DoD's 
improvement in the medical and disability evaluation processes in terms 
of: The VA/DoD single exam that was initiated at the Washington, D.C. 
VA Medical Center?

    Response: One of the major tenants of the disability examination 
system (DES) pilot is that there be one disability examination for the 
servicemember that meets the requirements of both VA and DoD. That 
examination, currently being conducted at the Washington, D.C. VA 
Medical Center using VA protocols, meets that requirement. As of June 
28, 2008, the most recent period for which we have data, examinations 
have been completed for 261 servicemembers in the pilot and an 
additional 99 servicemembers are currently in the examination process.

    Question 6(b): Have cost sharing issues been resolved between VA 
and DoD for the exam process? How will the costs be allocated between 
the Departments?

    Response: VA and DoD are working collaboratively to come up with a 
cost sharing mechanism for the examination process as the pilot expands 
and, if warranted, becomes the standard business practice. DoD is 
paying for the examinations in the pilot in the National Capital 
Region. An initial draft of a memorandum of understanding on 
examinations and cost sharing is being reviewed in both departments.

    Question 6(c): Have appeals issues been addressed and what will be 
the process?

    Response: To address your question we must make a distinction 
between the DoD appeals process while a member is still on active duty 
and the VA appeals process once a servicemember has become a veteran 
and been formally notified of his or her VA rating decision.
    In the DoD environment, a member has a specified period of time to 
rebut a decision of either the medical evaluation board (MEB) or the 
informal or formal physical evaluation board (PEB) decision. VA does 
not have a role in any attempted rebuttal of a MEB determination. At 
the PEB stage in the pilot a member may attempt to rebut three items: 
1) the basic fitness determination by the PEB, 2) what conditions are 
considered in the fitness determination by the PEB, and 3) the 
evaluation assigned for conditions found unfitting by the PEB. VA does 
not have a role to play in the first two situations. If the member 
wishes to rebut the evaluation assigned by VA, the member is entitled 
to a review of the decision on a one-time basis if the member presents 
an argument that there is an error in the application of the schedule 
and/or submits additional medical evidence supporting the assignment of 
a higher evaluation. A VA decision review officer (DRO) conducts the 
review in such rebuttals. Once the DRO has conducted the appropriate 
review, the PEB is advised that either the previous decision is 
affirmed or a revised decision is provided. This completes VA's 
involvement in the DES appeals process. Thus far three servicemembers 
have requested review by a DRO. In one case, request for review was 
denied because the evaluation with which the member disagreed was not 
for a DoD-determined unfitting condition. In the other two cases the 
DRO affirmed the initial VA evaluation assignment.
    The rebuttal process while a member is still on active duty in no 
way limits his or her appeal rights once the member is separated from 
service and provided with the formal VA decision on all unfitting and 
claimed conditions. Once separated, the veteran has 1 year from date of 
decision notification to file an appeal.

    Question 6(d): Can DoD refute a rating rendered by VA for a 
servicemember whose disability is not agreed upon?

    Response: Current DoD policy in the pilot generally requires the 
PEB to use the ratings assigned by VA. NDAA of 2008 requires that DoD 
use the rating schedule used in VA as governed by VA policy and 
governing court precedent. DoD can request that VA reconsider 
evaluations assigned; however DoD cannot direct VA to change 
evaluations assigned. The military services have the ability to 
decrease the evaluation if the current level of disability is shown to 
be associated with the member's failure to comply with medical 
direction regarding the treatment of the condition. Additionally, the 
services can determine that a medical condition pre-existed entry into 
service and was not aggravated by the military service.

    Question 7: Referring to section 1614 of the NDAA for fiscal year 
2008, in spite of efforts by a Joint Executive Council, Health 
Executive Council and a Senior Oversight Committee, veterans still fall 
through cracks when transitioning between DoD and VA. Have the 
Departments considered creating a Seamless Transition Office jointly 
staffed by DoD and VA representatives instead of operating across 
systems and with collaterally assigned staff?

    Response: DoD and VA are considering multiple venues to continue 
joint work. This includes realigning the Joint Executive Council (JEC) 
and Senior Oversight Committee (SOC) into a single chain of command or 
into a hybrid organization. This would align the strategic management 
of the JEC with the tactical capabilities of the SOC into a long-term 
combined staff organization with rapid response capability.

    Question 8: In reference to section 1621 of the NDAA for fiscal 
year 2008, how will the new TBI Center of Excellence coordinate with 
already existing experts in neurological care in other sectors?

    Response: The Center of Excellence for Psychological Health and 
traumatic brain injury is a Department of Defense organization. VA 
routinely collaborates and coordinates with this Center, as well as 
many other Federal and private sector agencies and organizations. How 
this Center will coordinate with other sectors is best addressed by 
DoD.

    Question 9: Competency is often an issue with TBI patients. How 
will the participation of family members and other caregivers be 
ensured?

    Response: VA works proactively to ensure the involvement of family 
members. For example, VA encourages and supports the involvement of 
family members in their role as caregivers through a combination of 
educational, logistical and administrative assistance interventions. 
Collaboration with the family begins prior to admission to one of the 
polytrauma/traumatic brain injury (TBI) system of care facilities, 
during which time the social worker case manager (SWCM) assigned to 
each patient initiates a relationship with the family. Within 24 hours 
of admission of the TBI patient, the SWCM establishes a communication 
plan with the family, which is documented in the social work 
assessment.
    Furthermore, the primary goals of the TBI patient and family, 
including the plan of care, and expected length of stay, are discussed 
to ensure that the family's input is incorporated into the treatment 
plan. Daily contact is made with the family members and they are 
encouraged to participate in all rehabilitation therapies, activities, 
outings and therapeutic passes. Weekly meetings between the family and 
the healthcare team are held to address questions, concerns, and 
patient and family educational needs. Family needs and skills are 
continually re-assessed and addressed throughout the inpatient 
rehabilitation process.
    Prior to discharge from the hospital, the caregiver's ability to 
adequately care for the veteran is assessed through such means as 
trials in independent living apartments, home passes, and home visits 
by medical center staff. During these visits, a VA staff member 
assesses the adequacy of the home environment and identifies any need 
for home equipment and home modifications. After the veteran returns 
home, services provided to ensure that the veteran receives appropriate 
care and that family members are supported in providing that care 
include: homemaker and home health aid services, respite care, home-
based primary care, and adult day care. Ongoing access to an assigned 
care case manager is also maintained to coordinate medical and 
psychosocial services, and serve as the first line responder to 
emerging needs and potential problems.
    Finally, extensive educational resources are also provided to 
patients and caregivers including the Polytrauma Rehabilitation Family 
Education Manual, and accessible materials on My HealtheVet Web site. 
The recently developed Family Care Map will identify and standardize 
best practices for working with families across the VA polytrauma/TBI 
rehabilitation centers, and provide the patient and family with a guide 
or roadmap of the rehabilitation process. The foundation of the 
rehabilitation process is VA's emphasis that family participation is 
critical to effective rehabilitation, especially when patients have 
diminished decisionmaking capacity as a consequence of the TBI.

    Question 10: In reference to section 1622 of the NDAA for fiscal 
year 2008, how will the PTSD Center of Excellence differ from the 
existing National Center for PTSD already funded by VA? How will they 
be detailed to interact?

    Response: VA believes that the post traumatic stress disorder 
(PTSD) Center of Excellence mentioned in the question refers to the 
program commonly known as the DoD Centers of Excellence (DCoE) for 
psychological health and TBI. The VA's National Center for PTSD 
(NCPTSD) and the DCoE for psychological health and TBI have 
complementary, but distinct missions.
    Generally, the NCPTSD's mission is to provide a VA center of 
excellence for research with education on the prevention, 
understanding, and treatment of PTSD. The NCPTSD has seven divisions 
across the country, with the purpose of improving the well-being and 
understanding of American veterans.
    The DCoE leads a collaborative effort toward optimizing 
psychological health and TBI treatment for DoD. The DCoE establishes 
quality standards for clinical care; education and training; 
prevention; patient, family and community outreach; and program 
excellence. The DCoE currently has four component centers, the Defense 
and Veterans Brain Injury Center, the Deployment Health Clinical 
Center, the Center for the Study of Traumatic Stress, and the Center 
for Deployment Psychology.
    Significant interaction and collaboration between the two centers 
are planned, due to their missions. VA will provide three staff members 
to work directly in the DCoE, including a Deputy Director, and two VA 
senior consultant/liaisons to ensure close coordination between VA and 
DoD. In fact, VA has already provided an Acting Deputy Director in the 
DCoE, who herself trained for 2 years at the NCPTSD and has significant 
connections to the NCPTSD. In addition, several members of the DCoE 
have visited the NCPTSD for consultation, and four members of the 
NCPTSD have attended strategic planning summits for the DCoE. 
Coordination of ongoing training efforts in evidence-based practice is 
already ongoing, as well.

    Question 11: Employability and quality of life are significant 
issues for those with mental health conditions. How will PTSD Center of 
Excellence deal with those issues?

    Response: A patient's reintegration into the community following 
deployment is a major focus of the DCoE for psychological health and 
TBI. The DCoE, in partnership with VA, has consulted with the 
Department of Labor to develop programs of employability. Further, the 
Deployment Health Clinical Center (one of the component centers of the 
DCoE) is conducting ongoing studies of quality of life and disease 
burden in individuals with PTSD. It is expected that the results of 
these studies will improve our understanding of quality of life 
decrements for individuals with PTSD. Finally, the Deputy Director from 
VA for the DCoE will explore opportunities for collaboration with VA 
vocational rehabilitation programs for those with mental health 
problems.

    Question 12: Interpersonal relationships are often difficult for 
those with PTSD and other mental illnesses. How will those issues be 
addressed and significant others included?

    Response: PTSD and other mental disorders can significantly impact 
interpersonal relationships, as they may lead to disturbance or deficit 
in an individual's social functioning and/or promote stress on family 
and significant others. VA is committed to providing the best available 
treatments for PTSD and other mental illnesses to not only reduce 
symptoms, but to also allow individuals to live full and meaningful 
social lives.
    VHA is actively working to disseminate evidence-based 
psychotherapies for a variety of mental health conditions throughout 
the VA healthcare system to help patients live full and meaningful 
social lives. Two programs are currently underway to provide clinical 
training to VA mental health staff in the delivery of cognitive 
processing therapy (CPT) and prolonged exposure therapy (PE) for PTSD. 
CPT and PE are recommended in the VA/DoD Clinical Practice Guidelines 
for PTSD at the highest level, indicating ``a strong recommendation 
that the intervention is always indicated and acceptable.'' These 
treatments often enable individuals who have suffered from PTSD to more 
comfortably and meaningfully interact and engage with others.
    VA is also working to promote state-of-the-art treatments that 
involve working with the families of veterans with serious mental 
illness to improve individual functioning and family relationships. VA 
is disseminating family psychoeducation (FPE), a compilation of 
evidence-based practice whereby the clinician works with a patient's 
family to provide the family with the skills and attitudes that have 
been shown to reduce relapse in individuals with serious mental 
illnesses. Components of FPE include careful assessment, provision of 
education, problem-solving, and an emphasis on improving current 
functioning in many areas including interpersonal relationships.
    In addition, VA has funded a national initiative to integrate 
mental health providers on each VA home based primary care (HBPC) team. 
A major component of the HBPC mental health provider's responsibility 
is working with family caregivers of homebound veterans to address 
neuropsychiatric or psychological symptoms associated with dementia or 
mental illness that may affect individual and family functioning.
    Individuals with serious mental illness, such as schizophrenia, may 
have skill deficits that limit interpersonal relationships. For these 
veterans, VA is implementing a national initiative to disseminate 
social skills training, and an evidence-based psychological 
intervention for individuals with serious mental illness that has been 
consistently found to increase skill-acquisition and improve social 
functioning.
    Finally, depression and anxiety can significantly reduce interest, 
motivation, and ability to engage in meaningful interpersonal 
relationships. VA is currently implementing national initiatives to 
train VA mental health staff in the delivery of cognitive behavioral 
therapy and acceptance and commitment therapy for depression and 
anxiety. These treatments promote changes in perceptions of self and 
others and work to increase positive behaviors that often lead to 
improvements in social functioning and interpersonal relationships.

    Question 13: In reference to section 1635 of the National Defense 
Authorization Act of 2008, why won't both Departments simply use VistA?

    Response: VA and DoD are currently working toward developing 
systems that are interoperable. This strategy will best serve the needs 
of veterans, those transitioning to veteran status, and beneficiaries 
of military heath care. Sharing information permits each department to 
meet the needs of the specific patient population while simultaneously 
sharing information to ensure it is available when and where it is 
needed. VA and DoD have both distinct information needs and areas of 
commonality. The departments have built their information systems to 
best support these distinct needs but allow for the necessary 
interoperability to care for shared populations.
    For example, DoD's armed forces health longitudinal technology 
application (AHLTA) includes capabilities that are used to treat DoD 
beneficiaries and soldiers on the ground and in theater. This 
capability is crucial to the care of our armed forces. VA clinicians do 
not provide treatment to patients in theater and therefore VistA is not 
built to support that requirement. To the extent VA clinicians need 
theater information to treat wounded warriors, VA and DoD data 
exchanges have the capability to electronically share this information.
    VA and DoD are now sharing most of the available electronic health 
data that is essential to the care of patients. The departments are 
working to expand data sharing to include other key areas, such as 
inpatient care. They are working together to determine the best way 
forward in the development of an inpatient solution. A joint study is 
in place to scrutinize the inpatient healthcare requirements and 
business practices of both communities. The study will then recommend a 
solution representing the best in inpatient healthcare for our Nation's 
soldiers and veterans.
    VistA has enabled VA to earn the highest healthcare quality 
ratings, and VistA is ranked as best in class by independent groups. 
Yet, it is now necessary to leverage improved technologies and tools to 
modernize VistA and improve VA information capabilities. As VA moves 
toward developing the next generation of VistA, HealtheVet, and as DoD 
continues its enhancement of AHLTA capabilities, the departments are 
working closely to leverage commonalities for information needs. This 
methodology permits the departments to jointly support common 
requirements and also best serve the information needs of those 
requirements that are unique to each community. VA and DoD will 
continue to assess new clinical and business applications for potential 
joint application and ensure their incorporation into HealtheVet, where 
it is technically and economically feasible to do so.

    Question 14(a): VA/DoD IT interoperability efforts have been 
underway for several years at this point. Why has there not been more 
success thus far?

    Response: VA and DoD have achieved significant success toward the 
development of interoperable health systems. VA and DoD are now sharing 
almost all essential health information that is available 
electronically in a bidirectional viewable format. This information 
includes outpatient pharmacy and allergy information, outpatient and 
inpatient laboratory orders and results, radiology reports, select 
inpatient information such as discharge summaries from key DoD military 
treatment facilities, and vital signs. DoD also sends clinical theater 
information, which is available to all VA hospitals, and scanned 
inpatient records and radiology images from key military treatment 
facilities to the four VA polytrauma centers receiving DoD's wounded 
warriors. In addition to sharing viewable information, VA and DoD have 
begun sharing computable allergy and pharmacy information that supports 
automatic drug-drug and drug-allergy interaction checks.

    Question 14(b): What are the current obstacles?

    Response: VA and DoD are sharing an unprecedented amount of health 
information at a level that is not achieved anywhere else in the 
industry. Despite this accomplishment, VA and DoD acknowledge that 
there are several layers of interoperability and that the departments 
are sharing most information in viewable format. In order to expand 
this capability to share more computable data, VA and DoD must leverage 
information standards that are mature and robust enough to support the 
exchange of information for patient care. Such standards do not yet 
exist in all clinical domain areas. VA and DoD are leading partners in 
the National effort to identify and implement health data standards 
that will support increased interoperability.
    Not all information needs to be shared in computable format to 
deliver high quality healthcare to patients. VA and DoD have formed a 
Joint Clinical Information Board (JCIB) that consists of clinicians 
from both departments. The JCIB is currently evaluating the additional 
data types that should be shared in computable format as well as 
identifying and prioritizing the next set of data to be shared between 
DoD and VA.

    Question 14(c): What are the next milestones?

    Response: On April 17, 2008, VA and DoD formed the Interagency 
Program Office, as required by the 2008 NDAA, for the purpose of 
guiding the departments to an interoperable electronic health record by 
September 2009. The departments are on target to meet this milestone 
and will achieve this, in part, based on the work of the JCIB. Also 
included in this work is the expanded bidirectional viewable data that 
are shared. For example, at the end of June 2008, VA and DoD expanded 
data sharing to include the capability to share vital sign information 
on patients. By September 2008, VA and DoD will begin sharing family 
and social history information on patients. The departments also are 
working on expanding a bidirectional image sharing pilot in six 
locations, and are finalizing an enterprise-wide plan for sharing 
images that will be delivered on October 2008.

    Question 15(a): The Dole/Shalala Commission recommended a singular 
Federal benefits portal last summer. a. What efforts have been made to 
make this a reality?

    Response: The following has been accomplished:

      Designation of VA as project lead for the e-benefits 
portal.
      VA/DoD e-benefits portal plan approved by Joint Executive 
Council co-chairs, 31 December 2007.
      Completion of requirements definition.
      Development of phased acquisition strategy, schedule, and 
key milestone.
      Development of technical approach.
      Approval of Joint Incentive Funds proposal to support 
funding the e-benefits portal initiative.

    Question 15(b): What other departments have been involved in 
providing information?

    Response: DoD (Personnel and Readiness, and Health Affairs/TRICARE 
Management Activity) and the Department of Labor are active 
participants in the development and implementation of an e-benefits 
portal in support of wounded, ill or injured servicemembers and 
veterans.

                                 

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                      June 19, 2008

The Honorable Robert M. Gates
Secretary of Defense
U.S. Department of Defense
The Pentagon, Room 3E718
Washington, DC 20301-1000
Dear Mr. Secretary:
    In reference to our Full Committee hearing on ``Implementing the 
Wounded Warrior Provisions of the National Defense Authorization Act 
for Fiscal Year 2008'' on June 11, 2008, I would appreciate it if you 
could answer the enclosed hearing questions by the close of business on 
August 4, 2008.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Debbie Smith by fax your responses at 202-225-2034. If you have any 
questions, please call 202-225-9756.

            Sincerely,
                                                         BOB FILNER
                                                           Chairman
                               __________
                      Hearing Date: June 11, 2008
                             Committee: HVA
                       Member: Congressman Filner
                        Witness: Hon. Dominguez

     Care, Management, and Transition of Recovering Servicemembers

    Question 1: Section 1615 of the NDAA requires the two agencies to 
submit a final report on the comprehensive policy that is required to 
be developed in section 1611 of the NDAA on improvements to care, 
management, and transition of recovering servicemembers.

    a.
        Could you tell the Committee the status of the report?
    b.
        If you do not believe that it will be finished in time, do you 
have an expected completion time?
    c.
        What, in your experience, has been the biggest barrier in 
carrying out section 1611?

    Response: Both Departments have made significant progress on 
developing a joint comprehensive policy on improvements to care, 
management and transition of recovering servicemembers since we issued 
our interim report. We are developing uniform standards for curriculum, 
training, workload, and processes to support the management and 
transition of recovering servicemembers to include development and 
execution of a comprehensive recovery plan for this patient population. 
Both agencies have conducted a review of existing policies and 
procedures that apply to or will be covered by the comprehensive policy 
to identify the most effective and patient-oriented approaches for care 
and management of our recovering servicemembers. The biggest barrier in 
carrying out section 1611 is that developing this policy requires 
extensive coordination between the military services as well as between 
both agencies, requiring additional time for coordination and policy 
development. We will provide a report to Congress detailing the 
comprehensive policy by August 15, 2008. The Department of Defense 
(DoD) in consultation with the Department of Veterans Affairs will 
issue a Directive Type Memo to provide interim guidance for 
improvements to care, management and transition of our recovering 
servicemembers no later than September 15, 2008, to be followed by a 
DoD Instruction.

                         Recovery Coordinators

    Question 2: Oftentimes we find out that implementing policy can be 
very difficult. section 1611 of the NDAA required a program for the 
assignment to recovering servicemembers of recovery coordinators.

    a.
        Could you discuss with the Committee the implementation of 
Federal Recovery Coordinator Program in terms of patient ratios and 
where the agencies believe the program will be in the future?
    b.
        Do you have any preliminary feedback as to the effectiveness of 
the program?
    Response: The Federal Recovery Coordinator (FRC) program and the 
FRC cadre will expand to meet the needed number to serve the severely/
catastrophically ill or injured recovering servicemember or veteran 
with the development and implementation of a Federal Individual 
Recovery Plan (FIRP). The initial proposed workloads of 1 to 20-30 will 
be adjusted based on acuity of recovering servicemembers/veterans being 
served according to the Department of Veterans Affairs clinical 
practice guidelines.
    The evaluation of the FRC program, in its first few months of 
operation, was a process evaluation not an outcome evaluation, and 
intentionally did not focus on measurements of ``effectiveness.'' 
Demographics of number and profile of individuals served are available 
along with first hand comments on experience in the program by the 
FRCs. The evaluation of the program in Phase 2 (May-Dec 2008) will 
capture experience and level of satisfaction of the wounded, ill or 
injured servicemember and their family with the FRC program and the 
FIRP. The evaluation will also look at the National Resource Directory 
and how it was used, by whom, and the level of helpfulness to those 
using it.

           Satisfaction Surveys with Veterans and Caregivers

    Question 3: Have either of the agencies worked on satisfaction 
surveys with veterans and caregivers who participate in the program? If 
not, are there any plans to conduct a survey in the future?

    Response: Yes. An assessment of the recovering servicemember, 
veteran and family experience in the Department of Defense/Department 
of Veterans Affairs Federal Recovery Coordination Program will be 
conducted by gathering data and capturing experience and level of 
satisfaction with the program and the Federal Individual Recovery Plan.

                     Federal Recovery Coordinators

    Question 4: Federal Recovery Coordinators have to be proficient in 
not only DoD and VA benefits but also those benefits that wounded 
servicemembers and their families will need to access under the 
Department of Labor and Social Security. How have the agencies dealt 
with training the coordinators so they are able to address all of the 
aspects required of them in assisting recovering servicemembers?

    Response: In January 2008, the Department of Defense (DoD) and the 
Department of Veterans Affairs (VA) provided an initial 2 week training 
course for our first group of Federal Recovery Coordinators. Both the 
Social Security Administration (SSA) and the Department of Labor (DoL) 
participated in this training, ensuring that the coordinators were 
provided with the most current information from these two 
organizations. A second session for reach-back training was conducted 
June 17-19, 2008. We have developed and implemented an online, web 
based training tool that provides refresher training and acts as a 
resource for the coordinators when addressing benefits for wounded 
servicemembers and their families. All newly hired coordinators are 
required to complete training prior to being deployed to the medical 
treatment facilities to support our wounded servicemembers and their 
families. In addition, DoD will continue to collaborate closely with 
Federal agencies with programs, services, benefits or compensation for 
recovering servicemembers or veterans. SSA has an ongoing relationship 
with DoD in care for wounded warriors, and is participating in the 
development of the DoD/VA National Resource Directory in concert with 
DoL. As an additional resource, the National Resource Directory will 
provide recovering servicemembers and their care coordinators with a 
national linkage to state, local, private and non-profit services and 
resources.

                                 

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                      June 18, 2008

The Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
    On Wednesday, June 11, 2008, Admiral Patrick V. Dunne, Acting Under 
Secretary for Benefits and Assistant Secretary for Policy and Planning, 
testified before the House Committee on Veterans' Affairs on 
Implementing the Wounded Warrior Provisions of the National Defense 
Authorization Act for Fiscal Year 2008. As a follow-up to the hearing, 
I request the enclosed questions be answered in written form for the 
record by close of business, 5 p.m. on Tuesday, July 29, 2008.
    It would be appreciated if the responses could be provided 
consecutively on letter size paper, single-spaced. Please restate the 
question in its entirety before providing the answer.
    If you or your staff have any questions, please contact Dolores 
Dunn, Republican Staff Director for the Subcommittee on Health, at 202-
225-3527.

            Sincerely,
                                                        Steve Buyer
                                          Ranking Republican Member

                               __________

                        Questions for the Record
                       The Honorable Steve Buyer
                       Ranking Republican Member
                  House Committee on Veterans' Affairs
                             June 11, 2008

  Implementing the Wounded Warrior Provisions of the National Defense 
                 Authorization Act for Fiscal Year 2008

    Question 1: What is the status of the review of all policies and 
procedures that relate to the care, management, and transition for 
recovering servicemembers required under section 1611 of Public Law 
110-181, of the National Defense Authorization Act (NDAA) for Fiscal 
Year 2008? Are there any policies and procedures that have yet to be 
reviewed?

    Response: The Department of Veterans Affairs (VA) has completed the 
review of all policies and procedures that relate to the care, 
management, and transition of recovering servicemember and veterans 
required under section 1611 of Public Law 110-181, the National Defense 
Authorization Act (NDAA) for Fiscal Year (FY) 2008. VA has chartered a 
group of clinical staff to review the systems of care for severely ill/
injured servicemembers and veterans, a report will be provided later 
this year.

    Question 2: I understand that the Senior Oversight Committee was 
expecting to complete a full review of all policies and procedures 
relating to the care and management of wounded, ill, or injured 
servicemembers/veterans and their families by April 27, 2008. Were 
these reviews completed? If so, please provide documentation.

    Response: VA has completed the review of all policies and 
procedures that relate to the care, management, and transition for 
recovering servicemember and veterans required under section 1611 of 
Public Law 110-181, the NDAA for FY 2008.
    VA policies reviewed:
    Veterans Health Administration (VHA) Directive 2007-012 Eligibility 
Verification Process for VA Healthcare Benefits (April 2007)
    VHA Directive 2005-045 Treatment of Active Duty Servicemembers in 
VA Healthcare Facilities (October 2005)
    VHA Directive 2005-020 Determining Combat Veteran Eligibility (June 
2005)
    VHA Directive 2007-013 Screening and Evaluation of Possible 
traumatic brain injury (TBI) in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF) Veterans (April 2007)
    VHA Directive 2006-041 Veterans Healthcare Service Standards (June 
2006)
    VHA Directive 2006-055 VHA Outpatient Scheduling Processes and 
Procedures (October 2006)
    VHA Directive 2006-038 Considerations for VA Support for the 
Department of Defense (DoD) Post Deployment Health Reassessment (PDHRA) 
Program for Returning Deployed Servicemembers (June 2006)
    VHA Directive 2006-59 Active Patients in the Primary Care 
Management Module (PCMM) (November 2006)
    VHA Directive 2007-016 Coordinated Care for Traveling Veterans (May 
2007)
    VHA Directive 2006-028 Process for Ensuring Timely Access to 
Outpatient Clinical Care (May 2006)
    VHA Directive 2003-003 Provision of Hospital Outpatient Care to 
Enrolled Veterans (January 2003)
    VHA Handbook 2007-1010.01 Transition Assistance and Case Management 
of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) 
Veterans
    VHA Handbook 2005-1172.1 Polytrauma Rehabilitation Procedures

    Question 3: What progress has been made since the issuance of the 
Interim Report on Policy Improvements on the Care, Management, and 
Transition of Recovering Servicemembers? If the final report will not 
be ready for release on July 1, 2008, please provide an explanation for 
the delay. Please provide the Committee with a copy of the final report 
when it is issued for the Committee's records.

    Response: The Federal Recovery Coordination Program (FRPC) was 
recently moved from it's location within the Veterans' Health 
Administration (VHA) and will now report directly to the Secretary. 
Karen Guice, MD, MPP, was hired as the Executive Director to run the 
program. Dr. Guice served as the Deputy Director of the President's 
Commission on Care for America's Wounded Warriors.
    Standards for the Federal recovery coordinator's (FRC) training 
curriculum and processes to support the management and transition of 
recovering servicemembers/veterans are in place. The FRCs are using an 
electronic tool to develop and execute the Federal individual recovery 
plan. Policies and procedures relating to care of recovering 
servicemembers and veterans have been reviewed by both agencies. The 
Departments have the appropriate clinical and non-clinical case 
management strategies in place and these programs are compatible 
between the Departments. Further, both Departments continue to fine 
tune their clinical care programs. DoD has established an on-going 
clinical practice group, attended by nurses from VA, to synchronize 
clinical models used across the services. VHA has convened a workgroup 
to develop a comprehensive VHA policy to integrate all aspects of care 
management. The report on Policy Improvements on the Care, Management, 
and Transition of Recovering Servicemembers is under review by both 
Departments, and will be provided to Congress by August 15, 2008. VA 
and DoD are jointly developing a directive to provide guidance for 
improvements to care, management and transition of our recovering 
servicemembers which will be available September 15, 2008.

    Question 4: To what extent will the Department of Veterans Affairs 
(VA) collaborate with other Federal agencies, such as the Social 
Security Administration and Department of Labor to develop policies on 
the care, management, and transition of recovering servicemembers and 
veterans?

    Response: FRCs receive training in both DoD and VA benefits, as 
well as Department of Labor and Social Security Administration 
benefits. More importantly, FRCs can readily access experts from each 
of these Departments to answer questions and address concerns.

    Question 5(a): Both VA and the Department of Defense (DoD) have 
promised to provide a Federal Recovery Coordinator (FRC) for every 
seriously injured servicemember who requests one. As of April 2008, 
eight FRCs had been placed in selected facilities. What is the target 
number of FRCs?

    Response: The total number of FRCs has not been determined. The 
program is in the process of tracking the current workload of each FRC 
as well as the complexity and intensity of needs of the servicemembers 
and veterans currently enrolled in the program. The program will also 
examine best practices in administrative and clinical care staffing 
models to better inform staffing decisions.

    Question 5(b): What is the target number of facilities that will 
have FRCs and where will they be located? How many FRCs will be at each 
facility?

    Response: The number of facilities and number of FRCs assigned to 
each facility will be determined following the collection and analysis 
of program workload and case complexity of the severely injured 
servicemembers and veterans served by the program.
    The FRCP office is recruiting staff to review the records of 
patients who are already in the community. The review process should be 
complete over the next 12 months. VA will work to expedite the 
placement of FRCs in additional facility locations.
    At the present time, site locations and FRC staffing are:


------------------------------------------------------------------------
    Current FRC FTEE                         Location
------------------------------------------------------------------------
                   2      Walter Reed Army Medical Center, Washington DC
------------------------------------------------------------------------
                   2      National Naval Medical Center, Bethesda, MD
------------------------------------------------------------------------
                   2      Brooke Army Medical Center, San Antonio, TX
------------------------------------------------------------------------
                   1              Naval Medical Center, San Diego, CA
------------------------------------------------------------------------
                   1                     Providence VA Medical Center
------------------------------------------------------------------------
                   1             Michael E. DeBakey VA Medical Center
------------------------------------------------------------------------


    Question 5(c): What progress has been made to hire additional 
coordinators?

    Response: VA has nine FRCs in place and is recruiting additional 
FRCs on a continuous basis. In addition, VA is recruiting a registered 
nurse case reviewer position to be located VA Central Office to review 
cases and determine if the patient would benefit from the services of 
an FRC.

    Question 5(d): What is the ideal ratio of coordinators to injured 
servicemembers and what is the basis for this ratio?

    Response: The ideal ratio of servicemembers assigned to an 
individual FRC coordinator has not been determined. FRCP is tracking 
and analyzing workload and case complexity of servicemembers and 
veterans enrolled in the program.

    Question 5(e): Is the role of the coordinator to work closely with 
individual servicemembers, or only to provide oversight for problems 
relating to the warrior transition units?

    Response: The FRC develops and oversees, the Federal individualized 
recovery plan (FIRP). The plan describes the resources necessary to 
assist the severely wounded, ill and injured servicemembers, veterans 
and families through recovery, rehabilitation, and reintegration into 
the community. The FRC will work closely with severely ill/injured 
servicemembers, veterans and their families, as well as DoD and VA case 
managers and State, local, private and public service organizations in 
assisting servicemembers and veterans as they transition from DoD to 
the community.

    Question 5(f): Will servicemembers who were discharged prior to the 
creation of FRCs have access to them?

    Response: In May 2008, the FRCP was expanded to include those 
severely wounded, ill and injured servicemembers, veterans discharged 
prior to the creation of the FRCP. The FRCP is working to identify 
those individuals who were or are being treated in VA rehabilitation 
programs (spinal cord injury, blind rehabilitation, and polytrauma 
units) and who might still benefit from the FRCP services. Case 
management data from DoD and TRICARE will also be reviewed to identify 
catastrophically wounded, ill and injured who are not currently 
enrolled in, or using VA healthcare.

    Question 6(a): Given that the number of servicemembers diagnosed 
with post traumatic stress disorder and traumatic brain injury has 
increased by almost 50 percent from 2006 to 2007, how is VA ensuring 
that adequate resources are available to address the needs of veterans?

    Response: The statement about a 50-percent increase in the 
diagnosis of post traumatic stress disorder (PTSD) and TBI appears to 
be related to a May 27, 2008 news release from the Pentagon about 
servicemembers diagnosed with PTSD in 2006 and 2007. It is not a 
statement about overall prevalence of PTSD. VA anticipates seeing more 
veterans with concerns related to PTSD and other war related disorders 
than those identified by DoD. However, the increase in DoD 
servicemembers with PTSD refers only to OEF/OIF era individuals. In FY 
2006, a total of 345,844 veterans with primary or secondary diagnosis 
of PTSD received treatment at VA medical centers and clinics, 27,049 of 
whom (7.8 percent) were OEF/OIF veterans. In FY 2007, VA saw 392,743 
veterans with a primary or secondary diagnosis of PTSD; 45,675 of them 
(11.6 percent of the total) were OEF/OIF veterans. Therefore, while 
there have been reports of a 50-percent increase in the diagnosis of 
PTSD and TBI among active duty personnel in the Army, increases in 
these conditions in VA have been lower; from 2006 to 2007, the increase 
in OEF/OIF veterans seen by VA with a provisional diagnosis of PTSD has 
increased only 23 percent and the overall number of veterans seen with 
PTSD has increased less than 14 percent.
    VA implemented a TBI screening program in April 2007, to screen all 
OEF/OIF veterans who seek healthcare at a VA facility. Over 171,000 
OEF/OIF veterans have been screened positive for possible TBI. Those 
who screen positive do not necessarily have a TBI, they are referred 
for a secondary comprehensive evaluation to confirm or rule out a 
diagnosis of TBI. This new initiative will provide the basis for 
determining the prevalence of mild TBI among OEF/OIF veterans, and 
monitoring increases or decreases from year to year. Presently, data 
are being compiled and analyzed for those veterans who have completed 
the screening and comprehensive secondary evaluation.
    Beginning FY 2007, 154 severe cases of TBI have received inpatient 
rehabilitation. Of these, 40 were combat injured treated in polytrauma 
rehabilitation centers.
    VA has provided supplemental funding to enhance the care of 
veterans with TBI/polytrauma. Additional funding for advanced 
technologies to provide state-of-the-art care for veterans with TBI/
polytrauma was provided in the following areas:

      Equipment for pain management, body weight support and 
rehabilitation in mobilization of individuals with musculoskeletal and 
neurological impairments
      Technologies to evaluate function and provide therapeutic 
interventions and rehabilitation for physical, neurological and 
cognitive functions; e.g., speech, voice, hearing, balance, low vision/
blindness, mobility
      Drivers training for patients with limited mobility or 
ambulation
      Assistive technologies (AT) labs with skilled personnel, 
AT assessment processes, and credible AT outcomes data to augment 
rehabilitation and provide injured veterans with the greatest potential 
for independent functioning

    Additional funding for dedicated core staff with specialized 
training and expertise in assessment and management of TBI/polytrauma 
at polytrauma system of care (PSC) facilities was also provided for a 
core staffing model that includes: nursing, psychology, social work and 
rehabilitation disciplines such as physiatrist, occupational therapy 
and speech language pathology.

    Question 6(b): What strategies are being employed to hire the 
number of mental health professionals needed to meet the increased need 
for mental health services for veterans and their families? What is the 
status of these efforts?

    Response: VA has taken several actions at multiple levels to 
promote the recruitment of qualified mental health professionals in 
VHA. In collaboration with the VA Healthcare Retention and Recruitment 
Office and the Office of Management Support, the Office of Mental 
Health Services has developed a comprehensive mental health enhancement 
recruitment initiative with several new recruitment resources, 
including:

      Mental health education debt reduction program (effective 
February 17, 2007);
      Mental health employee incentive referral initiative 
(effective February 17, 2007);
      Targeted and general advertising, including online and 
print job ads in leading professional journals and local and national 
newspapers;
      Development of a public relations toolkit;
      Brochure development; and
      Educational conferences and job fairs.

    The mental health education debt reduction program (EDRP) provides 
loan repayment for qualified student debt to mental health providers 
who previously had limited access to such resources, since in the past 
there has not been significant difficulty hiring in most mental health 
disciplines. As of June 24, 2008, total funding authorized for the 
mental health EDRP since its initiation last fiscal year was $5.9 
million. The employee incentive referral program provides a bonus to VA 
employees who refer mental health providers who are hired into VA 
positions.
    In addition to the above national recruitment initiative, VHA has 
established additional opportunities for facilities to engage in local 
advertising and recruitment activities, and to cover interview-related 
costs, relocation expenses, and provide hiring bonuses for exceptional 
applicants. VA has also established opportunities for supporting 
individual training and education activities for mental health 
employees, demonstrating an investment in staff that can have a 
positive impact on retention. VA has also funded several initiatives to 
provide comprehensive clinical training to VA mental health staff in 
the delivery of state-of-the-art, evidence-based treatments for PTSD, 
depression, and psychosocial rehabilitation.
    VHA closely tracks the hiring status of newly awarded mental health 
positions and backfill positions on a monthly basis through an online 
reporting and tracking system. Monthly reports on hiring activity and 
monthly change are reviewed by program staff and VHA leadership. In 
addition, VA has implemented a mental health staffing performance 
monitor that tracks the hiring status of newly awarded mental health 
positions and backfill positions against pre-set targets.
    Rates of hiring have increased significantly, following the 
implementation of these new recruitment resources. Since FY 2005, when 
VA began implementing its Mental Health Strategic Plan, VA has funded 
an additional 4,330 mental health enhancement positions; as of May 31, 
2008, 92 percent (3,983) have been hired.
    VA has also significantly expanded the number of VA psychology 
internship and postdoctoral fellowship positions, which provide a 
strong pipeline of highly qualified psychologists to VA. In fact, 73 
percent of psychologists hired in VA in the past 2 years have had VA 
training. The new training positions include 61 new internship 
positions and 98 post-doctoral fellowship positions, bringing the 
national number of training positions in psychology to 620 per year.
    The vet center program expansion began in FY 2004, and is scheduled 
to be complete by FY 2009, with results in increases in all vet centers 
staff from 943 in FY 2004 to 1,526 by the end of FY 2009. This is a 
result of adding 65 new vet centers, 100 outreach specialists and staff 
augmentations at existing vet centers.

    Question 6(c): What other strategies are in place to expand the 
mental health services available to returning servicemembers and 
veterans?

    Response: VA has a comprehensive treatment system for veterans with 
mental disorders that include inpatient, residential and outpatient 
services. Special programs for veterans with serious mental disorders 
who require intensive case management and for veterans who are homeless 
exist in all VA medical centers. Since FY 2005, VA mental health 
programs have had an expansion to enhance the continuum of care and 
improve clinical services through disseminating evidence based 
practices in psychotherapy and recovery and rehabilitation services for 
the seriously mentally ill. Programs for PTSD, special mental health 
teams for OEF/OIF veterans and substance use disorders have had 
significant expansions. As of the close of FY 2007, there were 238 
specialized PTSD programs and program modules across the Nation and 90 
specialized mental health OEF/OIF programs. Every VA medical center has 
outpatient PTSD specialty capability as do an increasing number of 
Community Based Outpatient Clinics (CBOCs). As of the end of the first 
quarter of FY 2008, 93 percent of CBOCs reported visits to mental 
health professionals either on-site, by telemental health or fee basis. 
There are increasing numbers of PTSD programs or tracks within PTSD 
programs to meet special needs such as veterans with co-occurring PTSD 
and substance use disorders and veterans who are survivors of military 
sexual trauma. Mental health programs, especially those for OEF/OIF 
veterans, have ties to the national, regional and local rehabilitation 
programs for polytrauma and TBI.

    Question 7(a): What lessons have been learned from the 
implementation of the disability evaluation system pilot currently 
underway in Washington, DC-area facilities?

    Response: A number of lessons have been learned from the disability 
evaluation system (DES) pilot in the National Capitol region. Among the 
most important are the following:

      VA and DoD can work collaboratively to successfully 
streamline the DES process; making it more transparent to the member.
      VA can meet the timeliness standards for examinations 
that are adequate for both DoD and VA.
      VA can produce timely ratings to meet the needs of the 
physical evaluation boards.
      VA can award benefits within days of the member's 
separation from service.
      Except for the war-wounded members in the DES, 
participants have similar disabilities as non-DES veterans.
      The amount of time spent by military service coordinators 
with participants is significant, and demonstrates a need for more 
staff in this area.
      Information technology (IT) connectivity issues can be 
significant processing bottlenecks but joint VA/DoD efforts can resolve 
them.
      This process needs to become paperless.
      More members are placed on the temporary or permanent 
disability retired list than historically has been the case.

    VA and DoD need to have the correct procedures and resources to 
assist servicemembers in more challenging environments.

    Question 7(b): GAO reported in February 2008 (GAO-08-514T), the 
departments had not finalized their criteria for expanding the pilot 
and had not developed measures to assess the performance of the pilot. 
What steps have the departments taken to develop the expansion criteria 
and performance measures for the pilot? What is the current status of 
the departments' plan to expand the pilot?

    Response: VA and DoD developed measures to assess the performance 
of the pilot. We believe that the key metrics for success of the pilot 
include:

      Customer satisfaction
      A significant reduction in the time from military 
evaluation boards (MEB) referral to receipt of VA disability benefits 
for those separated or retired
      Quality and consistency of decisionmaking across services 
with regard to disability evaluations
      Greater transparency and information to the member going 
through the process
      Savings to the government through use of only one 
examination for both agencies
      In the final analysis the over-arching metric is ``Is it 
better?''

    Early presentations to the Senior Oversight Committee (SOC) by DoD 
demonstrate that the pilot process is ``better'' in many ways.
    DoD has identified nine installations as the pool from which to 
select the first expansion site(s). A site checklist has been developed 
to assess the facilities' staffing, examination requirements, and the 
number of DoD physical evaluation board liaison officers (PEBLO) and VA 
military services coordinators needed for the expansion. A decision to 
expand the pilot requires the approval of the SOC.
    VA and DoD have also identified the minimum IT requirements needed 
to support the expansion. VA is moving aggressively to begin 
integration of paperless processing into the DES pilot.

    Question 7(c): I understand that even after DoD and VA combine the 
disability assessment examination, there will be two disability ratings 
assigned to a servicemember. What measures have been taken to reconcile 
the dual rating assignment given to an individual servicemember when 
determining disability benefits?

    Response: Although only one rating is prepared for a servicemember 
found unfit, the rating decision has two components. The first is the 
evaluation of those conditions identified as unfitting by DoD. When 
more than one condition is found unfitting, a combined evaluation for 
all unfitting conditions is provided.
    The second evaluation is of those additional conditions, if any, 
that the servicemember believes may have been incurred or aggravated by 
their military service. A combined evaluation for VA purposes for all 
conditions, unfitting and claimed, is provided. It is important to 
understand that for each condition only one evaluation is assigned. 
Prior to the pilot, it was possible for VA and DoD to evaluate the same 
condition differently.

    Question 8(a): What is the status of the planned September 30, 2008 
target date for the electronic exchange of medical records between the 
departments? Has the interagency program office encountered any 
barriers to meeting this date? If so, what have they done to address 
them?

    Response: The 2008 NDAA required the departments to form an 
Interagency Program Office (IPO) and achieve an interoperable 
electronic health record by September 30, 2009. On April 17, 2008, VA 
and DoD formed the IPO and are now on target to achieve the 
interoperability milestone.
    By October 2008, the departments will achieve the ability to share 
all ``essential'' electronic health information bidirectionally, as 
determined by the Joint Clinical Information Board (JCIB). ``Essential 
information includes: outpatient pharmacy and allergy information; 
outpatient and inpatient laboratory orders and results; radiology 
reports; inpatient information such as discharge summaries, inpatient 
consults, operative reports, history, physical reports, and vital 
signs. DoD also sends scanned inpatient records and radiology images 
from three key military treatment facilities to the four VA polytrauma 
centers receiving DoD's wounded warriors. The JCIB will evaluate 
additional data types, determine whether they should be shared in 
computable format or viewable format, and identify and prioritize the 
next set of data to be shared between DoD and VA.
    The departments do not anticipate any barriers to meeting the NCAA 
date of September 2009 for sharing of essential health information. 
However, the IPO faces the same challenges faced by the departments 
when working toward interoperability. For example, although not all 
data needs to be shared in computable format, in order to increase the 
sharing of computable data, the departments must identify and implement 
robust health data standards. To address this issue, the IPO will 
continue to support the standards-related efforts of the Health and 
Human Services Office of the National Coordinator for Health IT, and 
the VA and DoD subject matter experts that lead this effort.

    Question 8(b): Will medical records of National Guard and Reserve 
servicemembers be included in this effort?

    Response: The electronic exchange of medical records will include 
health information on deployed Guard and Reserve servicemembers.

    Question 8(c): What is the status of the reports on information 
technology (IT) interoperability that were mandated in conference 
report language for the 2008 NDAA legislation?

    Response: On April 29, 2008, VA and DoD delivered the first report 
to Congress detailing the steps it had taken to establish the 
interagency program office under section 1635 of the 2008 NDAA. VA and 
DoD are now on target to deliver the first annual report on the status 
of interoperability by December 2008, and updated annually thereafter, 
through 2014, as mandated by the legislation.
    Additionally, Conference Report 110-424 of H.R. 3043 and Conference 
Report 110-434 of H.R. 3332 required an interim joint report describing 
steps taken by the departments to achieve interoperability. The 
departments are currently finalizing the report and anticipate 
providing it to Congress by August 31, 2008.

    Question 9: When will VA publish its handbooks for the Transition 
Assistance and Case Management of OEF/OIF Veterans and for the Federal 
Recovery Coordinators?

    Response: On May 31, 2007, VA published Handbook 1010.01 Transition 
Assistance and Case Management of Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) Veterans. This handbook established 
procedures for the transition of care, coordination of services, and 
care management of OEF/OIF active duty servicemembers and veterans by 
VHA and Veterans Benefits Administration.
    A joint VA/DoD handbook for the FRCP is being developed and is 
expected to be published by the end of summer 2008.

    Question 10: On April 2, 2008, VA and DoD testified that they were 
working on a joint Military Eye/Vision Injury Registry. Please provide 
a timeline for the implementation of the eye registry.

    Response: We defer to DoD for this response.

                                 

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                      June 18, 2008

Honorable Robert M. Gates
Secretary
U.S. Department of Defense
The Pentagon, Room 3E718
Washington, DC 20301-1000
Dear Secretary Gates:
    On Wednesday, June 11, 2008, Michael L. Dominguez, Principal Deputy 
Under Secretary of Defense for Personnel and Readiness, testified 
before the House Committee on Veterans' Affairs on Implementing the 
Wounded Warrior Provisions of the National Defense Authorization Act 
for Fiscal Year 2008. As a follow-up to the hearing, I request the 
enclosed questions be answered in written form for the record by close 
of business, 5 p.m. on Tuesday, July 29, 2008.
    It would be appreciated if the responses could be provided 
consecutively on letter size paper, single-spaced. Please restate the 
question in its entirety before providing the answer.
    If you or your staff have any questions, please contact Dolores 
Dunn, Republican Staff Director for the Subcommittee on Health, at 202-
225-3527.

            Sincerely,
                                                        Steve Buyer
                                          Ranking Republican Member

                               __________

                      Hearing Date: June 11, 2008
                             Committee: HVA
                       Member: Congressman Buyer
                        Witness: Hon. Dominguez

     Care, Management, and Transition for Recovering Servicemembers

    Question 1: What is the status of the review of all policies and 
procedures that relate to the care, management, and transition for 
recovering servicemembers required under section 1611 of Public Law 
110-181, the National Defense Authorization Act (NDAA) for Fiscal Year 
2008? Are there any policies and procedures that have yet to be 
reviewed?

    Response: The Department of Defense (DoD) has completed our review 
of all policies and procedures that relate to the care, management and 
transition of recovering servicemembers. Our review covered United 
States Code, DoD level policies and procedures, military services' 
regulations, and other pertinent documents such as the Joint Federal 
Travel Regulations. We extracted the best practices and possible 
shortfalls as required by the National Defense Authorization Act Fiscal 
Year 2008 and have included them in our Report to Congress. In addition 
to identifying possible shortfalls, we identified several issues that 
may require either legislative or administrative actions to correct. We 
also reviewed the Department of Veterans Affairs policies that pertain 
to recovering servicemembers.

                 SOC Review of Policies and Procedures

    Question 2: It my understanding that the Senior Oversight Committee 
(SOC) was expecting to complete a full review of all policies and 
procedures relating to the care and management of wounded, ill, or 
injured servicemembers/veterans and their families by April 27, 2008. 
Were these reviews completed? If so, please provide documentation.

    Response: The Department of Defense (DoD) has completed our review 
of all policies and procedures that relate to the care, management and 
transition of recovering servicemembers. Our review covered United 
States Code (U.S.C.), DoD level policies and procedures, military 
services' regulations, and other pertinent documents such as the Joint 
Federal Travel Regulations. We extracted the best practices and 
possible shortfalls as required by the National Defense Authorization 
Act for Fiscal Year 2008 and have included them in our Report to 
Congress. In addition to identifying possible shortfalls, we identified 
several issues that may require either legislative or administrative 
actions to correct. We also reviewed the Department of Veterans Affairs 
(VA) policies that pertain to recovering servicemembers.
    The list of the most critical policies and procedures reviewed by 
DoD is provided below.
Policies and Procedures Relating to the Care and Management of Wounded, 
        Ill, or Injured Servicemembers/Veterans and Their Families 
        Reviewed by DoD:
Legislative
    U.S.C. Title 10
    U.S.C. Title 32
    Code of Federal Regulations, 199.17.32 Ch. I
    Joint Federal Travel Regulation Volume 1
    Joint Federal Travel Regulation Volume 2
DoD
    DoDD 1342.17 Family Policy (Dec 88)
    DoDD 5136.12 TRICARE Management Activity (TMA) (May 01)
    DoDD 5154.06 Armed Services Medical Regulating (Jan 05)
    DoDD 6010.14 Healthcare for Uniformed Services Members and 
Beneficiaries (Mar 07)
    DoDI 1300.18 Military Personnel Casualty Matters, Policies, and 
Procedures (Dec 00)
    DoDI 1332.38 Physical Disability Evaluation (Nov 96)
    DoDI 1332.39Application of the Veterans Administration Standards 
for Rating Disabilities (Nov 96)
    DoDI 1342.22 Family Centers (Dec 92) DoDI 6000.11 Patient Movement 
(Sep 98)
    DoDI 6000.14 Patient Bill of Rights and Responsibilities in the 
Military Health System (MHS) (Sep 07)
    DoDI 6010.23 Department of Defense and Department of Veterans 
Affairs Healthcare Resource Sharing Program (Sep 05)
    DoDI 6025.20 Medical Management (MM) Programs in the Direct Care 
System (DCS) and Remote Areas (Jan 06)
    DoDI 6490.03 Deployment Health (Aug 06)
    DoD Health Affairs Interim Policy for Clinical Case Management for 
the Wounded, Ill, and Injured Servicemember in the Military Health 
System UPDATE January 22, 2008
    DoD Health Affairs Policy 08-001 Implementation of New Medical 
Expense and Performance Reporting System Codes to Track Case Management 
Associated with Global War on Terror Heroes (Mar 08)
    DoD Health Affairs Policy 07-030 traumatic brain injury Definition 
and Reporting (Oct 07)
    DoD Health Affairs Policy 05-018 Expediting Veterans Benefits to 
Members with Serious Illnesses and Injuries (Sep 05)
    DoD Health Affairs Policy 04-031 Coordination of Policy to 
Establish a Joint Theater Trauma Registry (Dec 04)
    DoD Health Affairs Policy 03-026 Personnel on Medical Hold (Oct 03)
    DoD Health Affairs Policy 02-022 Department of Veterans Affairs 
Participation in TRICARE (Dec 02)
    DoD Health Affairs Policy 99-023 Inclusion of Department of 
Veterans (VA) Affairs Health Facilities TRICARE Network Providers (May 
99)
    DoD Health Affairs Policy 99-028 Establishment of DoD Centers for 
Deployment Health (Sep 99)
    DoD Financial Management Regulation, Volume 7A, Chapter 35 (Nov 05)
    DoD Financial Management Regulation, Volume 7A, Chapter 50 (May 06)
    TMA--Medical Management Guide (Jan 06)
VA
    VHA Directive 2007-012 Eligibility Verification Process for VA 
Healthcare Benefits (Apr 07)
    VHA Directive 2005-045 Treatment of Active Duty Servicemembers in 
VA Healthcare Facilities (Oct 05)
    VHA Directive 2005-020 Determining Combat Veteran Eligibility (Jun 
05)
    VHA Directive 2007-013 Screening and Evaluation of Possible 
traumatic brain injury in Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF) Veterans (Apr 07)
    VHA Directive 2006-041 Veterans Healthcare Service Standards (Jun 
06)
    VHA Directive 2006-055 VHA Outpatient Scheduling Processes and 
Procedures (Oct 06)
    VHA Directive 2006-038 Considerations for VA Support for the 
Department of Defense (DoD) Post Deployment Health Reassessment (PDHRA) 
Program for Returning Deployed Servicemembers (Jun 06)
    VHA Directive 2006-59 Active Patients in the Primary Care 
Management Module (PCMM) (Nov 06)
    VHA Directive 2007-016 Coordinated Care for Traveling Veterans (May 
07)
    VHA Directive 2006-028 Process for Ensuring Timely Access to 
Outpatient Clinical Care (May 06)
    VHA Directive 2003-003 Provision of Hospital Outpatient Care to 
Enrolled Veterans (Jan 03)
Army
    Warrior Transition Unit Consolidated Guidance (Mar 2008)
    Comprehensive Care Plan (Draft--Feb 2008)
    Soldier and Family Assistance Handbook
    Army Regulation 40-400 Patient Administration (Feb 08)
    Army Regulation 40-501 Standards of Medical Fitness (Dec 07)
    Army Regulation 635-40 Physical Evaluation for Retention, 
Retirement or Separation (Feb 06)
    Army Regulation 600-8-4 Line of Duty Policy, Procedures and 
Investigations (Apr 04)
    OTSG/MEDCOM Policy Memo 07-019 Guidance for MEDCOM Reunion and 
Reintegration of Redeploying Soldiers (Jun 07)
    OTSG/MEDCOM Policy Memo 07-029 Physical Evaluation Board Liaison 
Officer (PEBLO) Training and Certification (Jul 07)
    OTSG/MEDCOM Policy Memo 07-031 Access to Veterans Benefits 
Counseling (Aug 07)
    OTSG/MEDCOM Policy Memo 07-036 Escorts for non-Medical Caregivers 
and Families Traveling on Official Orders (Aug 07)
    OTSG/MEDCOM Policy Memo 07-038 Ombudsman Program in Support of 
Warriors in Transition (Sep 07)
    OTSG/MEDCOM Policy Memo 07-040 Metrics and Continuous Process 
Improvement for Medical Evaluation Board (MEB) and Physical Evaluation 
Board (PEB) (Sep 07)
    OTSG/MEDCOM Policy Memo 07-041 Patient Movement from Outside 
Continental United States (OCONUS) and Reception of Warriors in 
Transition to Continental United States (CONUS) Military Treatment 
Facilities (MTFs)
Navy
    Navy Policy Memorandum (Unnumbered) traumatic brain injury (TBI) 
Definition and Reporting (Dec 07)
    Navy Policy Memorandum 07-018 Case Management Policy (Jun 07)
    Navy Policy Memorandum 05-002 Implementing Traumatic Injury 
Protection Under the Servicemembers Group Life Insurance (Dec 05)
    SECNAVINST 1850 Severely Injured Marines and Sailors (SIMS) Pilot 
Program (Sep 06)
    SECNAVINST 1850.4E Department of the Navy Disability Evaluation 
Manual, Part 6--Policy Governing the Temporary Disability Retired List 
(Apr 02)
    JAGINST 5800.7D Reporting Requirements for Line of Duty (LOD) 
Determinations (Feb 05)
    BUMED Directive 5370.3 Navy Medicine Hotline Program (Apr 06)
    BUMED Directive 6300.10A Customer Relations (Aug 01)
    BUMED Directive 6320-12 Transfer of Patients of the Naval Service 
to Veterans Administration Facilities (Jan 87)
Marine Corps
    Casualty Care Process (Dec 07)
    Wounded Warrior Regiment Marine Reserve MEDHOLD Checklist Marine 
Corps Order 1754.8A Marine for Life (May 03)
    Marine Corps Order 6320.2E Administration and Processing of 
Injured/Ill/Hospitalized Marines (Nov 07)
    Leaders Guide for Managing Marines in Distress (web based)
Air Force
    Air Force Instruction 36-2910 Line of Duty (Misconduct) 
Determination (Oct 02)
    Air Force Instruction 36-3212 Physical Evaluation for Retention, 
Retirement and Separation (Feb 06)
    Air Force Instruction 36-3009 Airman and Family Readiness Centers 
(Jan 08)
    Air Force Instruction 44-102 Medical Care Management (May 06)
    Air Force Instruction 44-147 Air Force Order SISUP Medical 
Evaluation Boards (MEB) and Continued Military Service (Nov 07)
    Memorandum: PALACE HART (Helping Airmen Recover Together) (Feb 06)

 Report on Policy Improvements on the Care, Management, and Transition 
                      of Recovering Servicemembers

    Question 3: What progress has been made since the issuance of the 
Interim Report on Policy Improvements on the Care, Management, and 
Transition of Recovering servicemembers? If the final report will not 
be ready for release on July 1, 2008, please provide an explanation for 
the delay. Please provide the Committee with a copy of the final report 
when it is issued for the Committee's records.

    Response: Both Departments have made significant progress on 
developing a joint Comprehensive Policy on Improvements to Care, 
Management and Transition of Recovering servicemembers since we issued 
our interim report. We are developing uniform standards for curriculum, 
training, workload, and processes to support the management and 
transition of recovering servicemembers to include development and 
execution of a comprehensive recovery plan for this patient population. 
Both agencies have conducted a review of existing policies and 
procedures that apply to or will be covered by the comprehensive policy 
to identify the most effective and patient-oriented approaches for care 
and management of our recovering servicemembers. Developing this policy 
requires extensive coordination between the Services as well as between 
both agencies. We will provide a report to Congress detailing the 
comprehensive policy by August 15, 2008. The Department of Defense in 
consultation with the Department of Veterans Affairs will issue a 
directive type memo to provide interim guidance for improvements to 
care, management and transition of our recovering servicemembers no 
later than September 15, 2008, to be followed by a Department of 
Defense Instruction.

                       Inter-Agency Collaboration

    Question 4: To what extent will the Department of Defense (DoD) 
collaborate with other Federal agencies, such as the Social Security 
Administration and Department of Labor to develop policies on the care, 
management, and transition of recovering servicemembers?

    Response: The Department of Defense (DoD) is, and will continue to 
collaborate closely with the Department of Veterans Affairs (VA) and 
other Federal agencies with programs, services, benefits or 
compensation for recovering servicemembers or veterans. The Social 
Security Administration (SSA) has been engaged with DoD in care for 
wounded warriors since their participation in the DoD Military Severely 
Injured Center and the Department of Navy Seriously Injured Sailors and 
Marines programs. SSA is a member of the DoD/VA Case Management Working 
Group and participates in the development of the DoD/VA National 
Resource Directory. DoD is reaching beyond the Federal agencies in 
their identification and coordination of care, management and 
transition for recovering servicemembers through the National Defense 
Authorization Act mandated Comprehensive Recovery Plan. Through the 
National Resource Directory, recovering servicemembers and their care 
coordinators will have a national link to state, local, private and 
non-profit services and resources that the servicemember and care 
provider can interact with in developing the Comprehensive Recovery 
Plan.

                  Federal Recovery Coordinators (FRCs)

    Question 5: Both the Department of Veterans Affairs (VA) and DoD 
have promised to provide a Federal Recovery Coordinator (FRC) for every 
seriously injured servicemember who requests one. As of April 2008, 
eight FRCs had been placed in selected facilities.

    a.
        What is the target number of FRCs?
    b.
        What is the target number of facilities that will have FRCs and 
where will they be located? How many FRCs will be at each facility?
    c.
        What progress has been made to hire additional coordinators?
    d.
        What is the ideal ratio of coordinators to injured 
servicemembers and what is the basis for this ratio?
    e.
        Is the role of the coordinator to work closely with individual 
servicemembers, or only to provide oversight for problems relating to 
the warrior transition units?
    f.
        Will servicemembers who became wounded, ill, or injured, prior 
to the creation of FRCs have access to them?
    g.
        Have VA and DoD established performance measures for the FRC 
program?
    h.
       What are the requirements for the FRC program?
    i.
        How will those not meeting the criteria for the FRC program be 
served?

    Response: Federal Recovery Coordinator positions are established in 
four major military Treatment facilities: Walter Reed Army Medical 
Center, National Naval Medical Center, Naval Hospital San Diego 
(Balboa), and Brooke Army Medical Center. Although the Department of 
Defense (DoD) and the Department of Veterans Affairs (VA) are 
integrated in the Federal Recovery Coordination Program, the personnel 
and management aspects are under VA auspices. Therefore, DoD defers to 
VA to further address this issue.

                                  PTSD

    Question 6: Given that the number of servicemembers diagnosed with 
post traumatic stress disorder and traumatic brain injury has increased 
by almost 50 percent from 2006 to 2007, how is DoD ensuring that 
adequate resources are available to address the needs of these 
servicemembers?

    a.
        What strategies are being employed to hire the number of mental 
health professionals needed to meet the increased need for mental 
health services for veterans and their families? What is the status of 
these efforts?
    b.
        What other strategies are in place to expand the mental health 
services available to returning servicemembers?
    c.
        Does DoD have any efforts specifically targeted for suicide 
prevention?

    Response: We received $900 million to address the psychological 
health and traumatic brain injury needs of our servicemembers, of which 
approximately $300 million was targeted toward psychological health 
programs across the continuum of care. An additional $150 million was 
directed toward research in the areas of psychological health. 
Additionally, a comprehensive strategy has been developed to improve 
our ability to prevent, screen, diagnose, treat, and assist with the 
transition of our servicemembers who are exposed to the stresses of 
combat. We repeatedly assess this continuum for gaps as we evaluate the 
outcomes of newly established programs to ensure we are meeting 
emerging needs. Of particular note is the fact that under the auspices 
of the Senior Oversight Committee, we are aggressively partnering with 
the Department of Veterans Affairs (VA) to make the system as 
cooperative and supportive to the servicemember as possible.
    Several strategies are employed to increase the number of mental 
health professionals. Recruiting and retention bonuses are offered for 
military service as a mental health professional. TRICARE is currently 
working to increase the number of network providers available to care 
for beneficiaries and to support a 7-day access standard for initial 
mental health evaluation. Contract providers are being hired across the 
enterprise by the Services. The VA has already increased the number of 
mental health providers by 1172 since May 1, 2007. We entered into an 
agreement with the Department of Health and Human Services to assign 
200 Public Health Service Officers who are also mental health 
professionals to support the Department of Defense (DoD). We are 
expanding infrastructure and technological solutions to provide mental 
health services and support via Telehealth systems which will allow us 
to use difficult to recruit specialists in a more efficient manner.
    A comprehensive population- and risk-based staffing model is being 
validated by the Center for Naval Analyses that will account for 
meeting mental health needs through a variety of mechanisms to include:

      expanding embedding mental health providers into 
operational units;
      increasing integration of mental health providers into 
primary care clinics (approaching 70 percent of clinics in one 
Service);
      developing collaborative care models focused upon 
enhancing screening and treatment of PTSD and depression in primary 
care (Army's Re-Engineering Systems for the Primary Care Treatment of 
Depression and PTSD in the Military program);
      implementing Telehealth and technology initiatives 
including mental health clinical care;
      continuing to maximize pre-clinical support through 
MilitaryOneSource online and face-to-face counseling; and
      rolling out in July 2008 after-deployment resources for 
confidential online self-assessment and self-help.

    DoD and the Services have numerous programs targeted at suicide 
prevention including:

      annual suicide prevention training of servicemembers and 
DoD civilian employees;
      leadership training in suicide prevention;
      military leadership training to manage Service and family 
members in distress;
      frontline supervisor training;
      dissemination of suicide prevention training materials, 
videos, and posters;
      monitoring and analyzing lessons learned from suicides;
      risk assessment advanced training for providers;
      executing nationally recognized best practice suicide 
prevention initiatives;
      multiple initiatives to reduce stigma from seeking mental 
health support;
      chaplains' initiatives in suicide prevention and absolute 
confidentiality;
      Suicide Prevention Week activities;
      Signs of Suicide (SoS) programs in DoD school systems for 
children/adolescents;
      Train-the-Trainer workshops in various suicide prevention 
modalities as Ask your buddy, Care for your buddy, Escort your buddy, 
Applied Suicide Intervention Skills training, safeTALK;
      chain teaching programs for suicide prevention;
      case discussions for suicide prevention;
      improved access to care with more mental health providers 
and 7-day routine access standard;
      post-intervention support programs for unit members/
families of those who suicide;
      confidential behavioral health surveys to monitor risk 
factors and substance abuse;
      relationship building programs such as the Chaplains' 
Strong Bonds Program;
      civilian services staff training (Morale, Welfare and 
Recreation, Gym, hobby/auto shops, etc.) such as the ``Are You 
Listening?'' program to help recognize those in distress and facilitate 
help;
      substance abuse education and training;
      military family life consultant program;
      family support programs;
      family advocacy programs;
      sexual abuse recovery and support programs;
      community health promotion councils;
      integration delivery systems of community assets for 
psychological support;
      community action information boards;
      family readiness units;
      financial management training programs;
      responsible drinking educational programs;
      deployment support programs--Battlemind, Landing Gear, 
Operational Stress Control;
      web-based distance learning programs for suicide 
prevention;
      suicide prevention pocket cards and brochures;
      community awareness marketing for support services;
      drug demand reduction and prevention services/education 
programs;
      personal readiness summits;
      standardized suicide data reporting and DoD comprehensive 
database to monitor suicide;
      annual DoD/Department of Veterans Affairs suicide 
prevention conferences with leading academics and government agencies;
      academic collaborations developing suicide nomenclature;
      DoD-produced public announcements/videos re: suicide 
prevention; and
      active DoD Suicide Prevention and Risk Reduction 
Committee coordinating dissemination and coordination of programs

        Lessons Learned from Disability Evaluation System Pilot

    Question 7: What lessons have been learned from the implementation 
of the disability evaluation system pilot currently underway in 
Washington, DC-area facilities?

    a.
        As GAO reported in February 2008 (GAO-08-514T), the departments 
had not finalized their criteria for expanding the pilot and had not 
developed measures to assess the performance of the pilot. What steps 
have the departments taken to develop the expansion criteria and 
performance measures for the pilot? What is the current status of the 
departments' plan to expand the pilot?
    b.
        I understand that even after DoD and VA combine the disability 
assessment examination, there will be two disability ratings assigned 
to a servicemember. What measures have been taken to reconcile the dual 
rating assignment given to an individual servicemember when determining 
disability benefits?

    Response: The Department appreciates the Committee's interest in 
the performance evaluation, expansion, and further implementation of 
the pilot and the rating schematic. These questions require lengthy 
answers, which have been included in reports required by the National 
Defense Authorization Act for Fiscal Year 2008, Public Law 110-181. 
Specifically, the Department refers you to the initial report required 
by section 1644 (Authorization of Pilot Programs to Improve the 
Disability Evaluation System for members of the Armed Forces) and a 
forthcoming report required by section 1612(c), ``Assessment of 
Consolidation of Department of Defense and Department of Veterans 
Affairs Disability Evaluation Systems.'' The section 1644 report was 
submitted to Congress on April 30, 2008. We anticipate providing the 
section 1612(c) report to the Committee by August 1, 2008.

           Electronic Exchange of Medical Records Target Date

    Question 8: What is the status of the planned September 30, 2009 
target date for the electronic exchange of medical records between the 
departments? Has the interagency program office encountered any 
barriers to meeting this date? If so, what have they done to address 
them?

    a.
        Will medical records of National Guard and Reserve 
servicemembers be included in this effort?
    b.
        What is the status of the reports on information technology 
(IT) interoperability that were mandated in conference report language 
for the fiscal year 2008 NDAA?

    Response: We are on track to electronically exchange essential 
medical data between the Department of Defense (DoD) and the Department 
of Veterans Affairs (VA). A Joint Clinical Information Board (JCIB), 
comprised of DoD and VA Board Certified Physicians, was established to 
define, prioritize and validate health data deemed ``essential'' to 
continuity of care. The JCIB members examined the five criteria 
established by the Institute of Medicine (IOM) that define the core 
functionalities of an electronic health record (EHR). The five criteria 
from IOM \1\ are: 1) Improve patient safety, 2) Support the delivery of 
effective patient care, 3) Facilitate management of chronic conditions, 
4) Improve efficiency, and 5) Feasibility of implementation. Using the 
IOM model and their own clinical experience, JCIB members then made a 
determination of essential health data elements to share between the VA 
and DoD EHRs. The list of data elements below are identified by the 
JCIB members as ``essential'' for sharing between the two agencies 
based on these established criteria and the DoD Medical Readiness 
mission.
---------------------------------------------------------------------------
    \1\ Key Capabilities of an Electronic Health Record System, 
National Academies Press, 2003


------------------------------------------------------------------------
           Information Type              One-Way \2\   BiDirectional \3\
------------------------------------------------------------------------
Demographics                                May 2002           Oct 2004
------------------------------------------------------------------------
Outpatient Medication                       May 2002           Oct 2004
------------------------------------------------------------------------
Allergies and adverse reaction              May 2002           Oct 2004
------------------------------------------------------------------------
All radiology reports                       May 2002           May 2005
------------------------------------------------------------------------
Labs: chemistry, hematology,                May 2002           May 2005
 microbiology, serology, virology,
 toxicology, anatomical pathology
------------------------------------------------------------------------
Outpatient progress notes                                      Dec 2007
------------------------------------------------------------------------
Inpatient Notes:
 Discharge summary                                     Jul 2006
 Operative report, history                             Dec 2007
 and physical, inpatient consult
------------------------------------------------------------------------
Diagnosis and problem list                                     Dec 2007
------------------------------------------------------------------------
Vital Signs                                                    Jun 2008
------------------------------------------------------------------------
Questionnaires:
 Pre/Post Deployment Health         Jul 2005                N/A
 Assessment                                 Sep 2006                N/A
 Post Deployment Health
 Reassessment
------------------------------------------------------------------------
Family History                              Sep 2008
------------------------------------------------------------------------
Polytrauma Image Sharing                    Mar 2007
(Diagnostic Radiology)
------------------------------------------------------------------------
\2\ Uni-directional: information ``pushed'' from DoD to VA
\3\ Bidirectional: data made viewable between DoD and VA


    Currently, all health data determined to be ``essential'' by JCIB 
members is either being exchanged electronically between the DoD and VA 
electronic health records or will be exchanged by October 2008.
    The Interagency Program Office (IPO) does not anticipate any 
unforeseen difficulties meeting the planned October 2008 date for 
sharing essential health data

    a.
        This electronic exchange will include health data captured on 
deployed Reserve and Guard servicemembers.
    b.
        Section 1635 of the Fiscal Year 2008 National Defense 
Authorization Act mandated two information technology reports:
      1.
          No later than 30 days after enactment, the Secretary of DoD 
and the Secretary of VA shall jointly establish a schedule and 
benchmarks for the discharge of the office by its function:

    This report was submitted to the Chairs of the Senate Armed 
Services, Senate Veterans' Affairs, House Armed Services and the House 
Veterans' Affairs Committees on April 29, 2008, along with appointment 
letters for the Acting Director and Acting Deputy Director of the IPO.

      2.
          No later than January 1, 2009, and each year thereafter 
through 2014, the Director shall submit a report to Congress on the 
activities of the office during the preceding calendar year:

    Both Departments are actively engaged in the assembly and 
production of this requirement with expected delivery to the 
appropriate Congressional committees in December 2008.

                    VA's ``F'' Grade on FISMA Report

    Question 9: With VA's ``F'' grade on their recent Federal 
Information Security Management Act (FISMA) report, how does this 
affect their status as a trusted agent for DoD/VA medical records 
sharing?

    Response: We do not believe the Federal Information Security 
Management Act (FISMA) report grade impacts the Department of Defense 
(DoD)/Department of Veterans Affairs (VA) medical records sharing. The 
FISMA report addresses high-level Federal agency information assurance 
(IA) efforts and does not necessarily represent the status of specific 
initiatives such as DoD/VA sharing.
    The Military Health System (MHS) oversees an aggressive, vigilant 
IA program to help ensure the protection of medical data shared with 
the VA. The MHS IA program ensures compliance with Federal, DoD, and 
MHS policies such as the Health Insurance Portability and 
Accountability Act of 1996, DoD Directive 8500.01E, and DoD Instruction 
8500.2 to protect medical information systems and data. The MHS manages 
a rigorous DoD Information Assurance Certification and Accreditation 
Process (DIACAP) to assess electronic and physical security controls 
and ensure compliance with DoD security requirements. Additionally, the 
MHS follows industry best practices, using state of the art assessment 
tools developed by the Defense Information Systems Agency and the 
National Security Agency.
    In compliance with the FISMA of 2002, DoD and VA have developed a 
Memorandum of Understanding and an Interconnection Security Agreement 
as required by Chairman of the Joint Chiefs of Staff Instruction 
6211.02B, ``Defense Information System Network: Policy, 
Responsibilities and Processes'' and recommended by the National 
Institute of Standards, Special Publication 800-47, ``Security Guide 
for Interconnecting Information Technology Systems,'' September 2002. 
Routine security audits are conducted to ensure compliance.
    The information shared between DoD and VA is encrypted via an MHS 
managed virtual private network (VPN) device. The VPN device is part of 
the MHS VPN Mesh, which encrypts protected health information between 
each military treatment facility and key business partners, to include 
the VA. As DoD and VA work together to improve methods for sharing 
healthcare information, both agencies will continue to ensure 
compliance with Federal and DoD IA policies and guidance and take 
appropriate security measures to protect the health information of our 
beneficiaries.

  Policies Related to Recovering Servicemember's Return to Active Duty

    Question 10: What progress has DoD made toward developing policies 
related to a recovering servicemember's return to active duty?

    Response: On March 13, 2008, the Department of Defense (DoD) issued 
a Directive Type Memo (DTM) that provides supplemental and clarifying 
guidance on implementing those disability-related provisions of the 
National Defense Authorization Act of 2008 that are time sensitive and 
impact immediate decisions pertaining to the rating of conditions and 
the calculation of separation severance pay. Within this DTM, a 
revision to paragraph 3.12 of DoD Directive 1332.18, ``Separation or 
Retirement for Physical Disability,'' November 4, 1996, is required to 
reflect: ``The Secretary concerned, upon request of the member or upon 
the exercise of discretion based on the needs of the Service, may 
continue in a permanent limited duty status either on active duty or in 
the Ready Reserve, a member determined to be unfit because of physical 
disability when the member's service obligation or special skill and 
expertise justifies such continuation. Transfer to another Service may 
also be considered.''

                    Wounded Warrior Resource Center

    Question 11: Section 1616 of the ``Wounded Warrior Act'' required 
the Secretary of Defense to establish a Wounded Warrior Resource Center 
to provide a single point of contact for assistance servicemembers, 
families, including a toll-free telephone number and a website. Please 
provide a timeline for compliance with this section.

    Response: The Wounded Warrior Resource Center will operate under 
the universally known Military OneSource call center and take hotline 
calls, track all calls and responses, refer the issue for remediation, 
and conduct follow-up. The development, coordination, and resourcing of 
this requirement is complex and has required extensive examination. We 
continue to receive and refer calls for the wounded, ill, and injured 
through Military OneSource, which we will augment with all of the 
National Defense Authorization Act requirements by October 1, 2008.

                                 

                                     Committee on Veterans' Affairs
                                                     Washington, DC
                                                      July 16, 2008

The Honorable James B. Peake, M.D.
Secretary
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
    On June 11, 2008, the Committee held a hearing on the 
implementation of the ``Wounded Warrior'' provisions of Public Law 110-
181, the FY 2008 National Defense Authorization Act. When fully 
implemented, this law will significantly enhance the access to care and 
benefits for servicemembers injured in Operation Iraqi Freedom and 
Operation Enduring Freedom (OIF/OEF).
    The progress the Department of Veterans Affairs (VA) has made to 
improve the transition process for servicemembers, including the 
establishment of the Combat Veteran Call Center and the Federal 
Recovery Coordinator program is notable. I know that the wounds of 
wartime service are not always as visible as those caused by bullets or 
shrapnel and your actions to address the mental health needs of 
veterans and their families, especially those mental disorders 
associated with traumatic brain injury (TBI), post traumatic stress 
disorder (PTSD), and substance use disorder is also commendable. 
However, there is more that still must be done by both VA and the 
Department of Defense (DoD) to meet the needs of our returning 
servicemembers and the intent of the law to provide a truly seamless 
transition from active duty to veteran status.
    I am very concerned that a substantial number of the benchmarks set 
forth in Public Law 110-181 are not being met. Of critical importance 
are the requirements for VA and DoD to jointly develop and implement 
standards and policies for a comprehensive care, management, and 
transition improvement plan and physical disability evaluations. 
Further, the requirement for the development of an interoperable and 
bidirectional electronic health record that provides real-time transfer 
of information between VA and DoD is vital and long overdue. The 
exchange of electronic medical information between VA and DoD has been 
an issue of importance to the Committee for many years. I respectfully 
request immediate action be taken to ensure that the milestones are 
fulfilled in accordance with the law and the Committee is kept informed 
of the Department's progress.
    Returning OEF/OIF veterans present a broad range of injuries and 
illnesses that require some new approaches and present new challenges 
for healthcare and for research. It is also of the utmost importance 
that we aggressively support research to gain a better understanding of 
these complex injuries. To encourage innovative research across 
healthcare delivery systems and facilitate the nationwide sharing of 
information, I also ask for your leadership to promote greater 
collaboration of research activities with other Federal partners. 
Better coordination with the National Institutes of Health (NIH) and 
DoD will allow us to take full advantage of science-based information 
and maximize the adoption of evidence-based care and ``best practices'' 
in all settings to address the needs of this new generation of 
veterans.
    I thank you for your prompt consideration and attention to these 
matters and appreciate your continued cooperation with the Committee.

            Sincerely,
                                            Congressman Steve Buyer
                                          Ranking Republican Member

                               __________

                                  THE SECRETARY OF VETERANS AFFAIRS
                                                     Washington, DC
                                                     August 8, 2008

The Honorable Steve Buyer
Ranking Republican Member
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Congressman Buyer:
    This is in response to your letter regarding the implementation of 
``Wounded Warrior'' provisions of Public Law 110-181, the National 
Defense Authorization Act for fiscal year 2008 (NDAA).
    You requested information on the progress the Department of 
Veterans Affairs (VA) and the Department of Defense (DoD) are making on 
meeting the requirements of sections of the 2008 NDAA, specifically:

      Developing joint VA/DoD policies for comprehensive care, 
management, and transition improvement;
      Exchanging electronic medical records;
      Collaborating research activities with other Federal 
partners, such as National Institutes of Health (NIH); and
      Developing joint VA/DoD policies for physical disability 
evaluations.

    VA and DoD are making progress toward meeting the requirements of 
the NDAA as it relates to these areas. The enclosed fact sheet provides 
details on our accomplishments and progress in these areas.
    I hope this information is helpful to you. If you require 
additional information, please contact Karen Malebranche, who is 
Executive Director of VA's Operation Enduring Freedom/Operation Iraqi 
Freedom Program. She may be reached at 202-461-8457.

            Sincerely yours,
                                               James B. Peake, M.D.

Enclosure

                               __________

               Department of Veterans Affairs Fact Sheet
VA Progress on Implementing Sections of National Defense Authorization 
             Act Fiscal Year 2008 (NDAA) Public Law 110-181
  1. Comprehensive Care Management and Transition Efforts
    Through the structure provided by the joint Department of Veterans 
Affairs (VA) and Department of Defense (DoD) Senior Oversight 
Committee, VA's Care Management and Social Work Service has 
participated in a review of all policies and procedures that relate to 
the care, management, and transition for recovering servicemembers and 
veterans as required by section 1611 of the Fiscal Year (FY) 2008 NDAA. 
The review included clinical care management and non-clinical 
management. Both Departments identified best practices and possible 
shortfalls resulting in many modifications and improvements to current 
processes.
    VA and DoD are jointly developing a directory for the comprehensive 
care and management of catastrophically injured servicemembers and 
veterans served by the Federal Recovery Coordination Program.
    On May 31, 2007, VA published Handbook 1010.01, Transition 
Assistance and Case Management of Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF) Veterans. This handbook established 
procedures for the transition of care, coordination of services, and 
care management of OEF/OIF active duty servicemembers and veterans by 
Veteran Health Administration (VHA) and Veterans Benefits 
Administration. In May 2008, VA established a charter group comprised 
of specialty care managers across VA to include OEF/OIF teams, spinal 
cord, blind rehabilitation, mental health, polytrauma and others to 
make recommendations for improving the systemwide approach to care 
management with an emphasis on coordination between programs. This 
group is expected to submit its report to VA leadership by the end of 
FY 2008. The findings of this group, as well as the best practices and 
shortfalls identified by the comprehensive VA/DoD review, will lay the 
foundation for updating VHA's policy for care management. This document 
will be finalized by December 31, 2008.
  2. Development of Interoperable and Bidirectional Electronic Health 
        Records
    VA and DoD responded to the NDAA by immediately taking steps to 
implement Section 1635, the requirement for interoperable electronic 
health records between the Departments. On April 17, 2008, VA and DoD 
met a major milestone of the NDAA by forming the Interagency Program 
Office (IPO). By leveraging the prior accomplishments of the 
Departments toward the development of interoperable bidirectional 
electronic health records, the IPO is on target to meet the September 
2009 target date for interoperable health records identified in the 
law.
    To achieve interoperable and bidirectional electronic health 
records, VA and DoD will leverage the bidirectional capabilities that 
already exist. For example, VA and DoD are now sharing almost all 
essential health information that is available electronically in a 
bidirectional viewable format. This information includes outpatient 
pharmacy allergy information, vital signs, outpatient and inpatient 
laboratory orders and results, radiology reports, and select inpatient 
information such as discharge summaries from key DoD military treatment 
facilities. DoD also sends clinical theater information which is 
available to all VA hospitals as well as scanned inpatient records and 
radiology images from key military treatment facilities to the four VA 
polytrauma centers receiving DoD's wounded warriors. In addition to 
sharing viewable information, VA and DoD have begun sharing computable 
allergy and pharmacy information that supports automatic drug-drug and 
drug-allergy interaction checks. By September 2008, VA and DoD will 
begin sharing family and social history information on patients. The 
Departments also are working on expanding a bidirectional image sharing 
pilot at six locations and are finalizing an enterprise-wide plan for 
sharing images that will be delivered in October 2008.
    To expand the current sharing and to achieve interoperable health 
records, the Departments formed the Joint Clinical Information Board 
(JCIB), which consists of VA and DoD clinicians and end users who are 
defining the clinical data elements that are needed to treat the 
Departments' shared patients and support transition of wounded 
warriors. The JCIB has just recently identified the full set of 
prioritized data elements that must be made viewable and bidirectional 
between DoD and VA in order to support these requirements. Upon 
approval of the requirements by the DoD/VA Health Executive Council, 
the Departments will execute the development and testing necessary to 
implement the capabilities by September 2009.
    The JCIB is currently evaluating the additional data types that 
should be shared in computable format as well as identifying and 
prioritizing the next set of data to be shared between DoD and VA.
    Despite this accomplishment, VA and DoD acknowledge that there are 
several layers of interoperability and that the Departments are sharing 
most information in viewable format, rather than computable. In order 
to expand this capability to share more computable data, VA and DoD 
must leverage information standards that are mature and robust enough 
to support the exchange of information for patient care. Such standards 
do not yet exist in all clinical domain areas.
    Conference Report 110-424 of H.R. 3043 and Conference Report 110-
434 of H.R. 3332 required a joint report describing steps taken by the 
Departments to achieve interoperability pursuant to the law. On April 
29, 2008, VA and DoD delivered an interim report to Congress detailing 
the steps taken to establish the IPO under section 1635 of the NDAA. 
The Departments are currently finalizing a draft of the Final Report 
and anticipate providing it to Congress by August 31, 2008.
    The NDAA also required that VA and DoD deliver a series of reports 
to Congress advising it of the status of efforts to implement the law. 
VA and DoD are on target to deliver the first annual report on the 
status of interoperability by January 1, 2009. VA and DoD anticipate 
delivering an updated annual report every January thereafter, through 
2014, as mandated by the legislation.
  3. Research Support
    VA agrees that there should be aggressive support of research to 
gain a better understanding of the complex injuries that OEF/OIF 
veterans present and that we must promote better collaboration of 
research activities with our Federal partners. Toward these ends, VA is 
collaborating with DoD, the National Institutes of Health (NIH), the 
National Science Foundation (NSF), other Federal agencies, and the 
private sector. For example, VA participates on the Federal Interagency 
traumatic brain injury (TBI) Research Board of Scientific 
Administrators, designed to facilitate collaboration. This interagency 
group has begun collecting risk factor and health information from 
military personnel prior to their deployments to Iraq. Plans are to 
reassess them upon their returns from deployment to identify their 
needs.
    VHA's Office of Research and Development (ORD) has sponsored 
several meetings to develop mechanisms to facilitate DoD and VA 
Investigation Review Boards' (IRB) approvals of DoD/VA collaborative 
research and to transfer clinical data for research purposes between 
DoD and VA investigators. To increase awareness of research skills and 
interests, ORD is creating an electronic list server of DoD and VA 
investigators. Over 700 scientists have submitted their names to be 
part of this project.
    Other ongoing partnerships (and focus) include:

      Walter Reed Army Medical Center (WRAMC) (investigating 
immediate challenges faced by returning service personnel);
      Brooke Army Medical Center (examining challenges faced by 
amputees with burns);
      Defense Center on Psychological Health and TBI seeking 
collaborative research opportunities and helping to plan the National 
Intrepid Center of Excellence currently under construction at the 
National Naval Medical Center, Bethesda, Maryland;
      Founding member of the Defense and Veterans Brain Injury 
Center (DVBIC), which consists of three military treatment facilities 
(WRAMC, Wilford Hall Air Force Medical Center, and San Diego Naval 
Medical Center) and four VA medical centers (Richmond, Tampa, 
Minneapolis, and Palo Alto) (conducting clinical trials examining the 
effects of anxiety disorders, post concussion syndrome, agitation, and 
problems with memory and attention/concentration in TBl patients);
      Collaboration with DoD and NIH investigators to develop a 
family intervention program with spouses of servicemembers being 
treated for traumatic limb loss or TBI;
      Millennium Cohort Study participation following as many 
as 140,000 military personnel for up to 21 years to track changes in 
their health;
      Collaboration with DoD on projects to examine the short- 
and long-term benefits of advanced regional anesthesia techniques for 
pain control following combat-related traumatic injuries to 
extremities;
      ORD sponsored a TBI State of the Art Conference on 
Research to Improve the Lives of Veterans: Approaches to traumatic 
brain injury: Screening, Treatment, Management, and Rehabilitation, 
April 30-May 2, 2008. Participants included DoD, NIH, and DVBIC. 
Recommendations are being used to inform the Departments' priorities 
and activities; and
      VA and National Institute of Mental Health (NIMH) and DoD 
have issued a call for collaborative research focusing on combat-
related mental disorders and stress reactions.

    VA will continue to aggressively pursue enhanced coordination to 
ensure efficient, high quality research that contributes to optimal 
adoption of evidence-based care for this new generation of veterans.
  4. Disability Evaluation System
    VA and DoD are currently in the eighth month of the pilot of a 
joint disability evaluation system (DES) for those servicemembers who, 
due to disease, illness, or injury, are being considered for separation 
or retirement from service. As of July 20, 2008, almost 500 
servicemembers have entered the pilot. Over 100 disability evaluations 
have been prepared for the DoD, resulting in eight servicemembers 
having been separated to date and the balance in pre-separation leave 
status. Of those separated, six have been placed on the retired list, 
and two have been found less than 30 percent disabled. VA awarded 
benefits on the day that the member was retired or separated in seven 
of the eight cases. A slight delay to appoint a fiduciary to manage one 
servicemember's funds was needed, but that servicemember is also 
currently in pay status. VA and DoD are further refining and improving 
the DES transition process. Among the enhancements being studied or 
addressed are:

      VA will move the DES process into a paperless environment 
for all new entrants on or about September 1, 2008;
      The Services are moving to support this effort through 
the provision of imaged documents;
      Site assessments are being finished on nine potential 
pilot expansion locations that will allow further tests of the system 
and ensure that the new DES model is effective, efficient, transparent, 
and fair;
      Customer and stakeholder surveys will be conducted for 
the initial stages of the process in the near future; and
      The Senior Oversight Committee will be briefed on August 
12 on the progress of the pilot and possible expansion.

    VA agrees that it is essential that an effective transition plan 
exist for all returning veterans, whether returning wounded, ill, 
injured, or safely and we have been active in providing information and 
services for those who do not have immediate medical needs. VA 
continues to work closely with the Reserve components to ensure that 
returning citizen warriors receive appropriate briefings and claims 
assistance at the earliest possible opportunity following their 
demobilization. We have expanded the options available to 
servicemembers to file claims prior to separation with our quick start 
program for those servicemembers with less than 60 days of active duty 
remaining prior to separation. We are consolidating decisionmaking for 
all pre-separation claims, both benefits delivery at discharge (BDD) 
and quick start, into a focused number of offices to ensure rapid and 
consistent decisionmaking. And, we are aggressively moving to a 
paperless environment for BDD claims processing to enable VA to be more 
flexible and responsive to these combat veterans.

       Office of Operation Enduring Freedom/Operation Iraqi Freedom
                                     Veterans Health Administration
                                                        August 2008

                                 

                                         U.S. Department of Defense
                           Office of the Under Secretary of Defense
                                            Personnel and Readiness
                                                     Washington, DC
                                                    August 20, 2008

The Honorable Bob Filner
Chairman, House Committee on Veterans' Affairs
United States House of Representatives
Washington, DC
Dear Mr. Chairman:
    I am writing to correct the record regarding RAND Corporation's 
June 11, 2008 testimony to your Committee. We value research that 
advances the science on care for our Wounded Warriors. That said, some 
of the testimony provided by RAND's witnesses inaccurately 
characterized their research conclusions, and I respectfully request 
the public record be corrected. The following points are provided (page 
numbers refer to the draft hearing transcript):
Issue #1, page 7
    In her testimony, Dr. Jaycox states, ``Our telephone survey 
representing all previously deployed individuals found substantial 
rates of mental health problems in the past 30 days, with 14 percent 
screening positive for PTSD and 14 percent for major depression.''
    The accurate statement is, ``. . . with 14 percent screening 
positive for PTSD symptoms and 14 percent for major depressive 
symptoms.'' Positive clinical screens do not constitute actual 
prevalence. Although telephone survey tools may be sound in research 
and clinical screening methodology, only a full clinical evaluation can 
diagnose these conditions. A diagnosis of PTSD or depression requires a 
determination that the disturbance causes clinically significant 
distress or impairment in social, occupational, or other important 
areas of functioning. RAND's telephonic interview measures do not 
support evaluation of these factors for either condition.
Issue #2, page 7
    Dr. Jaycox goes on to state, ``Only about half of those with 
current PTSD or a major depression had sought help for a mental health 
problem in the past year.''
    The accurate statement is, ``Only about half of those who report 
PTSD or major depressive symptoms had sought help for a mental health 
problem in the past year.'' As noted above, in the absence of a full 
clinical evaluation, it cannot be determined that symptoms meet full 
diagnostic criteria for ``current PTSD or a major depression''.
Issue #3, page 21
    In her testimony, Ms. Tanielian states, ``Only about half of those 
who've sought care from a professional in the past year have received 
what we define as minimally adequate . . .''
    This statement should be stricken, along with any other conclusions 
regarding ``minimally adequate treatment'' of PTSD and major 
depression. According to RAND's full published report, their criteria 
for ``minimally adequate treatment'' of PTSD and major depression were 
developed by Wang et al. (2005) based on a comprehensive review of 
available guidelines for therapies that have demonstrated efficacy. 
However, these are based on guidelines for diagnosed cases and should 
not be considered the standard of care for individuals who seek relief 
from symptoms that do not meet full diagnostic criteria for these 
disorders. It should also be noted that in 2007 a Committee from the 
Institute of Medicine reviewed scientific studies of PTSD treatment and 
was unable to draw conclusions regarding optimal length of treatment 
with psychopharmacology or psychotherapy. Clearly this is an area that 
deserves further research.
Issue #4, page 8
    Dr. Jaycox later indicates, ``In our survey, we found 19 percent 
reported a probable TBI during deployment.''
    The accurate statement is ``. . . we found 19 percent reported an 
injury event during deployment and an associated transient alteration 
in mental status suggesting a possible TBI, which requires a clinical 
evaluation to confirm.'' Symptoms Mayor may not occur after concussion 
(mild TBI) and are not necessary for the inclusion of the definition of 
mild TBI. The interviewers had no means or expertise to assess for 
current symptoms or loss of function. It should be noted that VA post-
deployment screening and evaluation demonstrated that of 18\1/2\ 
percent of veterans who screened positive for TBI symptoms, 5 percent 
were diagnosed with residual symptoms of TBI following a full clinical 
evaluation. Studies of clinically treated civilian populations and 
sports populations have found that concussion (mild TBI), which is 
estimated to comprise 80 percent to 90 percent of all TBI, results in 
symptoms that generally resolve within days to months in 85 percent of 
these cases.
    The Department maintains its unwavering commitment to our Wounded 
Warriors and their families. The Military Health System continues to 
improve its support, investing $600 million from Fiscal Year 2007 
Supplemental Appropriations to fund more than 25 major new programs. 
Furthermore, the recently established Defense Centers of Excellence for 
Psychological Health and traumatic brain injury is planning a 
comprehensive study to address surveillance and epidemiological 
knowledge gaps as well as develop a ``stress test model'' applied to 
PTSD. An Expert Consensus meeting is convening shortly to identify 
directions, opportunities, needs, sustainability, and concepts. We will 
invite RAND to partner with us in this important endeavor and use the 
opportunity to share the best and most accurate ideas with the broader 
scientific community.
    I appreciate your support of the health and welfare of our military 
Servicemembers and for our Military Health System.

                                               Michael L. Dominguez
                                                   Principal Deputy

                               __________

                                         U.S. Department of Defense
                           Office of the Under Secretary of Defense
                                            Personnel and Readiness
                                                     Washington, DC
                                                    August 20, 2008

James A. Thomson
President and Chief Executive Officer
RAND Corporation
1776 Main St
Santa Monica, CA 90401
Dear Dr. Thomson:
    I sincerely appreciate RAND's interest in the health and welfare of 
our military Servicemembers and your invaluable support to the 
Department. I do have concerns however regarding testimony presented by 
Dr. Lisa Jaycox and Ms. Terri Tanielian to the House of Representatives 
Committee on Veterans' Affairs (HVAC) on June 11, 2008 (Implementing 
the Wounded Warrior Provisions of the National Defense Authorization 
Act for Fiscal Year 2008).
    I respectfully request you correct the record with the Congress and 
retract statements on the Arroyo Center website that claim one in five 
servicemembers returning from Iraq and Afghanistan are ``afflicted'' 
with PTSD or major depression. Those are certainly not substantiated by 
your research. I have, in the attached letter to Chairman Filner, 
identified the specific instances in which RAND researchers 
mischaracterized the results of their study. A RAND Arroyo Center 
Newsletter (also attached) repeats this unfortunate misrepresentation 
of your research findings. I ask for your assistance in correctly 
interpreting data from the study and in ensuring that future references 
to the data are accurately portrayed.
    As to the prevalence of PTSD for our active duty military 
population, we are planning a comprehensive study that will address 
surveillance/epidemiological knowledge gaps as well as develop a 
``stress test model'' applied to PTSD. Dr. Casscells will host an 
Expert Consensus meeting to identify directions, opportunities, needs, 
sustainability, and concepts. We invite and would very much appreciate 
RAND's participation in this project.
    Thank you for your continued support of the Military Health System.

                                               Michael L. Dominguez
                                                   Principal Deputy

Attachments

                               __________

Excerpt From:
  RAND Arroyo Center, Army Research Fellows Newsletter, August 2008, 
                                Issue 24
                Serving the Army with Objective Analysis
Policy Forum
Mental Health of Returning Soldiers
    On June 12, RAND hosted the Policy Forum ``Invisible Wounds of War: 
Addressing the Mental Health Needs of Returning Soldiers'' in the Santa 
Monica office. The event included introductions by Jim Thomson and Joe 
Sullivan, chair of the RAND Health Board of Advisors, and featured a 
panel discussion with Terri Tanielian, co-director of the RAND Center 
for Military Health Policy Research; Fred D. Gusman, Executive Director 
of The Pathway Home, California Transition Center for Care of Combat 
Veterans; and Paul Rieckhoff, Executive Director and founder of Iraq 
and Afghanistan Veterans of America. Lisa Jaycox, who co-led the 
research project with Tanielian, moderated the discussion. Panel 
Members addressed the issues raised by a recent RAND study, which found 
that nearly one in five servicemembers returning from Iraq and 
Afghanistan are afflicted with post traumatic stress disorder or major 
depression, yet only slightly more than half have sought treatment.
    The discussion addressed reasons that some servicemembers do not 
seek care-including challenges in accessing quality care and the stigma 
associated with treatment-as well as the individual and societal costs 
of failing to treat this population.
    The event drew nearly 200 attendees, including members of the RAND 
Policy Circle and RAND advisory boards, healthcare providers, regional 
government and community leaders, and members of the media. Organized 
by the Office of External Affairs, the presentation was part of RAND's 
Policy Forum series. Policy Forums are public, nonpartisan programs 
designed to inform and inspire debate on specific, timely policy 
issues.
    http://search.rand.org/search?input-form=rand-
simple&v%3Asources=rand-bundle&query=invisible+wounds
    [email protected]
    The RAND Corporation is a non-profit institution that addresses the 
challenges facing the public and private sectors around the world

                               __________

                                                     April 24, 2008
                    CALL BACK SCRIPT FOR BOTH PHASES
    Data points provided to contractor

    1.  Names from DMDC
    2.  Addresses (DMDC/MAP-D)
    3.  Phone Numbers (IRS, MAP-D and VADIR)
Message to contractor:
    Emergency Calls: If you feel that the veteran is experiencing an 
emergency--having chest pains, or indicates that he wants to harm 
himself, etc. please let the veteran know that you are connecting his/
her call to a nurse who can assist. Keep veteran on the line and 
contact the Dayton Nurse Call Center. (Number of the Dayton Call 
Center)
    Complaint Calls: If a veteran or family member begins to complain 
about their care at VA or bad experience when accessing VA care, 
explain that their concerns are very important to us and a VA hospital 
staff member (near their home) will call them back within 48 hours to 
ensure that we address the issues they are raising.
1. Answering Machine
    Good morning/afternoon/evening. I am (Agent Name) calling (name of 
veteran) again from the Department of Veterans Affairs. We spoke to 
(him/her) about 2 weeks ago and wanted to follow-up and ensure that 
(he/she) got the answers or information that we spoke about. Sorry to 
not reach you but please call us back at 1-866-606-8215 during business 
hours to confirm that you have the information we promised.
    Thank you very much
    End call

                               __________
2. Introduction
    Good morning/afternoon/evening. My name is (Agent Name) and I am 
calling (name of veteran) again on behalf of the Department of Veterans 
Affairs, to ensure that he/she received the information we spoke about 
several weeks ago. May I speak with (Mr/Ms _____)?
    Can go to:

    3--leave message with person,
    4--veteran answers,
    5--Caregiver or Guardian Answers

                               __________
3. Message
    Sorry he/she is not available. Could you please have him/her call 
us back at 1-866-606-8215 during business hours to confirm that he/she 
got the information we promised.
    Thank you very much
    End call

                               __________
4. Veteran Answers
    You received a call about 2 weeks ago and we wanted to follow-up to 
ensure that you got the answers or information that we spoke about.
    Did you hear back from us?
    If no, go to 9.
    If yes, continue with:
    I hope the information or contact was satisfactory. Is there 
anything else we can do for you?
    If yes go to 7,
    If they were not satisfied, go to 7a.
    If they heard from us and do not need anything else, go to 8

                               __________
5. Other person answering phone (guardian or caregiver) theoretically 
        we would want this person case managed
    You received a call about 2 weeks ago and we wanted to follow-up to 
ensure that you got the answers or information that we spoke about.
    Did you hear back from us?
    If no, go to 9.
    If yes, continue with:
    I hope the information or contact was satisfactory. Is there 
anything else we can do for you?
    If yes go to 7,
    If they heard from us and do not need anything else, go to 8

                               __________
6. More Information
    OK, it may be best for me to have a staff member at the local VA 
contact you within 48 hours to ensure that we have met your needs. I 
have your contact information and will have the appropriate staff 
member contact you. Thank you very much for letting us serve you.
    End of call

                               __________
7. Contact was made or information was sent but veteran needs more.
    I am sorry that we did not get you the information that you wanted. 
It may be best for me to have a staff member at the local VA contact 
you within 48 hours to ensure that we have met your needs. I have your 
contact information and will email the appropriate staff member contact 
you. Thank you very much for letting us serve you.
    End call

                               __________
8. All went well and veteran needs no more assistance
    Thank you again for (your or his/her) time and service. I am glad 
you got the information you needed. I would again like to leave you 
with our 1-800 number in case you need or have any questions. The 
number is 1-866-606-8212. It is staffed during business hours and will 
be able to provide information about a VA facility in your area.
    End call

                               __________
9. Did not hear back from us
    Ok, I really apologize that you have not heard back from us. Let me 
again verify your contact information
    I have your phone number which is ___________
    Your home address is ___________
    And your email address is ___________
    And your best time to call ___________
    Let me check into this and we will be back in touch with you in 48 
hours.
    Thank you
    End call.

                               __________

       Care Management Candidate Interview Call Script (Phase 1)
                           (Care Management)
    Data points provided to contractor

    4.  Names from Veterans Tracking Application (VTA/CMO and SWS 
Database)
    5.  Addresses (VTA/IRS/MAP-D/CMO Database)
    6.  Phone Number (VTA/CMO/VADIR Database)
    7.  Care Manager's Name if populated (PCCM)
Message to contractor:
    Emergency Calls: If you feel that the veteran is experiencing an 
emergency--having chest pains, or indicates that he wants to harm 
himself, etc., please let the veteran know that you are connecting his/
her call to a nurse who can assist. Keep veteran on the line and 
contact the Dayton Nurse Call Center.
    Complaint Calls: If a veteran or family member begins to complain, 
explain that their concerns are very important to us and a VA hospital 
staff member will call them back within 48 hours to ensure that we 
address the issues they are raising.
1. Answering Machine
    Good morning/afternoon/evening. I am (Agent Name) calling (name of 
veteran) on behalf of the Secretary of the Department of Veterans 
Affairs, Dr. Jim Peake. Dr. Peake has asked us to speak with you so 
that we can provide you with information about a change in VA benefits 
and to see if you are in need of our assistance. Please call the VA 
Combat Veteran Information Line at 1-866-606-8198 during business hours 
to speak with someone about this important information.
    Thank you for your service.
    End call

                               __________
2. Introduction
    Good morning/afternoon/evening. My name is (Agent Name) and I am 
calling (name of veteran) on behalf of the Secretary of the Department 
of Veterans Affairs, Dr. Jim Peake, to inform (him/her) of changes to 
veteran benefits recently adopted by Congress and approved by the 
President. May I speak with (Mr./Ms. _____)?
    Can go to:

    3--leave message with person,
    3a--veteran deceased,
    4--wrong number,
    5--veteran answers,
    6--guardian or caregiver.
    7--hang up (Document and try three times to reach veteran)

                               __________
3. Leave Message
    Several of the changes to the benefits program are time sensitive, 
and the Secretary does not want any veteran to miss out on any services 
to which they are entitled. Could you please have him/her call the VA 
Combat Veteran Information Line at 1--866-606-8198 during business 
hours so that we can provide him/her with this valuable information?
    Thank you.
    End call

                               __________
3a. Veteran Deceased
    I am very sorry to hear that (Mr./Ms. _____) has passed away. 
Please know that the Secretary and the entire VA Family are grateful 
for his/her service to our country. As you may or may not know, the VA 
has several programs for families of fallen servicemembers. Would you 
be interested in information from the VA regarding any survivor's 
benefits?
    If the answer is yes, continue with: Sure, we will have someone 
call you back within 48 hours to assist you. Would that be okay?
    If yes: go to 11
    If no: Once again Dr. Peake has asked me to convey his sincerest 
sympathies for the loss to your family.
    End call

                               __________
4. Inconvenience
    Sorry for your inconvenience. Hope you have a nice day.
    End call

                               __________
5. Veteran Answers
    The Secretary wanted you to be aware that the eligibility for 
combat veterans has been changed. Previously, individuals discharged 
from the military would receive 2 years of cost free VA healthcare for 
any condition potentially related to your combat service. This has been 
extended to 5 years. If you were discharged prior to January 28, 2003, 
you will have the enhanced enrollment benefits and cost free VA 
healthcare until January 27, 2011.
    Would you like to know more about another change underway to help 
veterans gain employment?
    If yes, go to 5b
    If no, go to 5c
5b. Employment Program Information
    The VA's new Veterans Employment Coordination Service, was 
established to oversee the Department's program to recruit new veterans 
into the VA workforce. The new office will work with military 
transition programs, VA managers, and human resource offices to ensure 
supervisors are aware of programs for hiring veterans.
    If you're interested in employment with the Department of Veterans 
Affairs, please contact the VECS team at [email protected] or (866) 606-6206 
for more information.
    Go to 5c
5c. VA Usage
    Finally, the primary reason for the call is Dr. Peake wanted to 
make sure that you were receiving the medical care you needed from the 
VA.
    Are you receiving the care you need?
    If yes: go to 12
    If no: If not would you share what issues you are having or reasons 
for not coming to the VA? (List the issues)
    Do you have any other healthcare or benefit questions that we can 
assist you with or would you like more information about your benefits?
    If yes: Go to 7
    If no: Go to 18

                               __________
6. Other person answering phone (guardian or caregiver) theoretically 
        we would want this person case managed
    As the primary caregiver for (name of veteran) the Secretary wanted 
you to know that the eligibility for combat veterans has been changed. 
Previously, individuals discharged from the military would receive 2 
years of cost free VA healthcare for any condition potentially related 
to (his/her) combat service. This has been extended to 5 years. If (he/
she) discharged prior to January 28, 2003, (he/she) will have the 
enhanced enrollment benefits and cost free VA healthcare benefits until 
January 27, 2011.
    As the first Medical Doctor to ever lead the VA, Dr. Peake knows 
the difficulties associated with being a primary caregiver. He wanted 
us to inquire if (name of veteran) or you on (name of veteran's) behalf 
have ever tried to enroll in the VA healthcare system?
    If they have enrolled: go to 12
    If they have not tried to enroll: go to 6b

    6a. If there are reasons you have not come to the VA, would you 
share those with us?
    If yes: List the reasons
    If no: go to 7

    6b. He also asked that we ensure you were receiving the information 
and assistance you needed.
    If yes: go to 7
    If no: go to 7

                               __________
7. More Information
    Do you want to speak with a clinical staff member at a nearby VA 
hospital?
    If yes, go to 12
    If no, continue to next question
    Can we provide you with any general information about your VA 
benefits?
    If yes, go to 9
    If no, go to 18
    If both are no answers, go to 18

                               __________
8. (Blank)

                               __________
9. How?
    OK, I want to make this as easy and convenient for you as possible, 
how can we best serve you?
    I can have someone call from the local VA hospital.
    I can mail you information, or
    I can e-mail information to you,
    Which would you prefer?
    Go to 11

                               __________
10. Call Back
    The Department of Veterans Affairs would like to ensure that 
everything we discussed or promised to do today is getting done in a 
timely manner. Would you mind if we also called you back in 10 to 14 
days to ensure that you received the information you requested and any 
questions or issues you raised were addressed to your satisfaction?
    Go to 18

                               __________
11. Demographic confirmation
    In order to accomplish everything that I have promised I want to 
confirm some information:

      Is your mailing address still?
      What is the best phone number for us to contact you?
      Is there a time you would prefer us to try to contact 
you?
      Can I have your primary e-mail address?

    Go to 10

                               __________
12. Care Manager
    Do you currently have a care manager?
    If no, go to 14
    If they answer yes and they don't have a care manager listed then 
go to 15
    If yes and the system has a care manager listed ask:
    I have (name of care manager from database) from (location of care 
manager from database) as your VA care manager. Is this correct?
    If the information is correct, go to 13
    If the information is incorrect, go to 14

                               __________
13. Would you like a call from CM?
    Do you have any questions or concerns that you would like me to 
have your care manager give you a call about?
    If yes, go to 11
    If no, go to 18

                               __________
14. Was another care manager assigned?
    As I previously told you our system has (name of care manager in 
database) as your care manager but you didn't recognize that 
individual, was another one assigned?
    If yes, go to 15
    If no, go to 17b.

                               __________
15. Update CM
    Okay. Can you tell me his/her name and the name of the VA hospital 
where he/she works?
    Do you have any questions or concerns or would you like (him/her) 
to call you?
    If yes, go to 11
    If no, go to 18

                               __________
16. More Care Management Info
    Our records do not show that you have an assigned care manager. Is 
this correct?
    If yes, go to 17a
    If no, go to 15

                               __________
17a. VA has a program called care management that provides a staff 
        member to assist you in getting the services you need and 
        answers to your questions. If you would like to know more about 
        our care management program,
    Continue to 17b
17b. (start here) I can arrange for someone from the VA to call you and 
        talk with you about the program. Would you like us to call you 
        back, and if so, at what time would it be convenient?
    If yes, go to 11
    If no, go to 18

                               __________
18. Thank you
    Thank you again for your/their time in service to our country, we 
are grateful for your/their sacrifice. I'd like to leave you with an 
800 number in case you need or have any other questions. The number is 
1-800-827-1000. It is staffed during business hours and will be able to 
provide information about a VA facility in your area.
    End Call

                               __________

             Combat Veteran Interview Call Script (Phase 2)
                                (Global)
    Data points provided to contractor

     8.  Names from DMDC
     9.  Addresses (DMDC/MAP-D)
    10.  Phone Numbers (IRS, MAP-D and VADIR)
Message to contractor:
    Emergency Calls: If you feel that the veteran is experiencing an 
emergency--having chest pains, or indicates that he wants to harm 
himself, etc., please let the veteran know that you are connecting his/
her call to a nurse who can assist. Keep veteran on the line and 
contact the Dayton Nurse Call Center. (Number of the Dayton Call 
Center)
    Complaint Calls: If a veteran or family member begins to complain 
about their care at VA or bad experience when accessing VA care, 
explain that their concerns are very important to us and a VA hospital 
staff member (near their home) will call them back within 48 hours to 
ensure that we address the issues they are raising.
1. Answering Machine
    Good morning/afternoon/evening. I am (Agent Name) calling (name of 
veteran) on behalf of the Secretary of the Department of Veterans 
Affairs, Dr. Jim Peake, to inform (him/her) of a new benefit recently 
put in place by the President and Congress. Please call the VA Combat 
Veteran Information Line at 1-800-606-8212 between the hours of ____ 
and ____ so that we can provide you with more information about this 
benefit.
    Thank you very much for your service.
    End call

                               __________
2. Introduction
    Good morning/afternoon/evening. My name is (Agent Name) and I am 
calling (name of veteran) on behalf of the Secretary of the Department 
of Veterans Affairs, Dr. Jim Peake, to inform (him/her) of changes to 
veteran benefits recently adopted by Congress and approved by the 
President. May I speak with (Mr./Ms. _______)?
    Can go to:

    3--leave message with person,
    3a--veteran deceased,
    4--wrong number,
    5--veteran answers,
    6--Caregiver or Guardian Answers
    7--Hang up (Document and try three times to reach veteran)

                               __________
3. Leave Message
    Several of the changes to the benefits program are time sensitive, 
and the Secretary does not want any veteran to miss out on any services 
to which they are entitled. Could you please have him/her call the VA 
Combat Veteran Information Line at 1-800-606-8212 during business hours 
so that we can provide him/her with this valuable information?
    Thank you.
    End call
3a. Veteran Deceased
    I am very sorry to hear that (Mr./Ms. _______) has passed away. 
Please know that the Secretary and the entire VA Family are grateful 
for his/her service to our country. As you may or may not know the VA 
has several programs for families of fallen servicemembers. Would you 
be interested in information from the VA regarding any survivor's 
benefits issues or questions?
    If the answer is yes, go to 9:
    If no:
    Once again Dr. Peake has asked me to convey his sincerest 
sympathies for the loss to your family.
    Thank you.
    End call

                               __________
4. Inconvenience
    Sorry for the inconvenience. Hope you have a nice day.
    End call

                               __________
5. Veteran Answers
    The Secretary wanted to be sure that if you are not enrolled in the 
VA healthcare system that you were aware that the eligibility for 
combat veterans has been changed. Previously, individuals discharged 
from the military would receive 2 years of cost free VA healthcare for 
any condition potentially related to combat service. This has been 
extended to 5 years. If you were discharged prior to January 28, 2003, 
you will have the enhanced enrollment benefits and cost free VA 
healthcare benefits until January 27, 2011.
    The second reason for the call is Dr. Peake wanted to make sure 
that you were receiving the medical care you needed and asked us to 
inquire if you have ever tried to enroll in VA healthcare? If you 
haven't we hope that it is because you haven't needed any healthcare 
since your military discharge. However, if there are other reasons you 
have not come to the VA, would you share those with us?
    If yes, gather comments and go to next question
    If no, go to next question
    Do you have any other healthcare or benefit questions that we can 
assist you with now or would you like more information about your 
benefits?
    If yes, go to 9
    If no, go to 8

                               __________
6. Other person answering phone (guardian or caregiver) theoretically 
        we would want this person case managed
    As the primary caregiver for (name of veteran) the Secretary wanted 
you to know that the eligibility for combat veterans has been changed. 
Previously, individuals discharged from the military would receive 2 
years of cost free VA healthcare for any condition potentially related 
to their combat service. This has been extended to 5 years. If (he/she) 
were discharged prior to January 28, 2003, (he/she) will have the 
enhanced enrollment benefits and cost free VA healthcare benefits until 
January 27, 2011.
    As the first Medical Doctor to ever lead the VA, Dr. Peake knows 
the difficulties associated with being a primary caregiver. He wanted 
us to inquire if (name of veteran) or you on (name of veterans) behalf 
have ever tried to enroll in the VA healthcare system?
    Capture Comments if any
    If no ask:
    If there are reasons you have not come to the VA, would you share 
those with us?
    Move to the next question
    If yes: move to the next question
    Because there are several special programs that (veterans name) may 
qualify for, I would like to suggest that I have a staff member from 
the local medical center call you back with more detailed information, 
would that be alright?
    If yes:
    Go to 10
    If No;
    Go to 8

                               __________
7. More Information
    Would you be interested in receiving more information about the 
changes to the benefits plan?
    If no, go to 8
    If yes, go to 9

                               __________
8. Thank you
    Thank you again for (your or his/her) time in service to our 
country, we are grateful for your/their sacrifice. I'd like to leave 
you with an 800 number in case you need or have any other questions. 
The number is 1-800-827-1000. It is staffed during business hours and 
will be able to provide information about a VA facility in your area.
    End call

                               __________
9. How?
    Ok, I want to make this as easy and convenient for you as possible, 
so there are several ways I can get you the information you're 
requesting:

      I can have someone call from the local VAMC,
      I can mail you information, or
      I can e-mail the information to you

    Which would you prefer?
    Go to 10.

                               __________
10. Call Back?
    The Department of Veterans Affairs would like to ensure that 
everything we discussed or promised to do today is getting done in a 
timely manner. Would you mind if we also called you back in 10 to 14 
days to ensure that you received the information you requested and any 
questions or issues you raised were addressed to your satisfaction?
    Go to 8

                               __________
11. Demographic Confirmation
    In order to accomplish everything that I have promised I want to 
confirm some information:

      Is your Mailing address still?
      What is the best phone number for us to contact you?
      Is there a time you would prefer us to try to contact 
you?
      Can I have your primary e-mail address?

    Go to 10.

                                Status of Congressionally Mandated Requirements for Implementing the Wounded Warrior Provisions of the National Defense Authorization Act 2008 (As of December 18, 2008)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                             Revised Due       Status/Milestones (Updates/progress (by
                       2008 NDAA Sect                                     Description from Act                          Reporting Requirement                 Due Date           Date                          date))
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1618                                                                                      COMPREHENSIVE PLAN ODirects joint planning among the DoD, the         07/26/08         09/15/08   Defense Center of Excellence (DCoE) concept
                                                                        MITIGATION, TREATMENT, AND REHABILITATIMilitary Departments, and the VA for the                                        of operations approved, Interim Director
                                                              OF, AND RESEARCH ON, TRAUMATIC BRAIN INJURY,           prevention, diagnosis, mitigation,                                     named, staff in process of being hired. DCoE
                                                                POST TRAUMATIC STRESS DISORDER, AND OTHER         treatment, and rehabilitation of, and                                                         announced 11/30/07. VA Legislative Affairs
                                                                                                    MENTAL HEALresearch on, TBI, PTSD, and other mental                                       has this item for action and is currently
                                                                  ARMED FORCES. The SecDef and the Sec VA     health conditions in members of the Armed                                                  working to change legislation.
                                                               shall direct joint planning among the DoD,   Forces, including planning for the seamless
                                                              the military departments, and the VA for the  transition of such members from care through                                          04/22/08: Force Health Protection and
                                                                       prevention, diagnosis, mitigation,               the DoD to care through the VA.                                     Readiness (FHP&R) and DCoE are working this.
                                                                    treatment, and rehabilitation of, and
                                                                 research on, TBI, PTSD, and other mental                                                                                         05/20/08: Ground breaking at Bethesda
                                                                health conditions in members of the Armed                                                                                                       scheduled for 06/05/08.
                                                              Forces, including planning for the seamless
                                                              transition of such members from care through                                                                                  05/27/08: FHP&R staff is working with Price
                                                                          the DoD to care through the VA.                                                                                   Waterhouse & Cooper contractors to develop a
                                                                                                                                                                                                                                report.

                                                                                                                                                                                                                 05/30/08: Memo signed.

                                                                                                                                                                                                09/20/08: Interim response submitted to
                                                                                                                                                                                                    Congress. Extension letters signed.

                                                                                                                                                                                                   10/08: Report submitted to Congress,
                                                                                                                                                                                                                                   COMPLETE.
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1624                                                                                      REPORT ON ESTABLISHMENT Report on establishment of centers of         07/26/08         10/31/08                                    04/22/08: Legislative tasking to FHP&R with
                                                                                                     EXCELLENCE. The SecDef shall submit repexcellence.                                                                                LoA 2 as lead; DCOE is established; Report
                                                                   on: the establishment of the center of                                                                                   is being written by DCoE, with Army input on
                                                                     excellence in prevention, diagnosis,                                                                                                                      Eye CoE.
                                                              mitigation, treatment, and rehabilitation of
                                                                  TBI; the establishment of the center of                                                                                                                    07/25/08: Letter to Congress. 09/05/08: This
                                                                     excellence in prevention, diagnosis,                                                                                          report is well underway but requires
                                                              mitigation, treatment, and rehabilitation of                                                                                  extensive work and coordination and will be
                                                              PTSD and other mental health conditions; and                                                                                                          submitted 10/31/08.
                                                                       the establishment of the center of
                                                                     excellence in prevention, diagnosis,                                                                                          11/08: Report submitted to Congress,
                                                              mitigation, treatment, and rehabilitation of                                                                                                                         COMPLETE.
                                                                                   military eye injuries.
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1645                                                                             REPORTS ON ARMY ACTION PLAN IReport on Army Action Plan in response to         06/01/08         07/14/08                       04/15/08: Army is lead.
                                                                         DEFICIENCIES IN THE ARMY PHYSICAL Ddeficiencies in the Army Physical Disability        06/01/09
                                                                                                      EVALUATION SYSTEM. The SecDef sEvaluation System.                                                 06/02/08: DA updated OSD (P&R).
                                                               report on the implementation of corrective
                                                                  measures by the DoD with respect to the                                                                                      06/18/08: Forwarded to Office of General
                                                                    Physical Disability Evaluation System                                                                                                                      Counsel.
                                                              (PDES). The Secretary shall post such report
                                                               on the Internet website of the DoD that is                                                                                    07/14/08: Report submitted to Congress via
                                                                                 available to the public.                                                                                                                 USD P&R. COMPLETE.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1650                                                           REQUIRED CERTIFICATIONS IN CONNECTION WITH   Certifications in connection with closure of        04/27/08         09/30/08   04/24/08: Plan due 09/08, certifications due
                                                                                                        CLOSURE OF WALTER REED ARMY MEDICALWalter Reed.                                                           after plan submitted.
                                                                                           DISTRICT OF COLUMBIA. The SecDef shall
                                                                    submit a certification of each of the                                                                                   05/07/08: Certification will be complete in
                                                               following: that a transition plan has been                                                                                    the next few days. ASA (M&RA) is the owner
                                                                       developed, and resources have been                                                                                                          of this requirement.
                                                                   committed, to ensure that patient care
                                                              services, medical operations, and facilities                                                                                            06/25/08: Submitted for approval.
                                                              are sustained at the highest possible level
                                                               at Walter Reed until facilities to replace                                                                                         08/01/08: Awaiting USD P&R signature.
                                                              Walter Reed are staffed and ready to assume
                                                               at least the same level of care previously                                                                                                                   09/08: COMPLETE.
                                                              provided at Walter Reed; that the closure of
                                                              Walter Reed will not result in a net loss of
                                                              capacity in the major medical centers in the
                                                                National Capitol Region in terms of total
                                                                bed capacity or staffed bed capacity; and
                                                                    that the capacity of medical hold and
                                                               outpatient lodging facilities operating at
                                                                        Walter Reed as of the date of the
                                                                       certification will be available in
                                                                  sufficient quantities at the facilities
                                                                 designated to replace Walter Reed by the
                                                                      date of the closure of Walter Reed.
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1662                                                               ACCESS OF RECOVERING SERVICEMEMBERS TO          All quarters of the U.S. and housing         07/28/08       Inspection          09/09/08: The inspections were to be
                                                                           ADEQUATE OUTPATIENT RESIDENTIAL FACIfacilities under the jurisdiction of the         01/28/09   completed 09/01/                         completed 09/01/08.
                                                                     All quarters of the U.S. and housing   Armed Forces that are occupied by recovering        07/28/09               08
                                                                 facilities under the jurisdiction of the   servicemembers shall be inspected on a semi-        01/28/10                              11/01/08: First report submitted.
                                                              Armed Forces that are occupied by recovering  annual basis for the first 2 years after the                       1st report
                                                              Servicemembers shall be inspected on a semi-           enactment of this Act and annually                    signed out 11/                                          COMPLETE and ongoing
                                                              annual basis for the first 2 years after the  thereafter by the inspectors general of the                             01/08
                                                                       enactment of this Act and annually                    regional medical commands.
                                                              thereafter by the inspectors general of the
                                                                               regional medical commands.
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1664                                                                     REPORT ON TRAUMATIC BRAIN INJURY              Report on Traumatic Brain Injury         04/27/08   Interim report         04/15/08: FHP&R lead for DoD; drafted
                                                                                                        CLASSIFICATIONS. The SecDef andclassifications.                          08/01/08     initial report but need VA inputs; expect
                                                              jointly shall submit a report describing the                                                                                  long coordination cycle, so began developing
                                                              changes undertaken within the DoD and the VA                                                                 Final Report 01/  an interim report to meet deadline. 04/22/
                                                              to ensure that TBI victims receive a medical                                                                          31/09       08: Interim report drafted, but not yet
                                                                designation concomitant with their injury                                                                                           reviewed and approved by Ms Embrey.
                                                                   rather than a medical designation that
                                                                assigns a generic classification (such as                                                                                     04/28/08: Received input from VA; interim
                                                                       ``organic psychiatric disorder'').                                                                                      report drafted; in coordination awaiting
                                                                                                                                                                                                                  DCoE and OGC replies.

                                                                                                                                                                                                                   05/06/08: No change.

                                                                                                                                                                                              05/20/08: Coordination is underway in the
                                                                                                                                                                                              DoD & VA; report is being reviewed by DoD
                                                                                                                                                                                              OGC. ICD-9 codes must be coordinated with
                                                                                                                                                                                             National Committee that meets in December.
                                                                                                                                                                                                              Final report will follow.

                                                                                                                                                                                            05/27/08: Changes made per DoD OGC guidance,
                                                                                                                                                                                                           coordination resumed 23 May.

                                                                                                                                                                                                 07/08/08: in ASD(HA) for coordination.

                                                                                                                                                                                                  08/04/08: Report signed and to VA for
                                                                                                                                                                                                              coordination on 07/16/08.

                                                                                                                                                                                               08/07/08: Interim signed by cochairs and
                                                                                                                                                                                                                 submitted to Congress.
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Conf. Rept. Overview 1611                                                                COMPREHENSIVE POLICY ONRequirement contained in the Conference         02/27/08                      04/07/08: USD P&R signed February report.
                                                                      CARE, MANAGEMENT, AND TRANSITION OF     Report Overview, not in HR 1585 language.         05/27/08
                                                                RECOVERING SERVICEMEMBERS. The SecDef and   Report on standards for recovery coordinator        08/25/08                     04/10/08: Documents submitted to Congress.
                                                                the Sec VA shall, to the extent feasible,                          and case management.         11/23/08
                                                                          jointly develop and implement a                                                                                          05/27/08: USD P&R signed May report.
                                                              comprehensive policy on improvements to the
                                                                      care, management, and transition of                                                                                    06/12/08: Documents submitted to Congress.
                                                              recovering servicemembers. The policy shall
                                                                cover each of the following: the care and
                                                              management of recovering servicemembers; the
                                                              medical evaluation and disability evaluation
                                                              of recovering servicemembers; the return of
                                                              servicemembers who have recovered to active
                                                                 duty when appropriate; the transition of
                                                                recovering servicemembers from receipt of
                                                              care and services through the DoD to receipt
                                                                         of care and services through VA.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
HAC 110-424                                                   A joint DoD/DVA report to the congressional          The report should include a detailed         08/30/08                      05/08/07 OIPT and 05/20/07 SOC: Reporting
                                                                 defense Committees detailing the actions         spending plan for the use of funding,                                     requirement is from 10/30/07 memo signed by
                                                              being taken by each department to achieve an       identify all other ongoing and planned                                                               both Secretaries.
                                                                  interoperable electronic medical record        projects and programs and identify the
                                                                                                   (EMR).   Departments' goals for interoperability and                                                08/08: Electronic Medical Record
                                                                                                            how these projects and programs will address                                        Interoperability Report and Information
                                                                                                                                            those goals                                     Interoperability Plan submitted to Congress.
                                                                                                                                                                                                                                   COMPLETE.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
HAC 110-434                                                   A joint DoD/DVA report to the congressional          The report should include a detailed         04/01/08         08/31/08   04/29/08: Interim report sent to Congress. A
                                                                 Defense Committees detailing the actions         spending plan for the use of funding,                                       final report will be sent in August 2008.
                                                              being taken by each department to achieve an       identify all other ongoing and planned
                                                                  interoperable electronic medical record        projects and programs and identify the                                                08/08: Electronic Medical Record
                                                                                                   (EMR).   Departments' goals for interoperability and                                            Interoperability Report submitted to
                                                                                                            how these projects and programs will address                                                                 Congress. COMPLETE.
                                                                                                                                            those goals
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1634a (741)                                                     REPORTS. The SecDef shall submit a report           Report on implementation of certain         04/27/08   12/31/08 Final       04/10/08: Army provided a copy of their
                                                              describing the progress in implementing the                                 requirements.                                                                 current policy.
                                                              requirements of sections 721 and 741 of the
                                                               John Warner National Defense Authorization                                                                                                                04/28/08: TBI Longitudinal study interim
                                                              Act for Fiscal Year. The SecDef shall submit                                                                                  report in coordination today; PTSD report--
                                                              a report setting forth the amounts expended                                                                                                              DCoE is working.
                                                                 by the DoD during the preceding calendar
                                                                  year on activities including the amount                                                                                    05/06/08: TBI longitudinal study report is
                                                               allocated during such calendar year to the                                                                                   in coordination with TMA legislative staff.
                                                              Defense and Veterans Brain Injury Center of                                                                                   PTSD pilot projects report is being written
                                                                                          the Department.                                                                                                    with DCoE taking the lead.

                                                                                                                                                                                               05/15/08: FHP&R lead; Study is underway;
                                                                                                                                                                                               Report is being written. Report on pilot
                                                                                                                                                                                                          projects from 741--C&PP lead.

                                                                                                                                                                                             05/20/08: The TBI report is being reviewed
                                                                                                                                                                                                   by DoD OGC; The PTSD report is being
                                                                                                                                                                                             reviewed by the Dir. DCoE--to HA on 05/21/
                                                                                                                                                                                                                                    08.

                                                                                                                                                                                            5/27/08: TBI report--DoD OGC concurred on 05/
                                                                                                                                                                                                          23, package forwarded to DoD Legislative
                                                                                                                                                                                                              Affairs for coordination.

                                                                                                                                                                                            06/12/08: TBI report forwarded to Congress.

                                                                                                                                                                                            08/18/08: PTSD report forwarded to Congress.
                                                                                                                                                                                                                                   COMPLETE.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1634b                                                           REPORTS. The SecDef shall submit a report            Annual reports on expenditures for         03/01/08                             04/15/08: FHP&R lead, draft report
                                                              describing the progress in implementing the                   activities on TBI and PTSD.                                       submitted, waiting for HA leg chop before
                                                              requirements of sections 721 and 741 of the                                                                                     ASD signature. 04/22/08 Interim report is
                                                               John Warner National Defense Authorization                                                                                                                with OGC and OLA for review before ASD
                                                              Act for Fiscal Year. The SecDef shall submit                                                                                                                   signature.
                                                              a report setting forth the amounts expended
                                                                 by the DoD during the preceding calendar                                                                                     04/28/08: Coordination from OGC to HA for
                                                                  year on activities including the amount                                                                                                                    signature.
                                                               allocated during such calendar year to the
                                                              Defense and Veterans Brain Injury Center of                                                                                   05/06/08: Signed 05/01/08 as a final report
                                                                                          the Department.                                                                                              satisfying the requirement--COMPLETE. Annual
                                                                                                                                                                                                                   Reports forthcoming.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1635                                                            Establishes an Interagency Program Office   Jointly establish a schedule and benchmarks         02/27/08                                                     04/08/08: Letter sent.
                                                                  (IPO) of the DoD and the VA to act as a        for the discharge by the Office of its
                                                                                            single point.                                    functions.                                     04/29/08: Cover letter to be co-signed. Plan
                                                                                                                                                                                                          being vetted through VBA/VHA.
                                                                                                                                                                                            04/29/08: Cover letter signed. Draft of IPO
                                                                                                                                                                                                            plan sent to Congress. COMPLETE
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1635                                                                                                   FULLYActivities of the DoD/VA Interagency Program        01/01/09                                        12/03/08: VA concurred.
                                                                                                      HEALTH INFORMATION FOR THE DEPARTMENT OF  Office.
                                                              DEFENSE AND DEPARTMENT OF VETERANS AFFAIRS.                                                                                           12/04/08: IPO's Annual Report is in
                                                                  The SecDef and the Sec VA shall jointly                                                                                                          coordination at DoD.
                                                                  develop and implement electronic health
                                                                record systems or capabilities that allow                                                                                                             Status: On track.
                                                                    for full interoperability of personal
                                                               healthcare information between the DoD and
                                                                   the VA; and accelerate the exchange of
                                                               healthcare information between the DoD and
                                                               the VA in order to support the delivery of
                                                              healthcare by both Departments. Establishes
                                                              an interagency program office of the DoD and
                                                                       the VA to act as a single point of
                                                              accountability for the DoD and the VA in the
                                                                  rapid development and implementation of
                                                                      electronic health record systems or
                                                                         capabilities that allow for full
                                                                  interoperability of personal healthcare
                                                              information between the DoD and the VA. The
                                                              function of the Office shall be to implement
                                                                      electronic health record systems or
                                                                         capabilities that allow for full
                                                                  interoperability of personal healthcare
                                                                  information between the DoD and the VA.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1635                                                                                                   FULLY INTERComptroller General assessment of the         07/28/08                        07/28/08: Report sent to Congress--COMPLETE
                                                                                                      HEALTH progress of the DoD/VA Interagency Program
                                                              DEFENSE AND DEPARTMENT OF VETERANS AFFAIRS.                                       Office.
                                                                  The SecDef and the Sec VA shall jointly
                                                                  develop and implement electronic health
                                                                record systems or capabilities that allow
                                                                    for full interoperability of personal
                                                               healthcare information between the DoD and
                                                                   the VA; and accelerate the exchange of
                                                               healthcare information between the DoD and
                                                               the VA in order to support the delivery of
                                                              healthcare by both Departments. Establishes
                                                              an interagency program office of the DoD and
                                                                       the VA to act as a single point of
                                                              accountability for the DoD and the VA in the
                                                                  rapid development and implementation of
                                                                      electronic health record systems or
                                                                         capabilities that allow for full
                                                                  interoperability of personal healthcare
                                                              information between the DoD and the VA. The
                                                              function of the Office shall be to implement
                                                                      electronic health record systems or
                                                                         capabilities that allow for full
                                                                  interoperability of personal healthcare
                                                                      information between the DoD and VA.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1636                                                                                    ENHANCED PERSONNEL AUTHOReports on strategies on recruitment of         07/28/08                       05/07/08: DASD for Clinical Programs and
                                                                            DEPARTMENT OF DEFENSE FOR HEALTHCARE      medical and health professionals.                                      Policies is the owner of this requirement.
                                                                                              PROFESSIONALS FOR CARE AND TREATMENT OF
                                                                 WOUNDED AND INJURED MEMBERS OF THE ARMED                                                                                       06/23/08: Memos to Military Departments
                                                                      FORCES. The SecDef may exercise any                                                                                         asking them to report to him on their
                                                                 authority for the appointment and pay of                                                                                                                     progress.
                                                                 healthcare personnel under chapter 74 of
                                                                title 38 for purposes of the recruitment,                                                                                       07/26/08: Services will have reports to
                                                                    employment, and retention of civilian                                                                                                                    Congress NLT 07/28/08.
                                                              healthcare professionals for the DoD if the
                                                                Secretary determines that the exercise of                                                                                       08/01/08: Report sent to Congress--COMPLETE.
                                                                  such authority is necessary in order to
                                                               provide or enhance the capacity to provide
                                                                   care and treatment for members who are
                                                                 wounded or injured on active duty and to
                                                              support the ongoing patient care and medical
                                                                       readiness, education, and training
                                                              requirements of the DoD. The Secretaries of
                                                              the military departments shall each develop
                                                                  and implement a strategy to disseminate
                                                              among appropriate personnel of the military
                                                               departments authorities and best practices
                                                                for the recruitment of medical and health
                                                               professionals. The authority of the SecDef
                                                                  to exercise authorities available under
                                                               chapter 74 of title 38 for purposes of the
                                                                recruitment, employment, and retention of
                                                                civilian healthcare professionals for the
                                                                          DoD expires September 30, 2010.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1644                                                                                  AUTHORIZATION OF PILOTInitial report on pilot programs to improve         04/27/08                           04/28/08: Report is in coordination.
                                                                                               THE DISABILITY EVALUATIthe Disability Evaluation System.
                                                                      OF THE ARMED FORCES. The SecDef may                                                                                       05/01/08: Report sent to Congress--COMPLETE.
                                                                establish and conduct pilot programs with
                                                                 respect to the system of the DoD for the
                                                              evaluation of the disabilities of members of
                                                              the Armed Forces who are being separated or
                                                                        retired from the Armed Forces for
                                                               disability. In establishing and conducting
                                                              any pilot program, the SecDef shall consult
                                                                      with the Sec VA. Each pilot program
                                                              conducted shall be completed not later than
                                                              1 year after the date of the commencement of
                                                              such pilot program. The SecDef shall submit
                                                              a report on each pilot program that has been
                                                              commenced as of that date. Not later than 90
                                                                   days after the completion of all pilot
                                                                  programs conducted, the Secretary shall
                                                                    submit a report setting forth a final
                                                                   evaluation and assessment of the pilot
                                                                  programs. The report shall include such
                                                                       recommendations for legislative or
                                                                   administrative action as the Secretary
                                                              considers appropriate in light of such pilot
                                                                                                programs.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1644                                                                                  AUTHORIZATION OF PILOTInterim report on pilot programs to improve    11/01/08 (180                       09/05/08: The pilot program is on track.
                                                                                               THE DISABILITY EVALUATIthe Disability Evaluation System.       days after
                                                                      OF THE ARMED FORCES. The SecDef may                                                  submission of                               12/01/08: Report submitted--COMPLETE.
                                                                establish and conduct pilot programs with                                                    the initial
                                                                 respect to the system of the DoD for the                                                        report)
                                                              evaluation of the disabilities of members of
                                                              the Armed Forces who are being separated or
                                                                        retired from the Armed Forces for
                                                               disability. In establishing and conducting
                                                              any pilot program, the SecDef shall consult
                                                                      with the Sec VA. Each pilot program
                                                              conducted shall be completed not later than
                                                              1 year after the date of the commencement of
                                                              such pilot program. The SecDef shall submit
                                                              a report on each pilot program that has been
                                                              commenced as of that date. Not later than 90
                                                                   days after the completion of all pilot
                                                                  programs conducted, the Secretary shall
                                                                    submit a report setting forth a final
                                                                   evaluation and assessment of the pilot
                                                                  programs. The report shall include such
                                                                       recommendations for legislative or
                                                                   administrative action as the Secretary
                                                              considers appropriate in light of such pilot
                                                                                                programs.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1644                                                                                  AUTHORIZATION OF PILOT PFinal report on pilot programs to improve    90 days after                        12/08: Awaiting completion of all pilot
                                                                                               THE DISABILITY EVALUATIthe disability evaluation system.    completion of                                                      programs.
                                                                      OF THE ARMED FORCES. The SecDef may                                                      all pilot
                                                                establish and conduct pilot programs with                                                       programs
                                                                 respect to the system of the DoD for the
                                                              evaluation of the disabilities of members of
                                                              the Armed Forces who are being separated or
                                                                        retired from the Armed Forces for
                                                               disability. In establishing and conducting
                                                              any pilot program, the SecDef shall consult
                                                                      with the Sec VA. Each pilot program
                                                              conducted shall be completed not later than
                                                              1 year after the date of the commencement of
                                                              such pilot program. The SecDef shall submit
                                                              a report on each pilot program that has been
                                                              commenced as of that date. Not later than 90
                                                                   days after the completion of all pilot
                                                                  programs conducted, the Secretary shall
                                                                    submit a report setting forth a final
                                                                   evaluation and assessment of the pilot
                                                                  programs. The report shall include such
                                                                       recommendations for legislative or
                                                                   administrative action as the Secretary
                                                              considers appropriate in light of such pilot
                                                                                                programs.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1647                                                                        ASSESSMENTS OF CONTINUING UTILITY Report on the assessment of the Temporary         07/26/08         09/30/08                   06/18/08: forwarded to OGC.
                                                                                                       ROLE OF TEMPORARY DISABILITY Disability Retired List.
                                                              The SecDef shall submit a report containing                                                                                               09/11/08 Report submitted--COMPLETE.
                                                              a statistical history since January 1, 2000,
                                                               of the numbers of members who are returned
                                                              to duty or separated following tenure on the
                                                                                                      TDRL and, in the case of members who were
                                                                  separated, how many of the members were
                                                              granted disability separation or retirement
                                                                  and what were their disability ratings.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1663                                                             STUDY AND REPORT ON SUPPORT SERVICES FOR   Conduct a study of the provision of support         07/26/08         11/14/08     09/05/08: On 25 Jul 08 a letter regarding
                                                                                                     FAMILIES OF RECservices for families of recovering                                          the status of this section was sent to
                                                                      SecDef shall conduct a study of the                               servicemembers.                                     Congress. The study is underway and expected
                                                               provision of support services for families                                                                                                    to be completed 30 Sep 08.
                                                                 of recovering servicemembers. The SecDef
                                                              shall submit a report on the results of the                                                                                       12/04/08: Report has been finalized and
                                                                            study, with such findings and                                                                                        forwarded to P&R for signature (OIPT).
                                                               recommendations as the Secretary considers                                                                                         Distribution only remains, therefore,
                                                                                             appropriate.                                                                                                               considered COMPLETE.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1665                                                                                                  EVALUATION OF THE POEvaluation of the Polytrauma Liaison O04/27/08         09/30/08   04/09/08: HA/TMA held a conference call with
                                                              NON-COMMISSIONED OFFICER PROGRAM. The SecDef            Non-Commissioned Officer program.                                                      VA and Service Polytrauma Liaison program
                                                                       shall conduct an evaluation of the                                                                                           managers. Interim report is pending
                                                                                              Polytrauma Liaison Officer/Non-Commissioned                                                     signature by ASD HA office with follow-on
                                                                    Officer program. The evaluation shall                                                                                      transmission to the Hill. Interim report
                                                                   include an evaluation of the program's                                                                                   will state an anticipated completion date by
                                                                effectiveness, manpower requirements, and                                                                                     the end of FY 2008 and includes status of
                                                              expansion of the program to incorporate Navy                                                                                            the Marine Corps liaisons and MOU
                                                                     and Marine Corps officers and senior                                                                                     development progress with VA to formalize
                                                                                      enlisted personnel.                                                                                   the program for each service. (POC: HA/TMA).

                                                                                                                                                                                             4/18/08: Interim report to Congress signed
                                                                                                                                                                                             by OASD(HA). Report delivered to Congress.
                                                                                                                                                                                             New projected completion date is end of FY
                                                                                                                                                                                                                                  2008.

                                                                                                                                                                                                 05/01/08: An interim report signed and
                                                                                                                                                                                                  delivered to Congress on 4/18 with an
                                                                                                                                                                                            anticipated completion date by the end of FY
                                                                                                                                                                                                                                  2008.

                                                                                                                                                                                                                     05/15/08: Ongoing.

                                                                                                                                                                                           07/02/08: First site visit complete, others
                                                                                                                                                                                                                               planned.

                                                                                                                                                                                               09/30/08: Report submitted to Congress--
                                                                                                                                                                                                                                   COMPLETE.
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1674                                                                            GUARANTEED FUNDING FOR WALTER REED ARMY      Walter Reed certification.         01/01/09                       04/28/08: Plan due will be completed 09/
                                                                                                   MEDICAL CENTER, DISTRICT OF COLUMBIA. The                    04/01/09                    2008; certifications due quarterly after the
                                                              amount of funds available for the commander                                                       07/01/09                                             plan is submitted.
                                                                of Walter Reed for a fiscal year shall be                                                       10/01/09
                                                                 not less than the amount expended by the                                                                                                                12/04/08: COMPLETE and on track with ongoing
                                                              commander of Walter Reed in fiscal year 2006                                                                                                           quarterly updates.
                                                              until the first fiscal year beginning after
                                                              the date on which the SecDef submits a plan
                                                              for the provision of healthcare for military
                                                                beneficiaries and their dependents in the
                                                              National Capital Region. The Secretary shall
                                                              certify on a quarterly basis that patients,
                                                              staff, bed capacity, functions, or parts of
                                                              functions at Walter Reed have not been moved
                                                                     or disestablished until the expanded
                                                                 facilities at the National Naval Medical
                                                              Center, Bethesda, Maryland, and DeWitt Army
                                                              Community Hospital, Fort Belvoir, Virginia,
                                                                are completed, equipped, and staffed with
                                                               sufficient capacity to accept and provide,
                                                               at a minimum, the same level of and access
                                                              to care as patients received at Walter Reed
                                                                                 during fiscal year 2006.
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1612                                                                                               MEDICAL EVALUATIONS AFeasibility and advisability of         07/01/08         07/30/08                       07/03/08: Report signed
                                                                                                      EVALUATIONconsolidating the disability evaluation
                                                                     The SecDef shall develop a policy on   systems of the military departments and the                                        07/07/08: Submitted to Congress via VA--
                                                               improvements to the processes, procedures,           disability evaluation system of the                                                                            COMPLETE.
                                                                     and standards for the conduct by the   Department of Veterans Affairs into a single
                                                              military departments of medical evaluations                 disability evaluation system.
                                                              of recovering servicemembers. The SecDef and
                                                                  the Secretary of the VA shall develop a
                                                                 policy on improvements to the processes,
                                                              procedures, and standards for the conduct of
                                                                       physical disability evaluations of
                                                                recovering servicemembers by the military
                                                                departments and by the VA. The SecDef and
                                                              the Sec VA shall jointly submit a report on
                                                                      the feasibility and advisability of
                                                                  consolidating the disability evaluation
                                                              systems of the military departments and the
                                                              disability evaluation system of the VA into
                                                                   a single disability evaluation system.
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1615                                                          REPORTS. Upon the development of the policy             Comprehensive policy on the care,         07/01/08        Report to   The pilot tests a new DoD and VA disability
                                                              required by section 1611. The SecDef and the     management, and transition of recovering                                  Congrsystem. The pilot will be a Servicemember
                                                              Sec VA shall jointly submit a report on the                               Servicemembers.                                08   centric initiative designed to eliminate the
                                                                    policy, including a comprehensive and                                                                                        duplicative, time-consuming, and often
                                                                detailed description of the policy and of                                                                                         confusing elements of the two current
                                                              the manner in which the policy addresses the                                                                                  disability processes of the Departments. Key
                                                                   detailed elements and the findings and                                                                                        features of the DES Pilot include: one
                                                               recommendations of the reviews. The SecDef                                                                                      medical examination and a single-sourced
                                                                   shall submit a report on the number of                                                                                   disability rating. One goal of the pilot is
                                                                 instances during the period beginning on                                                                                           to cut in half the time required to
                                                              October 7, 2001, and ending on September 30,                                                                                   transition a member for veteran status and
                                                              2006, in which a disability rating assigned                                                                                       provide them with their VA benefits and
                                                                      to a member by an informal physical                                                                                                                 compensation.
                                                              evaluation board of the DoD was reduced upon
                                                              appeal, and the reasons for such reduction.                                                                                    11/06/07: MOA signed to allow for a single
                                                                                                                                                                                                                   examination process.

                                                                                                                                                                                                  10/07/08: Technical Compliance Report
                                                                                                                                                                                              delivered to the Hill on 09/16/08. Action
                                                                                                                                                                                                                                   COMPLETE.
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1615                                                          REPORTS. Upon the development of the policy     Interim report on comprehensive policy on         02/01/08                          02/28/08: Submitted to Congress--COMPLETE.
                                                              required by section 1611. The SecDef and the      the care, management, and transition of
                                                              Sec VA shall jointly submit a report on the                    recovering Servicemembers.
                                                                    policy, including a comprehensive and
                                                                detailed description of the policy and of
                                                              the manner in which the policy addresses the
                                                                   detailed elements and the findings and
                                                                recommendations of the reviews.The SecDef
                                                                   shall submit a report on the number of
                                                                 instances during the period beginning on
                                                              October 7, 2001, and ending on September 30,
                                                              2006, in which a disability rating assigned
                                                                      to a member by an informal physical
                                                              evaluation board of the DoD was reduced upon
                                                              appeal, and the reasons for such reduction.
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1615                                                          REPORTS. Upon the development of the policy         Comptroller General assessment on the         07/28/08   Feb or Mar 2009       12/04/08: Actual submission to date to
                                                              required by section 1611. The SecDef and the     progress of DoD and VA in developing and         07/28/09                        Congress soft per GAO. Meeting with GAO
                                                              Sec VA shall jointly submit a report on the                          implementing policy.         07/28/10                                 scheduled for 12/10/08 (OIPT).
                                                                    policy, including a comprehensive and
                                                                detailed description of the policy and of
                                                              the manner in which the policy addresses the
                                                                   detailed elements and the findings and
                                                               recommendations of the reviews. The SecDef
                                                                   shall submit a report on the number of
                                                                 instances during the period beginning on
                                                              October 7, 2001, and ending on September 30,
                                                              2006, in which a disability rating assigned
                                                                      to a member by an informal physical
                                                              evaluation board of the DoD was reduced upon
                                                              appeal, and the reasons for such reduction.
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1615e                                                         REPORTS. Upon the development of the policy   Report on reduction in disability ratings by        02/01/09                      04/28/08: OSD P&R is working, it is labor
                                                              required by section 1611, the SecDef and the                                     the DoD.                                       intensive and cases must be pulled out of
                                                              Sec VA shall jointly submit a report on the                                                                                                         retirement to review.
                                                                    policy, including a comprehensive and
                                                                detailed description of the policy and of                                                                                      05/20/08: OSD DTM pending Navy approval.
                                                              the manner in which the policy addresses the
                                                                   detailed elements and the findings and                                                                                          12/04/08: On track. With contractor.
                                                               recommendations of the reviews. The SecDef                                                                                      Requires significant data mining (OIPT).
                                                                   shall submit a report on the number of
                                                                 instances during the period beginning on
                                                              October 7, 2001, and ending on September 30,
                                                              2006, in which a disability rating assigned
                                                                      to a member by an informal physical
                                                              evaluation board of the DoD was reduced upon
                                                              appeal, and the reasons for such reduction.
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HAC Rpt 110-279                                                Warriors in Transition Physical Disability    This report should include a review of the    01/15/08 then                          12/05/08: Quarterly Report--regularly
                                                                  Evaluation System Report to the Defense        differences among the Services' rating        Quarterly                         provided independently by SecDef. COMPLETE
                                                               Committees on plans to update the Physical        systems and the Department of Veterans                                                                    and ongoing.
                                                                     Disability Evaluation System to more     Affairs system, and provide a process for
                                                              accurately reflect the injuries of war. This    how and when these various rating systems
                                                                    report should include a review of the                         will be standardized.
                                                                   differences among the Services' rating
                                                                   systems and the Department of Veterans
                                                                Affairs system, and provide a process for
                                                                how and when these various rating systems
                                                                     will be standardized. SecDef report.
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Source: U.S. Department of Defense.

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